july 2010

Texas Dental Journal l www.tda.org l July 2010 633

July 2010

TEXAS DENTALTEXAS DENTALJournal

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STEPS-0262 OPE DentalAd_fl.indd 1 3/9/10 9:39 AM

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

Texas Dental Association 140th Annual Session2010 TEXAS Meeting Photo Contest Award: Best of ShowPhotographer: Dr. Roy TiemeyerTitle: “Skimmers”

For information on entering your photo in the 2011 TEXAS Meeting Photo Contest, please visit texasmeeting.com.


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Through August 31st, HeartSafe America is running a $999 special on the lightest, smallest, most durable AED on the market: the HeartSine Samaritan PAD.

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546 Texas Dental Journal l www.tda.org l June 2010

Free CE Credits Are Just a Click Away.

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

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STEPS-0262 OPE DentalAd_fl.indd 1 3/9/10 9:39 AM

636 Texas Dental Journal l www.tda.org l July 2010

ContentsTEXAS DENTAL JOURNAL n Established February 1883 n Vol. 127, Number 7, July 2010

ARTICLES

651 Current Development of Saliva/Oral Fluid-based Diagnostics Chih-Ko Yeh, Ph.D.; Nicolaos J. Christodoulides, Ph.D.; Pierre N. Floriano, Ph.D.; Craig S. Miller, D.M.D., M.S.; Jeffrey L. Ebersole, Ph.D.; Shannon E. Weigum, Ph.D.; John McDevitt, Ph.D.; Spencer W. Redding, D.D.S., M.S.E.D.

Researchers in Texas and Kentucky discuss the current consensus on developmentofsaliva/oralfluid-baseddiagnostics.

665 Weekly Monitoring of the Water Fluoride Content in a Fluoridated Metropolitan City — Results After 1 Year Ryan L. Quock,D.D.S. Jarvis T. Chan, D.D.S., Ph.D.

Theauthorsdiscussastudytodeterminetheextentoffluctuationofwater fluorideconcentrationinsamplesfromHouston,Texas,over1year.

677 Dental Unit Waterline Contamination — A Review Nuala Porteous, B.D.S., M.P.H.

The author discusses the positive responses from manufacturers of dental units to the American Dental Association’s and the Center for Disease Control and Prevention’schallengestodeliverpatienttreatmentwaterthatisatleastaspure asdrinkingwater.

ON THE COVERThecoverphoto,“LazyDayontheGuadalupe,”isarefreshingviewofsummerandwastakenbyMs.TessaKolodny,RDH,ofArlington.ItwonHonorableMentionintheSports/HumanEndeavorcategoryattheMay2010TEXASMeetingPhotoContestinSanAntonio.Ms.KolodnytookthephotoinJuly2009about5:00PMfromthetopofthemainbridgeinNewBraunfelsthatoverlookstheGuadalupeRiver.Ms.Kolodnyworksherwithhusband,CarterKolodny,DDS,attheirdentalpracticeinArlington.Formoreinformationonthe2011TEXASMeetingPhotoContest,pleasevisittexasmeeting.comorcalltheTDAcentraloffice,(512)443-3675.


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

aade

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 FEATURES640 President’s Message

644 The View From Austin

648 Guest Editorial

688 What’s on tda.org?

690 Value for Your Profession

694 In Memoriam / TDA Smiles Foundation

696 Calendar of Events

698 Oral and Maxillofacial Pathology Case of the Month

702 Dental Artifacts

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

707 Advertising Briefs

722 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.

638 Texas Dental Journal l www.tda.org l July 2010 Texas Dental Journal l www.tda.org l June 2010 557

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register on line at www.centerforard.com


“The Aesthetic Restorative Series at C.A.R.D. had the most effect on me and my practice than any other course I have taken in my 32years of practice.” RON BOSHER, D.D.S., GARLAND, TX “In my opinion, The Aesthetic Restorative Series is the best kept secret in continuingeducation. After taking these courses, my practice is a different place!” JERRY HERRINGTON, D.D.S., CONROE, TX “C.A.R.D. has provided forme an ‘extreme makeover’ for my attitude toward my profession of dentistry. Through five individual courses over the span of one year, I have come to realize what dentistry can provide in the way of contentment, prosperity and self respect. If you want to know what itmeans to be a true professional, Dr. Cutbirth can show you. He is there for dentists who want to be great, not just ok.” EDDIE PRUITT,D.D.S., HOUSTON, TX “It is rare in our profession to find a master technical dentist who also possesses exemplary skills in practice systems that lead to high profitability in a dental practice. Steve Cutbirth symbiotically blends both areas to allow each attendee of this seminar to vastly improve their level of success. I strongly recommend that dentists at all stages of their practice attend this seminar.” TOM MCDOUGAL, D.D.S., RICHARDSON, TX “Dr. Cutbirth’s series is a must for any dentist seeking a ‘top tier’ practice. His courses really helped ‘fill in the gaps’ when it comes to complex restorative cases, i.e., occlusion, changing vertical and facial pain. If you seek excellence, as Steve most certainly does, in the quality of your work and the way you run your office then I highly recommend this series.” MARK SIVLEY, D.D.S., ABILENE, TX “To take your dentistry to the next level, this is the clearest and most concise presentation of advanced aesthetic restorative studies that you’ll find! I am now, confidently and successfully, doing the dentistry that, just two years ago, I thought was relegated to ‘those guys’ on the lecture circuit.” DARREN DICKSON, D.D.S., PLANO, TX “In one word- TERRIFIC! What makes this series different: 1. The small class size encourages interaction. 2. Dr. Cutbirth’s straight forward approach and his willingness to share all his knowledge and experiences.” MICHEAL W. SCOTT, D.D.S., LUBBOCK, TX


Journal Ad Final 10 3/10/10 12:12 PM Page 1


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

This issue of the Texas Dental Journal has been inter-nally titled the Fluoride/Water Issue. Articles enclosed revisit two subjects long familiar to Texas dentist — fluoride in the water and from other sources and its effect on tooth enamel and contamination of the waterlines in dental units. The third subject, salivary diagnostics of systemic disease, is one of the newest and most exciting to emerge in dentistry.

Fluoridation of the water supply along with supple-ments in toothpaste and mouth rinses have markedly reduced tooth decay in treated municipalities in this country. Drs. Ryan Quock and Jarvis Chan examine the fluoride levels in a Texas city and finds variations that we all must consider in treating our patients. Patients could easily be under fluoridated and be underprotected from caries, or overfluoridated and potentially develp fluorosis.

Dr. Nuala Porteous reviews the dental unit waterline contamination issue and reports on the improvement in equipment to combat this problem. A challenge from the American Dental Association and guidelines issued by the Centers for Disease Control have influ-enced the dental equipment manufacturers to step up and provide dental units with the features needed to eliminate this problem.

Salivary diagnostics of systemic diseases is one of the most exciting developments in medicine and den-

tistry. The potential for early screening and diagnos-tics could indeed save countless lives with dentistry at the forefront of early detection and referral. The discovery of disease specific salivary biomarkers com-bined with nanotechnology allows for rapid, multiplex and miniaturized analytical assays. Dr Chih-Ko Yeh writes for us on current developments in this newest diagnostic modality.

***

As we celebrate the landmark events of the Texas summer — Memorial Day, Fathers Day, July 4th, and Labor Day — I hope that each of you took or take these opportunities for holiday recreation. After all, it is through recreation that we are restored and again can be the productive individuals and families that make Texas great.

Summer opportunities in Texas to sharpen our skills as dentists are many: The Lone Star Dental Conference, the Dentists Who Care Conference, and the El Paso Dental Conference just to name a few. Combined with a getaway, for example a visit to South Padre Island or Galveston or the Hill Country, the whole family can be recreated.

Just pick one of these great meetings, and I will see you there!


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contact human resources at: 214-342-5757 or send resume to: [email protected]

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The member side is for TDA member dentists and Texas dental students. It includes top stories and TDA news, an online job board, upcoming meetings and events, the online discussion group “Ask a Colleague,” online member dues, TDA publi-cations and references, component society web pages, personal web pages, a searchable member directory and contact information. Members can also update their personal contact information online.

The public side of TDA’s website is for patients and the public, non-member dentists and non-dentist dental professionals. It includes information about TDA, how to join TDA, general oral health information, resources for dental insurance, finan-cial help, charitable activities, careers in dental health, TDA contact information, and a “Find a Dentist” search function.

The Texas Dental Association’s ADA Golden Apple award-winning website is the official website of the Texas Dental Association.

Log in using your ADA # with dashes (123-45-6789) and TX + license number for your password, with TX in caps (TX1234)

The DENPAC website (denpac.org) offers general information about DENPAC, legislative, leadership, and contact informa-tion, news articles and membership information. Users can also sign up as DENPAC club member online.

The TDA Smiles website (tdasf.org / tdasmiles.org) includes program information on oral health education, Texas Mission of Mercy (TMOM), and Donated Dental Services (TXDDS). It also includes a calendar of upcoming events, history, and contact information. Users can also sign up for upcoming events and make contributions online.

The Freedom-of-Choice Dental Plan website (freedom-of-choicedental.com / paiddental.com) offers detailed informa-tion on Direct Reimbursement and Paid Dental.

The TDA Perks Program website (tdaperks.com / tdamemberbenefits.com) includes links to all TDA Member Benefits Endorsed Vendors, Board of Directors contact information, and additional helpful articles.

The TEXAS Meeting website (texasmeeting.com) allows users to register for courses and housing for the TEXAS Meeting, as well as access general information, education, travel, special events, exhibits, and governance information.

Contact: Stefanie Clegg (512) 443-3675 or [email protected]

Peer Review Sign Amalgam Fillings HIPAA and TMPA info How to Obtain an NPI Professional Recovery Network Medicaid CHIP Dental Recall - Firm Press ReleasesDental Student Info

ARCHIVESDr. John Findley Elected ADA President-electNew TDA Website!

UPDATE PROFILEChange your home or office address, phone, fax or e-mail.

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FEATURESCalendar of Events TDA Publications Member Discussion References Online Classifieds Job Placement Center In Memoriam

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To go to a specific page on an affiliate website, simply mouseover the website name and a menu will appear.

You can always get back to the homep-age, by clicking on “Home” under each menu.


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

Beginning with this July issue of the Journal, photographs from the photo contest held at the annual meeting of the Texas Dental Association will be pub-lished. One photograph will be printed on the cover of the July issue and other photographs will be printed in the pages of the Journal throughout the year. I have always found the displayed photos at the annual meeting to demonstrate the creativity and high photographic skills of our dental colleagues. The contest is judged by noted photographer Kevin Stillman who has more than 30 years experience as a professional photographer and is a graduate of the Art Institute of Pittsburg. He has served as aTexasHighways magazine photographer, worked as pho-tographer for the Texas Depart-ment of Transportation for 20 years, and, in 2002, received the Texas Department of Transporta-tion’s Lone Star Award for ser-vice to the Texas travel industry.

The winners of this years contest are listed to the right. Congratu-lations to all involved.

Best of ShowDr. Roy Tiemeyer

Portrait: People & Animals1st: Dr. Patrick E. Daniels2nd: Dr. Patrick E. Daniels

3rd: Ms. Leanna R. Sims-GowanHonorable Mention: Dr. Alex Gonzalez

Sports/Human Endeavor1st: Dr. Patrick E. Daniels

2nd: Dr. Alex Gonzalez3rd: Dr. C. Doug Foster

Honorable Mention: Ms. Tessa Kolodny, RDH

Built Environment1st: Dr. Steven M. Aycock

2nd: Ms. Leanna R. Sims-Gowan3rd: Dr. Mark Peppard

Honorable Mention: Dr. Edwin W. Roberts

Black & White/Abstract/Artistic1st: Leanna R. Sims-Gowan

2nd: Dr. Steven M. Aycock3rd: Dr. C. Doug Foster

Honorable Mention: Dr. Mark Peppard

Natural Wonders1st: Tessa Kolodny, RDH2nd: Dr. Steven M. Aycock

3rd: Dr. Roy TiemeyerHonorable Mention: Ms. Sarah ShootHonorable Mention: Juan D. Villareal

The View From Austin


Texas Dental Association 140th Annual Session2010 TEXAS Meeting Photo Contest Category: Sports/Human EndeavorAward: 2nd PlacePhotographer: Dr. Alex Gonzalez of El PasoTitle: “Backstroke Frenzy”

Forinformationonenteringyourphotointhe2011TEXASMeetingPhotoContest,pleasevisittexasmeeting.com.

Texas Dental Journal l www.tda.org l July 2010 647 Texas Dental Journal l May 2009 403

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Texas Dental Journal l February 2009 139 Texas DenTal Journal H January 2009 H 23

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Wealth and Happiness Never Seem to Add UpWayne Radwanski, D.D.S., President, Capital Area Dental Society (District 10), 2008-09ThisarticleisreprintedwithpermissionfromtheCapitalAreaDentalSociety.ItoriginallyappearedintheApril2009issueoftheStarnewsletter.

There’s a lot of evidence that we Americans are very much on a quest to be happier. Shortly before the current recession, an article in Fi-nancial Times titled “Why Happiness is Priceless” documented that Americans are both unhappier and richer than ever. This anxiety of affluence has prompted many sociological studies that document what we always knew — or thought we knew — that higher incomes do not translate automatically to increased happiness. In fact, something of the reverse seems to happen. The more we have, the unhappier we become. Now, the article is careful not to glamorize poverty. Rich people may be stressed and anxious, but not as much as the poor.

I remember happiness in a three bedroom home with one bath; with closets deep enough for clothes, but no deeper. And this was with a family of six kids! I suspect many of you too can remember happiness in a simpler time — a simpler place.

We have all paid a high price in stress, anxiety, family, and marital dysfunction for our affluence, and perhaps the most important task in front of us is to determine how it is to be maintained in the frantic, har-ried, and almost out-of-control work and lifestyle it has created without losing something precious about our humanity.

Randy Pausch, the professor and author from Carnegie Mellon, who authored TheLastLecture and recently died of pancreatic cancer, said it best, “It’s not the things we do in life we regret, it’s the things we don’t do.” He goes on to say, “You will not find your passion in money because the more things and the more money you have, the more you will use that as a metric, and there will always be someone with more money and things.”

If dentistry is our passion, then we will want to learn and grow more and more in its knowledge so we can serve others the very best we can. If you talk to those that have retired from the dental profession, they will most likely tell you, “those were the best years of my life.” Their wealth has been measured not by the dollars but by the love and service to those in need.

Serve on, my fellow dental professionals. It’s where we will find real wealth and happiness.

Guest Editorial


2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference

Air vs. electric handpieces for fixed prosthodontics

2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental Conference2010 Lone Star Dental ConferenceSeptember 9 - 11 • Austin, Texas

AT&T Executive Education Conference Center

Your FutureNEW ASPECTS OF DENTISTRY - 2010Presented by Dr. Gordon ChristensenOpen to the entire dental team7 hours lecture credit • AGD Code: 250This brand new, full-day program includes many of the new concepts in restorative dentistry compared to the long proven products and techniques. The morning session is a comparison of porcelain-fused-to metal restorations and the several competing types of all-ceramic crowns and fixed prostheses. The afternoon session is a multi-topic discussion and comparison of the many techniques and materials used in fixed prosthodontics.

Friday Course • September 10 • 8:00am - 4:00pm

Criteria for crowns vs. direct restorations in view of new •superior direct restorative materialsBuilding-up teeth rapidly and well•The best posts and cores compared•Air vs. electric handpieces for fixed prosthodontics•

Conventional and digital impressions. Which is best?•The best cements for specific situations•Many everyday dilemmas and solutions•And much more!•

Topics will include:

Air vs. electric handpieces for fixed prosthodontics

Saturday Workshops • September 11Stain & Glaze Made Easy

Presented by Dr. Todd Ehrlich

8:00 a.m.- 12:00 p.m.4 hours hands-on creditAGD Code: 610 & 780

Sponsored byIvoclar Vivadent Inc.

How to Use Digital Imaging to Improve Your

Case AcceptancePresented by

Dr. Mike Malone8:00 a.m. - 12:00 p.m.4 hours hands-on creditAGD Code: 130 & 730

Sponsored by PracticeWorks / Kodak Dental Systems

The Abused MouthPresented by

Presented byDr. Jerry Bouquot

8:00 a.m. - 12:00 p.m.4 hours hands-on creditAGD Code: 730 & 750

Sponsored by the Jack T. Clark Foundation

First Dental Home Training

Presented by Dr. Linda Altenhoff

9:00 a.m. - 11:00 a.m. 2 hours lecture credit

AGD Code: 430Provided by the Texas Department

of State Health Services

2010 LSDC EventsThursday • September 9 TAGD Leadership ReceptionAll LSDC attendees are invited to the Leadership Reception on Thursday night where we celebrate the achievements of our local state compo-nents as well as local leaders who have demonstrated their commit-ment to dental excellence through education. TAGD will also announce its second New Dentist of the Year recipient at this event. Attendance is complimentary, guests are welcome, just RSVP with the TAGD office.

Friday • September 10 Texas Dentist of the Year Gala™The 2010 Texas Dentist of the Year Gala™ celebrates dentists throughout the state who exhibit a commitment to continuing dental education, service to the community and activism in the dental profession. Nomi-nees are selected by their colleagues from dental societies and local components around the state. Tickets are $95. This is a formal, black tie event.

# 2193281/1/06 - 12/31/10

To register or for more information visit w w w.tagd.org or call the TAGD office at 512.244.0577 (toll-free 877.464.8243)

Space is limited in all courses so be sure to register today!


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Current Development of Saliva/Oral Fluid-based DiagnosticsChih-Ko Yeh, Ph.D.; Nicolaos J. Christodoulides, Ph.D.; Pierre N. Floriano, Ph.D.;

Craig S. Miller, D.M.D., M.S.; Jeffrey L. Ebersole, Ph.D.; Shannon E. Weigum, Ph.D.;

John McDevitt, Ph.D.; Spencer W. Redding, D.D.S., M.S.E.D.

AbstractSaliva can be easily obtained in medical and non-medical settings, and contains numerous bio-molecules, includ-ing those typically found in serum for disease detection and monitor-ing. In the past two decades, the achieve-ments of high-throughput approaches afforded by biotechnology and nanotechnology allow for disease-specific salivary biomarker discovery and establishment of rapid, multiplex, and miniatur-ized analytical assays. These developments have dramatically ad-vanced saliva-based diagnostics. In this review, we discuss the current consensus on development of saliva/oral fluid-based diagnos-tics and provide a sum-mary of recent research advancements of the Texas-Kentucky Saliva Diagnostics Consortium. In the foreseeable future, current research on saliva based diagnostic methods could revolu-tionize health care.

KEY WoRDS: Point of care, multiplexed test, biomarkers, salivary diagnostic, lab-on-a-chip, AMI, cancer. Tex Dent J;127(7):651-661.

Dr. Yeh is a professor and geriatric/research dentist, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio; Geriatric Research, Education and Clinical Center (GRECC), Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX.Dr. Christodoulides is a senior scientist, Department of Bioengineering, BioScience Research Collaborative.Dr. Floriano is a senior scientist, Department of Bioengineering, BioScience Research Collaborative; www.tastechip.com.Dr. Miller is a professor, Oral Medicine, University of Kentucky College of Dentistry, Lexington, KY; http://www.mc.uky.edu/microbiology/miller.asp.Dr. Ebersole is an Alvin L. Morris professor/director/associate dean for research, Center for Oral Health Re-search, University of Kentucky College of Dentistry, Lexington, KY.Dr. Weigum is a postdoctoral fellow, Department of Bioengineering, Rice University, BioScience Research Col-laborative, Houston, TX.Dr. McDevitt is a Brown-Wiess professor, Departments of Bioengineering & Chemistry, Rice University BioSci-ence Research Collaborative; http://www.tastechip.com.Dr. Redding is a professor and chair/Castella Dental Chair, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio, San Antonio, TX.

Address correspondence and reprint requests to Dr. Yeh, Geriatric Research, Education and Clinical Center (182), Audie L. Murphy Division, South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, Texas 78229-4404; Phone: (210) 617-5300, ext. 16684; Fax: (210) 617-5312.

Introduction Saliva, or oral fluid, has long been of interest as a substitute for blood and other body fluids for disease diagnosis and disease/drug monitoring because it is readily accessible, as it can be obtained non-invasive-ly. However, saliva diagnostics are not widely used due to the lack of well-defined salivary biomarkers for spe-cific diseases, appropriate technologies for low sample volume analysis, and social and medical professional acceptance (1, 2).

Yeh Christodoulides Floriano Miller

Ebersole Weigum McDevitt Redding

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To fully realize the potential of saliva as a diag-nostic fluid, the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) has recently invested in research efforts aimed at discovering and validat-ing salivary biomarkers of disease, as well as in the development of dedicated technologies for their measurement. In the past few years, these efforts have fostered interdisciplinary research projects that allow clinicians, biologists, chemists, physi-cists, engineers, and commercialization partners to collaborate, investigate, discover, and translate the potential of saliva to diagnose systemic disorders, such as neoplastic, cardiovascular, metabolic, in-fectious, and neurological diseases.

Based on the reported results of these initial efforts, it may be envisioned that in the foresee-able future, saliva-based diagnostic testing can become a component in routine medical practice in doctors’ offices and/or in the field for disease diagnosis, prevention, screening, and monitoring. Dental professionals who encounter saliva/oral fluid in their daily professional life are perceived as saliva experts in the medical field and can thus play an important role in the future of salivary diagnostics for dental and systemic diseases.

This brief review provides a description of sali-vary physiology and provides an update on cur-rent advances in salivary biomarker discovery and validation derived from the combined efforts of the Texas/Kentucky Saliva Diagnostic Con-sortium including the University of Texas Health Science Center at San Antonio, the University of Kentucky, and Rice University. Further, herein described is the development and application of a powerful point of care nano-bio-chip (NBC) technology that hosts saliva-based tests for the measurement of biomarkers for local and sys-temic diseases.

Saliva/oral fluid physiologyOral fluid is usually referred to as whole saliva that includes secretions from salivary glands, up-per gastrointestinal and respiratory tracks, and the gingival sulcus (crevicular fluid). Human sali-vary glands produce about 500-1000 mL of saliva per day by three distinct major salivary gland

pairs, i.e., parotid, submandibular and sublin-gual glands, and numerous minor salivary glands in oral palatal, buccal, and labial mucosa. Glan-dular, parotid, and submandibular/sublingual saliva can be collected non-invasively. Microscop-ically, a salivary gland secretory unit consists of acina and a ductal system. There are two types of acinar cells, i.e., serous and mucous, depending on protein produced. The ductal system consists of intercalated, striated, and excretory ducts. Salivary secretion is tightly controlled by the autonomic nervous system through a two stage secretion — primary saliva produced by acinar cells, followed by ductal system modification — resulting in a hypotonic solution when it reaches the mouth. Saliva is known to play essential roles in lubrication, digestion, and host defense since it contains electrolytes (e.g., Na+, K+, Cl-, Ca2+, HCO3

-, PO43-), digestive enzymes (e.g., amy-

lase, lipases, proteases and DNAse/RNAse, etc.), antimicrobial proteins (e.g., lysozyme, IgA, lac-toferin, defensin, peroxidase, histatins, etc.), and other major proteins (e.g., mucins, proline-rich proteins, statherin, etc.).

While salivary gland cells synthesize and secrete many salivary components, serum contents such as cytokines, antibodies, hormones, and drugs can also be transferred to saliva by passing through capillary walls in salivary gland tissues. These molecules travel though the basement membrane and salivary cell barriers to enter saliva involving possible mechanisms of passive transcellular diffusion, paracellular ultrafiltra-tion, energy dependent active transport, and/or pinocytosis (3-5). The relationship of salivary molecule concentration to blood (or saliva/plasma ratio; S/P) is influenced by serum/saliva pH, mo-lecular pKa, molecular weight, lipophilicity, and protein binding. Serum components can also be transported to whole saliva via gingival fluids or mucosal cells. Additionally, normal human whole saliva contains numerous normal and pathogenic microorganisms (e.g., bacteria, fungi, or viruses) and their metabolites, as well as multiple cell types shed or migrated from oral mucosa or gin-gival crevices. Therefore, saliva provides a large number of analytes that are comparable to blood for disease diagnosis and monitoring (Table 1).

Saliva/Oral Fluid-based Diagnostics

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Saliva/oral fluid as diagnostic fluid

Saliva provides biological materials, e.g., mammalian and microorganism pro-teins, DNAs, and cells for potential medical and law enforcement use. Dentists and oral biologists have utilized the culture counts of Streptococcus mutans and lactobacillus from sali-va to predict caries risk (6). It is well known that saliva samples have been used for forensic DNA testing. The development of salivary/oral fluid-based diagnos-tics has focused on testing hormones, drugs, and an-tibodies with some success in the past few decades. For example, commercial-ized saliva based testing systems have been used for detection of HIV antibodies with high specificity and sensitivity similar to blood testing (7). Antibodies to hepatitis B, C, and several other infectious pathogens (e.g., rubeola and dengue) can also be detected in saliva (8). Further direct detection of local or sys-temic infectious pathogens in saliva such as bacteria, viruses, and fungi is also possible by using salivary culture and/or polymerase chain reaction (PCR).

The salivary/oral fluid based home testing sys-tem of estradiol has been used to predict premature birth. Changes in salivary levels of estrogen, testos-terone, progesterone, and electrolytes have been used for monitoring or assessing

Potential Biomarkers

Electrolytes: Na+, K++, HCO3-, Ca2+, P04

3-

Proteins (Proteome) Salivary proteins Salivary serum components

Transcriptome mRNA and miRNA profiles

DNA: mammalian cells (epithelial and inflammatory cells and micro-organisms (e.g., bacteria, fungi, viruses)

Table 1.

Biomarker Discovery and Strategies for Saliva/oral Fluid Diagnostics

Strategies of Saliva Diagnostics

Multiplex: Multiple samples Multiple analyses

High sensitivity and specificity

Miniaturization: Portable Nanotechnologies: lab-on-a- chip (LOC)

Automated and self-powered Point of care (POC)

female reproductive cycles and overall health (3, 4). It is also well ac-cepted to assess a subject’s stress level by measuring salivary cortisol level in psychological studies (4, 9). The salivary steroid hormone levels are preferred by many investigators because hormones in saliva are in free form (active form) in contrast to in serum where most hormones are protein bound which complicates the estimation of true activity. Saliva has been widely studied as a medium for pharmacokinetic and thera-peutic drug monitoring (2, 3). The usefulness of saliva for drug monitor-ing is dependent on the saliva/plasma (S/P) ratio that has already been established for numerous drugs, a list which is continually expanding. In recent years, there has been vast interest from law enforcement agen-cies to develop oral fluid based point of detection methods for illegal drugs and/or legal intoxication limits, resulting in an international cooperative study for roadside testing (e.g., European Commission on Roadside testing assessment (Rosita)) (3, 10, 11). In this study, a large number of recreational and illicit drugs (e.g., amphetamine, opium, alcohol, lysergic acid diethylamide, marijuana, and phencyclidine, etc.) and their metabolites have been evaluated in saliva samples in compari-son to their serum counterparts. In addition, the various commercial oral testing prototypes for drug detection will be evaluated with labo-ratory validation. Salivary cotinine and thiocyanate contents are also commonly used for documenting tobacco use and second-hand smoke exposure. A summary of current and potential saliva/oral fluid diagnos-tics is listed in Table 2. The future application of saliva/oral fluid diag-nostics for medical use, epidemiological studies, and law enforcement is dependent on the availability of reliable point-of-care systems.

Current challenges and advances in salivary/oral fluid diagnosticsThe challenge for successful use of saliva for medical diagnostics re-sides in maximizing the advantages and overcoming the disadvantages of using saliva/oral fluids. Compared to serum samples, the volume of

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saliva that can be obtained is relatively limited and disease-specific salivary biomarkers are still largely unknown. However, saliva can be obtained by patients themselves or by personnel with little medical training. Furthermore, saliva col-lection is associated with less stress and discom-fort to the patient/donor. Therefore, saliva-based diagnostics can be applied in medically disadvantaged areas or non-conventional medical settings, such as in developing or under-developed countries, re-mote rural areas, patients’ homes, as well as in the dentist’s office or neighbor-hood pharmacy.

Recent studies have dem-onstrated improvement of sensitivity and specificity using a combination of multiple biomarkers in-stead of a single biomarker in disease detection (12, 13). Therefore, a successful saliva/oral based diagnos-tic should provide accu-rate, non-invasive, disease-specific, multi-analyte and rapid outcome measure-ments, as well as be por-table and cost-effective. Current efforts emphasize the discovery and valida-tion of disease biomarkers in saliva, the development of multiplexed nanotech-nologies (lab-on-a-chip) for point-of-care, and their ultimate translation into the real world through an industrial partner (Table 1).

Current existing assays with active development of new detection systems

Pharmacological monitoring (11)Therapeutic drugs Law enforcement applications Drug intoxication Illicit drugs ForensicsSmoking exposure Cotinine and thiocyanate Steroid hormones (4) Cortisol, estrogen, testosterone, and progesterone

Infectious diseases (35) Antibody testing: HIV, HCV and HBV Antigen detection: Bacterial, Viral, Fungal DNA/RNA/Protein Microorganism recovery: Bacterial, Viral, Fungal cultures

Table 2.

Current and Potential Use of Strategies for Saliva/oral Fluid Diagnostics

Potential use in near future

Autoimmune diseases (22, 23) Autoantibodies: Sjögren’s syndrome Allergic markers

Cardiovascular diseases (13) Acute myocardial infarction Cardiac risk

Cancer screening and diagnosis (19, 36-38) Oral cancer Breast cancer Cancer-specific markers

Periodontal diseases (20, 39)

Development of analytical technologies in the post genomic era has al-lowed for large scale identification of proteins/peptides (proteome) and ribonucleic acids (RNA; transcriptome), and their functions/structures in cells and fluids. The high throughput proteomic studies have cata-logued at least 1,166 proteins in the major salivary gland secretions, of which 914 are recovered from parotid and 917 from submandibular/sublingual ductal saliva, with 57 percent of these proteins present in both glandular saliva (14). The proteome of human minor salivary gland secretion showed 56 proteins, 12 of these proteins have never been indentified in the glandular saliva (15). Analysis of human whole saliva and plasma has identified a total of 1,939 proteins in whole saliva, with 740 proteins in glandular saliva proteomes and 597 saliva proteins in plasma (16). More surprisingly, the salivary transcriptome (RNAs) has been discovered using microarray profiling in recent years. It is estimated that approximately 3,000 messenger RNAs (mRNAs) have been identified in cell-free whole saliva. Most recently, the pres-ence of microRNA (miRNA; -50) was also discovered in whole saliva. Unlike mRNA, miRNA consists of 18-24 nucleotides transcribed from non-protein coding genes and regulates protein translation through an RNA-induced silencing complex (RIST) (17). These advances have provided a large number of salivary molecular targets, e.g., proteins and RNAs, for disease biomarker discovery. Several investigators have already attempted to use high throughput technologies and current salivary proteomic and transcriptomic knowledge for biomarker dis-


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covery in the areas of oral cancer, breast cancer, periodontal diseases, cardiovascular disease, and Sjögren’s syndrome (13, 17–23).

In the past few years, multiplex biomarker detec-tion systems have emerged through remarkable progress in the development of lab-on-a-chip (LOC) and point-of-care (POC) technologies (24). The goal of these efforts is to build automated, miniaturized, and multiplexed platforms for rapid assays and readout. In general, the principles of conventional enzyme-liked immunosorbent assay (ELISA) and/or nucleic acid hybridization are applied often with either electrochemical sensors or a microbead reactor (12, 13, 25). The electro-chemical approach uses gold electrode arrays (multiplex chips) in which one set of electrodes (i.e., working, counter, and reference electrodes) is used for one analyte measurement applied with the cyclic square wave electrical field to facilitate chemical reaction, followed by ampero-metric readout (12). The UCLA School of Den-tistry “UCLA Collaborative Oral Fluid Diagnostic

Research Center” is the leading institute for this nano/micro-electrical-mechanical development. Alternatively, the microbead reactor system developed by the Texas-Kentucky Saliva Diagnos-tic Consortium consists of porous bead sensors consisting of a nano-net of agarose fibers serving as a chemical reaction matrix sequestering and concentrating analytes. The beads are placed in a microchip holder with each bead serving as a 3-dimensional reactor. Multiple beads can be placed in the holder with modulation of their an-alyte specificity through the capturing antibody they are conjugated to, providing a multi-analyte testing platform. The reaction reagents are deliv-ered through a self-contained microfluidic infra-structure and the measurement is reported by nano-particle fluorescent particles or dyes that are conjugated to detecting antibodies. This ap-proach results in increased signal to noise ratios and amplification several orders above conven-tional assays (24) (Figure 1).

Figure 1. Microbead-based reactor systems: Agarose microbeads that serve as single enzyme-linked immunosorbent as-say (ELISA) reactor sensors (a) are arrayed in microchips (b) assembled into a disposable microfludic cassette that can be inserted into an analyzer (d) for automated assay execution and processing of image data acquired within this optical sensor (Modified from Jokerst et al. Nanomedicine, 2010 (24)).

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The Texas/Kentucky Saliva Diagnostics Consor-tium is in the forefront of developing 3-D bead saliva/oral fluid diagnostics for cardiovascular, cancer, and periodontal diseases (13, 26, 27). As compared to other systems, this approach is cost-effective and more flexible than any other LOC system reported in the literature. For ex-ample, the bead reactor can be replaced with a thin-polymeric membrane for analyzing cell isola-tion/trapping from saliva or serum or oral brush biopsy samples, e.g., oral cancer cell studies.

Current efforts to develop a saliva-based nano-biochip test for acute myocardial infarction (AMI) at the-point-of-care, particularly in the emergen-cy settings, and for cytological diagnosis of oral cancers are briefly described below.

oral fluid-based lab-on-a-chip testing for detection of acute myocardial infraction (AMI) in pre-hospital settings

Cardiovascular disease remains the leading cause of death in developed countries, includ-ing the United States. Coronary artery disease (CAD), a major component of cardiovascular diseases, caused one of every five deaths in the United States in 2004, while CAD mortality was at 451,326. In 2010, an estimated 785,000 Americans will have a new coronary attack, and about 470,000 will have a recurrent attack. It is estimated that an additional 195,000 silent first myocardial infarctions occur each year. Every 26 seconds, an American will have a coronary event, and about every minute someone will die from it (28). The survival of AMI is dependent on how soon intervention can be initiated. Early diagno-sis and early intervention is the key for a good patient prognosis.

Currently, electrocardiogram (EKG or ECG) is standard equipment in the emergency medical services (EMS) ambulance setting and is used as a diagnostic standard for emergency triage of patients with chest pain and/or unconscious-ness. A typical EKG abnormality for an AMI is a ST segment elevation (STEMI). Unfortunately,

EKG alone only identifies ~35 percent of all AMI cases admitted to the emergency department (ED) and misses the remaining 65 percent (NSTE-MI) that do not exhibit the characteristic EKG changes. The triage of potential AMI cases in the ED depends on supplemental blood testing that often includes cardiac troponins T and I (cTnT, cTnI), creatine kinases-MB (CK-MB), total CK and myoglobin (MYO) (13). However, these tests are, for the most part, limited to the clinical labora-tory setting and the few that have been developed for point of care testing lack the analytical and clinical sensitivity and specificity to efficiently diagnose AMI (29). Furthermore, the invasive nature of blood testing and the absence of a sen-sitive enough test on a point of care instrument that could perform such a test preclude use of a blood test in an ambulance setting. There is in-deed a need to have a non-invasive test with the required analytical and clinical performance that could be used in an ambulance setting to mini-mize the time from diagnosis to treatment of AMI patients. Saliva presents itself as an ideal fluid in this situation (Figure 2).

To achieve this goal, our collaborative research group has first evaluated the potential use of AMI biomarkers in saliva. Unstimulated whole saliva was collected within 48 hours from more than 80 patients with a definitive diagnosis of AMI and from more than 80 healthy controls. Samples were assayed for 21 cardiac related proteins using conventional methodologies, such as LUMINEX, ELISA and Beckman Access instru-mentation. Data gathered demonstrated cardiac biomarkers/proteins such as C-reactive protein (CRP), myeloperoxidase (MPO), interleukins, ma-trix metallo-perteinase-9 (MMP-9), and cellular adhesion molecule-1 (sICAM-1), can be detected in saliva samples but, most importantly, demon-strated a capacity to differentiate healthy controls from AMI patients. Strikingly, the logistic regres-sion and receiver operating characteristics (ROC) analysis shows that AMI diagnosis was greatly improved with combination of EKG and the AMI proteins in saliva (13). For example one model has shown that the area under the ROC curve (AUC) was improved from 0.75 to 0.94 if the EKG readout was combined with salivary markers CRP and MPO 13 (Figure 2).


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In parallel to discovering salivary AMI biomark-ers, the critical steps for salivary marker mea-surement using NBC technology include ambu-lance sample collection, temperature, humidity, reagent stability, mechanical disturbance of the instrument, compromised light source, and sample contamination are being developed and standardized. Here, the NBC-based sensor sys-tem is in development as a portable, modular device dedicated to saliva-based diagnosis of AMI (Figure 1) (24). In Figure 1, an example of a fluo-rescence micrograph of a LOC multiplex assay for salivary CRP, IL-1ß, MYO, and MPO in healthy control, NSTEMI, and STEMI patients is shown (13). The results demonstrate the increased ex-pression of AMI biomarkers in saliva from NSTE-MI and STEMI cardiac subjects as compared to a healthy control. This promising evidence suggests that saliva-based tests using the NBC system could provide a more convenient rapid screening method for initial and subsequent cardiac events in pre-hospital stage AMI patients.

Exfoliative cytology based on nano-bio-chip sensor platform for oral cancer detection Oral cancer is a global health problem afflicting more than 300,000 people worldwide each year. In the United States, greater than 35,000 new cases and nearly 7,600 deaths were estimated in 2009 (30). Despite surgical and therapeutic ad-vances in the treatment of oral cancer, the 5-year survival rate (approximately 50 percent remains among the lowest for all major cancers. At the present time, early diagnosis and intervention is the key for a better prognosis underscoring the value of advanced screening and diagnostic techniques for oral cancer and, more importantly, pre-cancerous lesions.

As compared to the conventional surgical bi-opsy procedure, an approach that is rapid and less invasive is desirable for early detection and screening. Recently, non-invasive exfoliative cytology using OralCDx® Brush Test (OralScan Laboratories, Suffern, NY) has been widely pro-moted for oral cancer screening. This technique is based on quantitative cytomorphometry and DNA aneuploidy with computer-assisted analysis (31). However, the limited specificity of current cytology-based analysis is still a major hindrance

for early oral cancer detection and intervention (32, 33). Since exfoliative cytology also gath-ers cellular DNA, RNA, and protein biomarkers, new diagnostic techniques targeting early tumor biomarkers and molecular transformation could enhance the role and utility of oral cytology in clinical diagnostics.

Addressing this clinical need, research groups at Rice and the University of Texas Health Sci-ence Centers at San Antonio and Houston have adapted the bead-based NBC sensor system to establish a platform for whole cell analysis of tumor biomarkers in oral exfoliative cytological specimens (34). The cellular-NBC sensor replaces the microbead array, found in the saliva-based NBC design, with a porous membrane that func-tions as a micro-sieve to capture and screen cells from a cytology suspension (Figure 3). Once captured, “on membrane” immunofluorescent assays reveal the presence and isotype of inter-rogated cells via automated microscopic imaging and analysis. This technique and its potential in oral diagnostics were recently described in a pilot study examining both molecular and morphologi-cal biomarkers associated with oral dysplasia and malignancy (34). Here, the oral epithelial cells (<10μm) were captured on a membrane filter (0.4μm pore size) followed by immunofluorescent labeling for the well-known epidermal growth fac-tor receptor (EGFR) biomarker. Concurrently, the cytoplasm and nuclei were stained with fluores-cent dyes Phalloidin and DAPI, respectively, for cytomorphometric measurements (Figure 3). The nuclear area, nuclear diameter, N/C ratio, and EGFR expression were found to be significantly altered in malignant and dysplastic oral lesions as compared to normal control epithelial cells. Logistic regression and ROC curve analysis fur-ther identified the morphological features as the best predictors of disease individually, AUC ≤ 0.93 (97-100 percent sensitivity and 86 percent speci-ficity), while a combination of morphometric and EGFR biomarker expression further enhanced discrimination power between cancerous/precan-cerous and healthy conditions to an AUC 0.94 (97 percent sensitivity and 93 percent specificity; Figure 3). These results suggest that the com-bined cytomorphometry and EGFR panel likely holds the greatest potential for cancer detection and diagnosis. Yet, the true diagnostic need lies not in the identification of oral cancer but in the identification of dysplastic, premalignant lesions.

TDJ July 2010.indd 657 7/6/10 3:36 PM


An 850-patient clinical study targeting oral dysplasia using an expanded biomarker panel is currently underway and aims to further validate the clinical utility of the NBC system for early detection of high-risk premalignant oral lesions. With continued advances in cancer biomarker discovery and sensor technology, rapid and POC screening for cancer is likely achievable.


Conclusion

Saliva and oral fluids contain multiple biomarker materials that can be readily obtained in conven-tional and non-conventional medical or medical laboratory settings. With current advancements in the development of nano-bio-technology, saliva is now closer to meet its full capability to be used as a diagnostic fluid at the point of care. While oral fluid/saliva-based diagnosis of AMI is

Figure 2 Saliva AMI testing in ambulance: (a) 12 lead EKG used by paramedics to transmit initial findings to emergency room physicians (left). The portable saliva-based diagnostics NBC platform can complement EKG for the identification of AMI cases. (b) Logistic regression and ROC analysis using serum and salivary biomarkers in conjunction with EKG exhibited improvement of diagnosis of AMI. The EKG and AMI biomarkers of 42 healthy controls, 46 AMI (23 NSTEMI and 23 STEMI) are measured and compared. In serum, the ROC curve was improved from 0.81 to 0.92 in triage biomarkers (cTnI, myoglobin and CK-MB) were used as diagnostic indexes (left). However, the combined use of salivary CRP and MPO in conjunction with EKG (right), produced an excellent ROC 0.94 (i.e., >90 percent specificity and sensitivity of AMI diagnosis). (c) Multiplex lab-on-a-chip (LOC) for AMI biomarker antigens screening. Examples of fluorescence micrographs of a LOC multiplex assay for CRP, IL-1ß, MYO and MPO are shown for non-AMI control, (d) NSTEMI and (e) STEMI patients. NEG, negative; CAL, calibrator (Modified from Floriano et al. Clin Chem, 2009 40).

TDJ July 2010.indd 658 7/6/10 3:36 PM


demonstrated, use of a saliva-based test is not intended to replace current serum based diagno-sis, but simply to complement it. Current major challenges are discovery of disease specific mark-ers, determinations of specificity and sensitivity of the specific tests, and standardization of saliva collection methods and holding solutions. Once these challenges are met, saliva-based diagnos-tics can be validated within the context of large clinical studies en route to final approval by the Food and Drug Administration (FDA) for ultimate clinical/field application. While still several years away from achieving this goal, practicing den-tists, as a part of the health care team, should be kept updated about developments in the field of saliva/oral fluid diagnostics for oral and systemic diseases.

Acknowledgements

This review was supported by NIDCR/NIH U01 DE017793 grant which funded the program entitled “Development of a Lab-on-a-chip System for Saliva-Based Diagnostics.” References1. Tabak LA. A revolution in biomedical assess-

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Figure 3. Application of the cell-based NBC sensor system for cyto-logical assessment of healthy and cancerous oral mucosa. (a) Exfo-liative cytology speci-mens were obtained using the OralCDx® cytobrush (http://www.sopreventable.com/How2Use.htm); (b) Next, cells were cap-tured on the membrane filter (panel i) followed by EGFR immunolabel-ing (panel ii, green) and staining of the cell cyto-plasm (red) and nuclei (blue) for morphometric measurement; (c) Rep-resentative images of healthy epithelia (panel i) and a cancerous le-sion (panel ii) examined using the NBC sensor illustrate the increase in EGFR expression and nuclear-to-cytoplasm ratio associated with disease progression; and (d) Logistic regres-sion and ROC analy-sis of individual and combined biomarkers (adapted from Weigum et al. Cancer Detect. Prevent, 2010 34).

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7. Roberts KJ, Grusky O, Swanson AN. Outcomes of blood and oral fluid rapid HIV testing: a literature review, 2000-2006. AIDS Patient Care STDS 2007; 21(9):621-637.

8. Lima DP, Diniz DG, Moimaz SA, Sumida DH, Okamoto AC. Saliva: reflection of the body. Int J Infect Dis 2009.

9. Vreeburg SA, Hoogendijk WJ, van PJ et al. Major depressive disorder and hypothalamic-pituitary-ad-renal axis activity: results from a large cohort study. Arch Gen Psychiatry 2009; 66(6):617-626.

10. Samyn N, Laloup M, De BG. Bioanalytical proce-dures for determination of drugs of abuse in oral fluid. Anal Bioanal Chem 2007; 388(7):1437-1453.

11. Lillsunde P. Analytical tech-niques for drug detection in oral fluid. Ther Drug Monit 2008; 30(2):181-187.

12. Wei F, Patel P, Liao W et al. Electrochemical sensor for multiplex biomarkers detec-tion. Clin Cancer Res 2009; 15(13):4446-4452.

13. Floriano PN, Christo-doulides N, Miller CS et al. Use of saliva-based nano-biochip tests for acute myocardial infarction at


the point of care: a feasibil-ity study. Clin Chem 2009; 55(8):1530-1538.

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15. Siqueira WL, Salih E, Wan DL, Helmerhorst EJ, Op-penheim FG. Proteome of human minor salivary gland secretion. J Dent Res 2008; 87(5):445-450.

16. Sun X, Salih E, Oppenheim FG, Helmerhorst EJ. Ac-tivity-based mass spectro-metric characterization of proteases and inhibitors in human saliva. Proteomics Clin Appl 2009; 3(7):810-820.

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19. Streckfus CF, Storthz KA, Bigler L, Dubinsky WP. A Comparison of the Pro-teomic Expression in Pooled Saliva Specimens from Individuals Diagnosed with Ductal Carcinoma of the Breast with and without Lymph Node Involvement. J Oncol 2009; 2009: Article ID 737619. http://www.ncbi.nlm.nih.gov.libproxy.uthscsa.edu/pmc/articles/PMC2801014/pdf/JO2009-737619.pdf

20. Giannobile WV, Beikler T, Kinney JS et al. Saliva as a diagnostic tool for peri-odontal disease: current state and future directions. Periodontol 2000 2009; 50:52-64.

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23. Ryu OH, Atkinson JC, Hoehn GT, Illei GG, Hart TC. Identification of pa-rotid salivary biomarkers in Sjogren’s syndrome by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry and two-dimensional dif-ference gel electrophoresis. Rheumatology (Oxford) 2006; 45(9):1077-1086.

24. Jokerst JV, McDevitt JT. Programmable nano-bio-chips: multifunctional clinical tools for use at the point-of-care. Nanomed 2010; 5(1):143-155.

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26. Jokerst JV, Raamanathan A, Christodoulides N et al. Nano-bio-chips for high per-formance multiplexed pro-

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tein detection: determina-tions of cancer biomarkers in serum and saliva using quantum dot bioconjugate labels. Biosens Bioelectron 2009; 24(12):3622-3629.


28. Lloyd-Jones D, Adams RJ, Brown TM et al. Heart Disease and Stroke Statis-tics--2010 Update. A Report From the American Heart Association. Circulation 2009.

29. Fermann GJ, Suyama J. Point of care testing in the emergency depart-ment. J Emerg Med 2002; 22(4):393-404.

30. American Cancer Society. Cancer Facts and Figures 2009. 2009. American Cancer Society.

31. Sciubba JJ. Improving detection of precancerous and cancerous oral lesions. Computer-assisted analysis of the oral brush biopsy. U.S. Collaborative OralCDx Study Group. J Am Dent Assoc 1999; 130(10):1445-1457.

32. Poate TW, Buchanan JA, Hodgson TA et al. An audit of the efficacy of the oral brush biopsy technique in a specialist Oral Medicine unit. Oral Oncol 2004; 40(8):829-834.

33. Scheifele C, Schmidt-Westhausen AM, Dietrich T, Reichart PA. The sensi-tivity and specificity of the OralCDx technique: evalu-ation of 103 cases. Oral Oncol 2004; 40(8):824-828.

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bio-chip sensor platform for examination of oral exfolia-tive cytology. Cancer Detect Prevent 2010; 3(4):518-528.

35. Malamud D, Abrams WR, Bau H et al. Oral-based techniques for the diagno-sis of infectious diseases. J Calif Dent Assoc 2006; 34(4):297-301.

36. Hu S, Arellano M, Boon-theung P et al. Salivary proteomics for oral can-cer biomarker discovery. Clin Cancer Res 2008; 14(19):6246-6252.

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40. Floriano PN, Christo-doulides N, Miller CS et al. Use of saliva-based nano-biochip tests for acute myocardial infarction at the point of care: a feasibil-ity study. Clin Chem 2009; 55(8):1530-1538.

TDJ July 2010.indd 661 7/6/10 3:36 PM


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Weekly Monitoring of the Water Fluoride Content in a Fluoridated Metropolitan City — Results After 1 YearRyan L. Quock, D.D.S., Jarvis T. Chan, D.D.S., Ph.D.

AbstractIt continues to be the goal of the United States Depart-ment of Health and Hu-man Services to fl uoridate community water supplies to prevent dental caries. In Houston, Texas, where com-munity water is assumed to contain in the range of 0.7-1.2 ppm fl uoride, water samples were taken from the same source on approxi-mately a weekly basis over a period of 52 weeks. The purpose of this study was to determine the extent of fl uc-tuation of water fl uoride con-centration in these samples. Water fl uoride analysis with an ion-specifi c electrode and millivolt meter of the data set showed a range of 0.33 to 1.00 ppm fl uoride, with a mean of 0.70 ppm and a standard deviation of 0.15. This wide range of fl uoride concentrations may create a risk for fl uorosis in pediatric patients who are prescribed dietary fl uoride supplements.

KEY WORDS: Community drinking water, fl uoride supplements, fl uorosis, tap water

Tex Dent J;127(7):665-671.

Dr. Quock is an assistant professor, Department of Restorative Dentistry & Biomaterials, University of Texas at Houston Dental BranchDr. Chan is a professor, Department of Integrative Biology & Pharmacology, University of Texas at Houston Medical School; and adjunct professor, Department of Pediatric Dentistry, University of Texas at Houston Dental BranchAddress 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

The fl uoridation of community drinking water rais-

es many questions and continues to be a source of

controversy (1, 2). In the United States, the Cen-

ters for Disease Control and Prevention (CDC) is a

strong proponent of drinking water fl uoridation for

the prevention of dental caries (3). Furthermore,

it has been a stated goal of the United States De-

partment of Health and Human Services that by

the year 2010, 75 percent of the United States

population would have access to fl uoridated drink-

ing water, with fl uoride concentrations falling in

the range of 0.7-1.2 parts per million (ppm) (4, 5).

QuockChanQuockChan


Following this trend at the federal level, states

like Louisiana and cities like San Diego have re-

cently taken action to fluoridate their respective

public water supplies (6, 7).

A primary health risk of consumption of fluoride is dental fluorosis. Dental fluorosis is a disruption of enamel formation whose manifestation can range from white spots or streaks to brown pits and stains (8, 9). Fluorosis related to the consump-tion of drinking water with high levels of fluoride has been well documented in the literature (10, 11, 12).

Recently, a study of drinking water samples collected over a 10-year period from various zip codes in the Houston metro-politan found a wide variance in water fluoride concentration, even within the same zip code area (13). Considering the pro-posed dental caries preventive purpose of water fluoridation, as well as the evident risk for fluorosis, it would be beneficial to further examine the relative consistency of fluoride concen-tration in community drinking water sources. The purpose of this study was to look for trends in the fluoride content of tap water from a common source in Houston over a 1-year period of time, with the hypothesis that the study’s findings would be comparable to those reported by the Houston’s Department of Public Works & Engineering for the calendar year 2008 — av-erage water fluoride concentrations of 0.54 ppm with a maxi-mum concentration of 0.74 ppm (14).

During the period between July 17, 2008, and July 7, 2009, a 10 mL sample of tap water was taken from the same source in U.S. postal zip code 77030 at a frequency of once per week. The tap was allowed to run for 5 minutes before each water sample was collected in a Falcon 15 mL polystyrene coni-cal tube (Becton Dickinson, Franklin Lakes, NJ). After each sample was collected, the conical collection tube was sealed with the accompanying cap and stored at room tempera-ture. Upon collection of the entire set of samples, any water that had evaporated over the course of the year was replaced with deionized and distilled water. An Orion fluoride-specific electrode and millivolt meter (Orion model 701A and 720A+, Thermo Orion, Beverly, MA) was used for water fluoride analy-sis. Water samples were thoroughly mixed in a 1:1 ratio with total ionic strength adjustment buffer (TISAB) II, in accordance with manufacturer instructions prior to measurement for fluo-

Materialsand Methods


ride. After fluoride concentrations for all samples were determined, the following analyses of the data set were performed: mean fluoride concentration, standard deviation, 95 percent confidence interval, and median fluoride concentration.

Tap Water Fluoride Measurements(Samples Collected July 17, 2008 - July 7, 2009)

Week Date of Measured Date of Measured Collection ppm Week Collection ppm

1 7/17/08 0.84 27 1/13/09 0.64 2 7/24/08 0.85 28 1/22/09 0.70 3 7/31/08 0.93 29 1/28/09 0.33 4 8/7/08 0.94 30 2/4/09 0.53 5 8/14/08 0.93 31 2/11/09 1.00 6 8/21/08 0.93 32 2/18/09 0.45 7 8/28/08 0.87 33 2/25/09 0.85 8 9/4/08 0.87 34 3/4/09 0.76 9 9/11/08 0.86 35 3/11/09 0.56 10 9/18/08 * 36 3/19/09 0.60 11 9/25/08 0.39 37 3/25/09 0.64 12 10/2/08 0.48 38 4/1/09 0.62 13 10/9/08 0.70 39 4/8/09 0.56 14 10/16/08 0.86 40 4/15/09 0.60 15 10/23/08 0.81 41 4/22/09 0.66 16 10/28/08 0.80 42 4/29/09 0.65 17 11/6/08 0.61 43 5/6/09 0.52 18 11/13/08 0.56 44 5/13/09 0.61 19 11/20/08 0.61 45 5/20/09 0.63 20 11/26/08 0.58 46 5/28/09 0.73 21 12/4/08 0.73 47 6/4/09 0.62 22 12/11/08 0.75 48 6/10/09 0.68 23 12/18/08 0.72 49 6/18/09 0.71 24 12/23/08 0.73 50 6/25/09 0.68 25 12/31/08 * 51 7/2/09 0.67 26 1/7/09 0.68 52 7/7/09 0.68

*Sample not collected. Mean = 0.70, SD = 0.15

Fifty water samples were analyzed for fluoride concentration in this study. Fluo-ride concentrations ranged from 0.33 to 1.00 ppm for the data set (Table). Mean fluoride concentration for 50 water samples was 0.70 ppm (95 percent CI = 0.41 to 0.98 ppm). Median fluoride concentration for the data set was 0.68 ppm.

Results


The United States Environmental Pro-tection Agency (EPA) has designated the range of 0.7-1.2 ppm as the optimal level of fluoride concentration in drink-ing water for the prevention of dental caries (5). Additionally, the EPA has set 2.0 ppm as a suggested maximum water fluoride concentration, and 4.0 ppm is the enforceable maximum water fluo-ride concentration (15,16). Twenty-seven out of 50 samples (54 percent) in this study had water fluoride concentrations lower than 0.7 ppm, and no samples had fluoride concentrations greater than 1.2 ppm. However, the mean water fluoride concentration for this study approximat-ed the U.S. government recommended concentration for the Houston area (0.70 ppm), with a maximum recorded fluoride concentration of 1.0 ppm (17). These figures are higher than those reported by the City of Houston for the calendar year 2008 (14).

Figure 1. Chart of Tap Water Fluoride Measurements (Samples Collected July 17, 2008 - July 7, 2009)

Water Fluoride Content

DiscussionAlthough risk for fluorosis may be minimal with regard to consumption of tap water measured in this study, the range of fluoride concentrations does exhibit regular fluctuation in water fluoride concentration (Figure 1). Flu-oride concentrations varied from the target concentration of 0.70 ppm by as much as 52.9 percent on the lower end (0.33 ppm) and by as much as 42.9 percent (1.00 ppm) on the upper end of the range. Furthermore, four out of 50 samples deviated from the target concentration of 0.70 ppm by at least 30 percent on the lower end (≤0.49 ppm), and five out 50 samples deviated from the target concentration of 0.70 ppm by at least 30 percent at the up-per end (≥0.91 ppm). Thus, 18 percent of the samples in the study deviated from the target fluoride concentrations by at least ± 30 percent. Even though the mean fluoride concentration for


samples in this study approxi-mated the target concentration as established by the U.S De-partment of Health and Human Resources, it might be desir-able to reduce the occurrence and magnitude of fluctuation from this target fluoride con-centration.

The wide range of fluoride concentrations observed in this study may also indicate a pos-sible fluoride over-consumption risk. Ten out of the 50 water samples from this study had fluoride concentrations under 0.60 ppm. The American Den-tal Association, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics recommend dietary fluoride supplements for pe-diatric patients, depending on patient age and fluoride con-centration of the patient’s com-munity drinking water (Figure 2). The major water fluoride concentration thresholds for these recommendations are 0.3 and 0.6 ppm; if the patient’s community drinking water is above 0.6 ppm fluoride, then no

Fluoride ion level in drinking water (ppm)*

Age less than 0.3 ppm 0.3 - 0.6 ppm greater than 0.6 ppm

Birth - 6 months None None None

6 months - 3 years 0.25 mg/day** None None

3 - 6 years 0.50 mg/day 0.25 mg/day None

6 - 16 years 1.0 mg/day 0.50 mg/day None

* 1 part per million (ppm) = 1 milligram/liter (mg/L) ** 2.2 mg sodium fluoride contains 1 mg fluoride ion.

Approved by the American Dental Association, the American Academy of Pediatrics, and the American Academy of Pediatric Dentistry.

Figure 2. Dietary Fluoride Supplement Schedule (18, 19, 20)

supplementation is prescribed (18, 19, 20). Patient’s drinking water fluoride concentration is determined by requesting a tap water sample from the patient and then sending it to a laboratory for analysis. If tap water fluoride concentration remained the same over time, then this might be an accept-able way to determine whether dietary fluoride supplementa-tion is warranted, according

to the guidelines. However, the data from this study sug-gests that if the patient’s water sample is taken on a day when the fluoride concentration hap-pens to be under 0.6 ppm, fluo-ride supplementation may be unnecessarily prescribed. The mean water fluoride concen-tration for the entire data set was 0.70 ppm, suggesting that a patient drinking water from this source may derive, on av-

The wide range of fluoride concentrations observed in this study may also indicate a possible fluoride over-consumption risk.


erage, an acceptable amount of fluoride from the tap water alone. At the same time, 20 percent of the collected samples had fluoride concentrations below 0.60 ppm, which could potentially result in an unnecessary prescription of additional fluo-ride, increasing the patient’s risk for fluorosis, among other effects. The authors recommend that, in order to minimize risk for fluorosis, prac-titioners following these fluoride supplementation guidelines analyze multiple water samples taken on different dates before making any fluoride supplementation decisions. Indeed, the supple-mentation of dietary fluoride for pediatric pa-tients is a practice that may need to be examined more critically (21). It is the authors’ intent to present these findings to the local water author-ity, especially with regard to possible discrepan-cies between data collected by this study and by the city. Hopefully appropriate improvements could be identified to stabilize the fluoride level of the drinking water.

To conclude, the water samples taken on a weekly basis for approximately a year in this study had a mean fluoride concentration of 0.70 ppm and a maximum concentration of 1.00 ppm; these values were higher than those reported by the City of Houston for the calendar year of 2008 — mean fluoride concentration of 0.54 ppm and maximum concentration of 0.74 ppm (14). There are a few limitations to this comparison. Al-though this study examined water samples taken on an approximately weekly basis, to the authors’ knowledge, there are no such weekly records available from the City of Houston for direct comparison. Also, for this study water samples were collected from July 17, 2008, and July 7, 2009, thus including data from two calendar years. City of Houston annual reports are published based on the calendar year, so the 2008 data from the City of Houston does not account for the entire time span of this study. It may be beneficial in the future to examine water samples taken during one calendar year, so that a more direct comparison can be made to City of Houston statistics. Finally, City of Houston annual water quality reports are orga-nized with regard to source of water and not specifically by zip code. The majority of the geographical area served by the City of Houston utilizes the surface water main system; isolated ground water sources supply other areas. Thus, the zip code of the water

Water Fluoride Content

…in order to minimize risk for fluorosis, practitioners following these fluoride supplementationguidelines analyze multiple water samples taken on different dates before making any fluoride supplementation decisions.


samples in this study, 77030, was one of many included in the surface water main system category — only one average fluoride level and maximum level was given for this catego-ry. To the authors’ knowledge, there is no publicly available data on fluoride concentrations in Houston water supplies or-ganized by zip code.

ACKNOWLEDGEMENTThe authors would like to thank Cathy Quock, M.A., for her assistance in the prepara-tion of this manuscript.

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11. Srikanth R, Chandra TR, Kumar BR. Endemic Fluorosis in Five Villages of the Palamau District, Jharkhand, India. Fluoride 2008;41(3)206-211.

12. Akosu TJ, Zoakah AI. Risk factors associated with dental fluorosis in Central Plateau State, Nigeria. Com-

munity Dent Oral Epidemiol. 2008 Apr;36(2):144-8.

13. Quock RL, Chan JT. Wa-ter fluoride concentrations in and around the Greater Houston metropolitan area. Tex Dent J 2009 Feb;126(2):146-149.

14. City of Houston Depart-ment of Public Works and Engineering. Water Quality Report 2008.

15. US Environmental Protec-tion Agency. 40 CFR Part 141.62. Maximum con-taminant levels for inor-ganic contaminants. Code of Federal Regulations 1998:402.

16. US Environmental Protec-tion Agency. 40 CFR Part 143. National secondary drinking water regulations. Code of Federal Regulations 1998;514-7.

17. US Department of Health and Human Services. Wa-ter fluoridation: a manual for engineers and techni-cians. 1986:19.

18. Meskin LH, ed. Caries diagnosis and risk assess-ment: a review of preven-tive strategies and manage-ment. J Am Dent Assoc 1995;126(suppl):1S-24S.

19. American Academy of Pe-diatric Dentistry. Special issue: reference manual 1994-95. Pediatr Dent 1995;16(special issue):1-96.

20. American Academy of Pedi-atrics Committee on Nutri-tion. Fluoride supplemen-tation for children: interim policy recommendations. Pediatrics 1995;95:777.

21. Ismail AI, Hassan H. Fluoride supplements, dental caries and fluoro-sis: a systematic review. J Am Dent Assoc 2008 Nov;139(11):1457-68.


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AbstractManufacturers of dental units have responded positively to the challenge from the American Dental Association (ADA) and the subsequent guidelines is-sued by the Centers for Disease Control and Prevention (CDC) to deliver patient treatment water that is at least as pure as drink-ing water. Dental units are now routinely manufactured with anti-retraction devices that are designed to control oral fl uids from being aspirated into the lines during treatment and many units have water systems that isolate source water from mu-nicipal water supply. The dental industry has also produced an array of devices and cleaning/disinfectant products to further facilitate the use of clean patient treatment water. Products that claim disinfectant effi cacy must be registered with the Environ-mental Protection Agency (EPA). If they are not EPA-registered, they can be labeled as waterline cleaners only. Waterline treat-ment devices that are sold sepa-rately and require connection to dental units must be registered with the Food and Drug Adminis-tration (FDA) as medical devices. Patient treatment water quality can be monitored by using in-offi ce chairside kits or through commercial laboratory services..

KEY WORDS: Dental unit waterline contamina-tion, biofi lm, dental unit waterline treatment products cessation

Tex Dent J;127(7):677-685.

Dental Unit Waterline Contamination —A ReviewNuala Porteous, B.D.S., M.P.H.

Dr. Porteous is an associate professor, Department of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio Dental School; Phone: (210) 567-6334; Fax: (210) 567-6348; E-mail: [email protected].

Porteous

A Historical Perspective

Contamination of patient treatment water and its

reduction with chlorhexidene was fi rst described

in the British Dental Journal over 40 years ago (1).

Ten years later, it was reported that bacterial lev-

els in water emitted from highspeed handpieces,

air/water syringes, and ultrasonic lines were as

high as 2-3 million colony forming units per mil-

liliter (CFU/mL) (2). Although the American Den-

tal Association (ADA) issued a recommendation in

1978 that dental unit waterlines (DUWL) should

be fl ushed with chemical germicides, they de-

ferred to dental unit manufacturers on treatment

methods at that time (3). National guidelines and

recommendations were subsequently developed in

the 1990’s and later revised, as illustrated in the

following timeline (4-9).

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Contamination of dental patient treatment water is caused by the presence of biofilms on the inner sur-faces of DUWL, feeding a continuous source of bac-teria to the water flowing through the lines (Figure 1). A biofilm may be defined as “bacterial populations adher-ent to each other and/or to surfaces or interfaces” (10). Biofilm bacteria predomi-nate in all nutrient-sufficient ecosystems. They differ from free-floating (planktonic) mi-crobes because adhesion to a surface triggers the produc-tion of an exopolysaccharide (slime layer) that encases and protects them. A mature biofilm consists of an efficient bacterial community with enhanced tolerance to disin-

CDC recommended infection-control practices for dentistry–1993. MMWR 1993;42(No. RR-8).

• Installation of and maintenance of anti-retraction valves to limit retraction of contaminated fluid• Flushing lines between patients and beginning of

each day• Use of sterile irrigants for surgical procedures

CDC guidelines for infection control in dental health-care settings–2003. MMWR 2003;52(No. RR 17).

“Use water that meets EPA regulatory standards for drinking water (<500 CFU/mL) for routine dental treatment water output.”

ADA statement on DUWL:

• Industry and profession challenged to deliver patient treatment water <200 CFU/mL by Y2000.

ADA updated statement:

http://www.ada.org/1856.aspx

1996 2004

1993 2003

Figure 1. BiofilmmassoninteriorsurfaceofDUWLtubingafter8weeksofuse.

Source of the problem

Dental Unit Waterline Contamination


fectants, causing a significant challenge for its elimination (10). DUWL tubing is usually composed of polyurethane or polyvinyl that is 1/16” or 2 mm in diameter, providing a surface area to volume ratio of approximately 6:1 (Figure 2). Flow rates in a dental unit are typically 60-100mL/min and occur intermittently through-out the day, allowing periods of water stagnation. Further, some water delivery lines, such as the ultrasonic line may be idle for days at a time, am-plifying the contamination. The physical properties of the tubing, along with the fact that chemical additives in DUWL tubing can be an additional source of nutrition, provide an ideal, sometimes undisturbed environment for DUWL biofilm formation (11).

Types of flora recovered from DUWLOrganisms are mainly derived from source water, comprised of heterotrophic (use organic carbon from another source), mesophilic (grow in moderate temperature) bacteria, predom-inantly gram-negative (gram -ve) species. These are gener-ally termed heterotrophic plate count (HPC) bacteria. Oppor-tunistic pathogens, such as Pseudomonas species that can grow readily in distilled water and in dilute disinfectants, e.g., chlorhexidene and iodophors; non-tuberculosis mycobacteria (NTM) that are present any-where from 1-50 percent in the municipal water supply, de-pending on geographic location;

Figure 2. A.DUWLtubing1/16”diameter,cutsurfaceblackened.B.Tubingsec-tionedtoexposenarrowlumen(blackened).

and Legionnella (causative organism of Legionnaire’s disease and the milder Pontiac fever) species have all been isolated from DUWL (12-15). Fungi have also been found and even in air samples in dental offices, and studies have shown that levels decrease after disinfection of waterlines (16, 17). Oral organisms that enter the dental water system during patient treatment such as Streptococci and Porphyromonas gingivalis have also been isolated from DUWL (18, 19).

Who is at risk?HPC bacteria are found ubiquitously in all water systems and their level is used as a gauge of how well a water system is maintained (8). There is no correlation between the presence of controlled numbers of HPC bacteria in drinking water and human disease, as long as the entry water is biologically safe (20). Microbes of concern are the aforementioned opportunistic pathogens that are commonly isolated from stagnant water sources where biofilms proliferate. They are a known cause of disseminated disease and wound infections in immunocompromised patients and can also colonize respiratory tracts in healthy individuals without caus-ing disease (21-24). In 1974, dental personnel were reported to have nasal Pseudomonas species corresponding to DUWL biofilm load, with the all the affected dentists reporting rhinitis, but con-founding variables such as immune status and hypersensitivity were not reported (25). In the 1980’s, Martin et al. published a case report of medically compromised dental patients, who were infected with Pseudomonas aeruginosa that originated in DUWL.


A follow-up report concluded that the organisms were not a cause for concern in healthy individuals, as organisms could not be detected in the healthy patients 5 weeks after treat-ment with affected water, in spite of initial colonization (26). Other studies have shown a high prevalence of Legionnella seropositivity in dental person-nel compared to non-dental workers, but no correlation with disease among personnel (27-29).

In the medical literature, sev-eral studies have reported a significant association between the presence and severity of asthma and raised concentra-tion of airborne gram -ve bac-teria in the indoor environment (30, 31). The bacterial cell wall of gram -ve bacteria is a po-tent source of endotoxin and high levels have been found in DUWL (32). Matthew et al. ob-served a significant decrease in lung function in asthmatic children 30 minutes after receiving dental treatment (33). A cross-sectional multicenter survey of 265 dentists in practice concluded that the temporal onset of asthma may be associated with occupational exposure to DUWL because dentists who were exposed to DUWL >200CFU/mL were more likely to report symptoms of asthma since starting dentistry (34). On the other hand, a survey of 817 dental students in three dental schools concluded that the dental environment does not increase the risk for respiratory infection in healthy dental students (35).

Pankhurst at al. reviewed the scientific evidence from 1966-2007 on DUWL as a source of occupational and acquired infections and concluded that the report by Martin et al. was the only one clini-cal case directly associated with dental procedures (26, 36). In the absence of epidemiological data from randomized control trials to show otherwise, we can conclude that the risk for healthy individu-als appears to be low. Nevertheless, the documented presence of opportunistic pathogens in DUWL and their association with human disease poses a risk for immunocompromised individuals (21-24).


Matthew et al.

observed a significant

decrease in lung

function in asthmatic

children 30 minutes

after receiving dental

treatment


In 2007, a dental patient filed a lawsuit claiming that her unprotected eye (no protective eye-wear provided) was splashed with contaminated water during a dental procedure and resulted in chronic eye damage (37). The judge rejected the case, but this and other previously reported lawsuits reinforce the need for all dental of-fices to ensure vigilance with an office infection control policy that reflects laws, guidelines, and recommendations issued by federal state and lo-cal agencies (11). Furthermore it should include routine maintenance of patient treatment water at <500CFU/mL of HPC bacteria, in accordance with CDC recommendations (7).

How to reduce level of contaminationThe control of DUWL contamination is a two-part process consisting of biofilm removal and control, and reduction of planktonic microbes. Dental of-fices should consult with the dental manufactur-ers on treatment methods to ensure compatibility of products with equipment. They should also consult the owner’s manual or contact the manu-facturer to determine whether testing or mainte-nance of devices, including anti-retraction valves is required, as these have been show to fail (6, 7, 38, 39). The CDC recommends that handpieces, ultrasonic scalers, or air/water syringes should be operated to discharge water and air for a minimum of 20–30 seconds after each patient to flush out patient material that might have en-tered the turbine, air, or waterlines (7). However, it must be noted that flushing alone is no longer considered a practical solution for the treatment of DUWL contamination, because of the lack of effect on biofilm (7). Autoclavable or single-use tubing systems that can deliver sterile water or other solutions to handpieces (Genesis Tech, Elmwood, WI) and ultrasonic scalers (Acteon Inc., Mt Laurel, NJ) are also available.

Dental units are connected either directly to the municipal water supply, or have independent systems that allow the dental unit to be isolated from the municipal water supply. The self-con-tained bottle in an independent system is used to hold source water, with or without the addi-tion of chemicals, for distribution throughout the

Figure 3. ConfocalImagingofbiofilminsideDUWLtubingshowingliveanddeadbacterialactivity.

lines. Using untreated, unfiltered source water alone containing <500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in an independent system does not eliminate bacterial contamina-tion in treatment water if biofilms in the lines are not controlled (Figure 3).

Chemical treatment products for use with independent systemsThere is a wide range of chemical products on the market. Some common chemicals used are: sodium hypochlorite; hydrogen peroxide; chlorhexidene; chlorine dioxide; iodine; ozone; peracetic acid. These products claim to remove, inactivate, or prevent formation of biofilm, and reduce endotoxin levels from gram -ve bacteria. Products that carry germicidal claims for den-tal unit water system usage must be registered with the Environmental Protection Agency (EPA) and assigned a specific EPA number. Without EPA registration, products can be marketed as cleaners only, not disinfectants. To get the EPA registration for their products, manufacturers are required to submit their own efficacy data as standard efficacy testing methods have yet to be completed.


Chemical agents may be added to the source water in low concentrations and used continu-ously for patient treatment. The main effect of these continuous-use products is on plank-tonic bacteria with very little impact on mature biofilm. Agents that target biofilm can be used intermittently by adding a high concentration to the source water, running the product through, and leaving it in the lines for a brief period of time that can range from minutes to hours to overnight to weekend, and then flushed out for patient treatment. Products, utilizing a combi-nation treatment method, requiring initial and periodic intermittent (shock) treatments, along with the routine use of a continuous-use product, are also available.

Source water treatment devices Source water treatment devices, sometimes termed water purifiers, are retrofitted close to the junction box to treat incoming water from munic-ipal water supply. Systems are designed to use a holding tank in a central location or they may be plumbed directly into the units. They also require FDA clearance as medical devices. There are numerous types on the market. Some sys-tems continuously remove source water contami-nants using de-ionization and sub-micron filtra-tion. Others generate ozone from oxygen through exposure to ultraviolet light and the ozonated gas sterilizes water in the reservoir. They have no direct effect on biofilm inside DUWL; conse-quently patient treatment water quality may not improve without the addition of a biofilm-control-ling agent. Some of these devices automatically introduce chemical agents.

Other approaches Researchers are currently studying innovative methods that interfere with biofilm formation through modification of the inner tubing surface


to reduce microbial adhesion or to delay biofilm formation and some promising results have been published. A study that tested polyvinylidene flu-oride tubing over 185 days showed it to be effec-tive in preventing bacterial adhesion (40). Biofilm-controlling functions have also been found with the incorporation of a rechargeable N-halamine compound into polyurethane tubing (41).

Literature review on chemical productsMost published studies that have tested the ef-ficacy of DUWL products have limitations, due to small sample size, lack of standardized test-ing methods, and short duration of testing time. Thus, it is difficult to do a comparative review of studies particularly when translating bench-top efficacy into clinical effectiveness. However, there is strong evidence to show that many chemical products will reduce contamination of output water temporarily, but not permanently, by reducing, but not removing biofilm (42, 43).

DUWL chemical products may have disadvan-tages to their use and their effect on the bonding strength of dental materials has been researched in laboratory settings. A majority of those stud-ies have shown no deleterious effect on dentin or enamel bonding agents when compared with controls (44-46). There is limited evidence to show that halogen-containing products may mo-bilize mercury from waste amalgam. Two stud-ies that tested a number of disinfectants used in water delivery and evacuation lines concluded that chlorine-containing products released more mercury from amalgam waste than other clean-ers, such as quaternary ammonium chloride products or deionized water (47, 48). Another study that tested a DUWL iodine-releasing device showed that iodine can mobilize mercury from amalgam particulate resulting in higher levels of mercury in wastewater (49). Dental offices should consider their amount of amalgam use and the active ingredients in products used to treat all lines (water delivery and evacuation lines) when choosing a suitable disinfectant.


Water quality monitoring The CDC recommends that waterline treatment schedules should include water quality monitoring, which should be performed as frequently as instructed by the product manufac-turers (7). This can be done by simply taking a water sample and using one of two testing methods. In-office chairside kits (Millipore Corp., Billerica, MA) are available, but there is strong evidence to show that chairside kits underestimate bacte-rial counts when compared to standard methods and fail to grow certain phenotypes. Therefore, they should be considered screening tools for estimating bacterial counts in the range of 0-500 CFU/mL (50, 51). Although lower, results obtained with chairside kits have been found to be consistent, so it has been suggested that bacterial counts <500 CFU/mL may be corrected by a factor of 1.5 to get a more accurate reading (52). If chairside kits repeatedly show counts above 500 CFU/mL, dental offices should consult with product manufacturers to ensure product is being used correctly. Alternative testing methods or treatment products should be considered if counts continue to be high.

Laboratories across the U.S. offer mail-in testing services that can provide accurate testing readings. When mailing water samples to a commercial testing site, it is important that the samples should be stored at an average temp pf 4.5°C and sent immediately for processing, as variables such as time and temperature can affect results (53, 54). Information on these services and products are available on the ADA and Organiza-tion for Safety and Asepsis Procedures (OSAP) online websites (6, 55).

ConclusionIn general, much progress has been made towards facilitating the delivery of patient treatment water that is consistent with EPA drinking water quality, in accordance with the CDC Guide-lines. The source of the problem, biofilm, has been identified and products that target biofilm prevention and/or control have been developed. However, many questions remain unanswered; current treatment methods, products and devices have not been proven fail-safe; and further research on biofilm elimina-tion is needed.

Limited epidemiological reports suggest that the risk of disease transmission from contaminated DUWL for healthy individuals appears to be minimal, but the potential appears high for im-munocompromised individuals. Dental offices should adhere to a strict infection control policy that includes routine treatment and monitoring of patient treatment water, regardless of specu-lation and lack of evidence of associated morbidity or mortality.

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40. Yabune T, Imazato S, Ebisu S. Assessment of inhibitory ef-fects of fluoride-coated tubes on biofilm formation by using the in vitro dental unit waterline biofilm model. Appl Environ Microbiol 2008;74(19):5958-64.

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49. Stone ME, Kuehne JC, Cohen ME, Talbott JL, Scott JW. Effect of iodine on mercury concentrations in dental unit wastewater. Dent Mat 2006;22(2):119-124.

50. Bartoloni JA, Porteous NB, Zarzabal LE. Measuring the validity of two in-office water test kits. J Am Dent Assoc 2006;137(3):363–371.

51. Smith RS, Pineiro SA, Singh, R, Romberg E, Labib ME, Williams HN. Discrepancies in bacterial recovery from dental unit water samples on R2A medium and a com-mercial sampling device. Curr Microbiol 2004;48:243–246.

52. Cohen ME, Harte JA, Stone ME, O’Connor KH, Coen ML, Cullum ME. Statistical modeling of dental-unit-water bacterial test kit performance. J Clin Dent 2007;18:39–44.

53. Palenik CJ, Burgess K, Miller CH. Effects of delayed microbial analysis of dental unit waterline specimens. Amer J Dent. 2005;18:87–90.

54. Noce l. Giovanni D, Putnins EE. An evaluation of sam-pling and laboratory procedures fro determination of heterotrophic plate counts in dental unit waterlines. J Can Dent Assoc 2000;66:262.

55. Organization for Safety and Asepsis Procedures - Den-tal Unit Waterlines, available at: http://www.osap.org. Accessed April 13, 2010.


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January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 January 13-15, 2011 Dal las Convention Center Dal las Convention Center Dal las Convention Center Dal las Convention Center Dal las Convention Center Dal las Convention Center Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas Dal las, Texas

Their support is invaluable to the Texas Dental Association’s production of one of the largest dental meetings in the country.

We appreciate their support and the important role they play in the success of the TEXAS Meeting.

Visit texasmeeting.com to view the Sponsors and Exhibitors from the 2010 TEXAS Meeting.ex

hibi

torssp nsors

2010 TEXAS Meetingthanks


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

Due to the positive feedback and overall success with the TDA New Dentist Committee pod-cast 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 2010 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].

Join our Facebook group: groups.to/texasdental

Follow us on twitter.com/theTDA

Get LinkedIN at linked.com, search “Texas Dental Association”

TDA Video Highlights on tda.org

®

Top Section: Google search box (top-right corner), Helpful Tips, Contact Info (top-left), News scroll of top headlines, Local weather update

Left-hand margin: RSS News Center, Calculators, Meetings/Planners, Weather Center, Announcements from TDA, Events Calendar, TDA News and TDA Perks Program highlights, List of TDA and affiliate websites, and World Indices

Middle section (portlets) - Content divided into 7 sections:• Dental News & Videos: TDA video library, ADA Podcast Network, and dental specialty news. • News & Publications: Business and personal news, magazines, television, and Internet links. • Dental: Links related to the profession and dental office needs. • Personal: Links to travel, weather, people, sports, and other leisure interests. • Finance: Banking and finance related links, including investment, retirement, and bankruptcy. • Tools: Variety of helpful links such as office and tech tools, research, demographic, and people searches. • My Links: Links and categories created by the user.

Contact: Stefanie Clegg (512) 443-3675 or [email protected]

EXPRESSEXPRESSThe Texas Dental Association has integrated the existing TDA website (www.tda.org) into the “TDA Express” Internet portal. The TDA Express portal allows members to customize their homepage to show only the content in which they're interested.

Members can choose from existing links or add their own. TDA Express now includes a video library showcasing TDA videos and podcasts. Be sure to view the “Welcome” video by Mary Kay Linn, TDA Executive Director.

TDA NewsTDA News

RSS News Center Meetings/Planners

Calculators Weather Center

TDA Perks ProgramTDA Perks Program

TDA Members WebsiteTDA Members Website

TDA Public WebsiteTDA Public Website

DENPAC WebsiteDENPAC Website

TDA Smiles WebsiteTDA Smiles Website

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Announcement

Click HERE - TDA Express FeedbackTDA Express has been enhanced! Along with a new look, TDA Express now has its very own TDA video library.

Events Calendar

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Austin Weather: Overcast 70More News...Cargo plane crashes in Uganda's Lake Victoria (AP) Yahoo News

Dental News & Videos News & Publications Dental Personal Finance Tools My Links

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Implantology

Welcome to the TDA Video LibraryIntroduction to the new TDA video libraryby Mary Kay Linn, TDA Executive Director

TDA Committee on the New Dentist Podcast: Starting a New PracticeThe second installment of the TDA Committe on the New Dentist podacstseries, conducted by Dr, Josh Austin.

• How to Reduce Stress Dr. Ben Bernstein has created a stress reduction m... 11/14/2008 10:00:00 AM • Understanding, Planning and Funding My Retirement This podcast addresses topics related to retiremen... 11/14/2008 10:00:00 AM • Revive, Refresh, Renew — Creating Balance for the Dental Has your get up and go, got up and left? This uniq... 11/14/2008 10:00:00 AM • Dental Professional Liability 101 This podcast addresses topics related to professio... 11/14/2008 10:00:00 AM • More Headlines...

• Five-year follow-up of a root canal filling material in the Oral Surgery, Oral Medicine, Oral Pathology, Oral ... 3/20/2009 10:21:05 AM • A longitudinal study of dental caries risk among very Community Dentistry and Oral Epidemiology 3/20/2009 10:21:05 AM • Putative signaling action of amelogenin utilizes the Journal of Periodontal Research 3/19/2009 10:25:15 AM • Silver Diamine Fluoride: A Caries Silver-Fluoride Bullet Journal of Dental Research 3/19/2009 10:25:15 AM • Current Diagnostic Tests to Assess Pulp Vitality Journal of the Canadian Dental Association 3/19/2009 10:25:15 AM

• More Headlines...

• Patient Image Selection Criteria for Cone Beam Computed Seminars in Orthodontics 3/19/2009 10:25:14 AM • Likelihood ratio methodology to identify predictors of Oral Surgery, Oral Medicine, Oral Pathology, Oral ... 3/18/2009 11:15:34 AM • Effects of a Liquid Diet on Temporomandibular Joint Journal of Dental Research

DOW JONES 7278.38 -122.42

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value for your profession

Provided by TDA Perks Program

Get the Best Deal on Your Office Lease

Evan Reynolds, The Reynolds Company

The vast majority of dental profession-als will face the challenge of negotiating a lease for offi ce space at some point in their careers. Leasing space in the right location at the right price is obvi-ously critical to most practices. It can be a frustrating and confusing process, not to mention costly, if not approached in a strategic way. Fortunately, you can successfully negotiate a new lease by following a few key recommendations detailed below.

Start Early It typically takes approximately 6 months to complete the entire process of setting up a new

dental offi ce. This may include demographic analysis, competition studies, mar-ket research, lease negotiations, design and construction and many other items. The process can certainly take longer if you run into many unexpected delays. There may be delays in securing a construction permit or you may have to wait on the landlord to repair some items before you start your construction.

It is best to establish a target occupancy date early in the process so that everyone understands your time objectives. This will also help you develop a


time line for hiring staff, initiating your marketing plan, and other key start-up tasks. There may also be seasonal and tax considerations that will impact when you want to open your office, so you will need to plan accordingly.

Assemble Your TeamLeasing an office space is not a one-person job. You need a team of pro-fessionals that can assist you in all phases of the process. A real estate broker who specializes in working with dental professionals can help you with finding the right location and lease negotiations. Your attorney, fellow doctors, or dental equipment supplier may be able to steer you to such a professional. Real estate brokers exclusively represent your interests and are paid a standard commission by the building owner when the project is completed.

You will need to meet with a lender in the early stages of the process to determine the amount of financ-ing that you can secure. This will be important for everyone involved in the project. There are several dental specific lenders that have special programs to meet the unique needs of the dental professional. They are a good place to start.

An architect or space planner should be another key member of your lease team. You need one to draft a tentative floor plan to determine how a particular space might work for your needs, as well as producing the final architec-tural documents. Most of the dental equipment vendors will provide this service at little or no cost if you purchase their equipment.

In almost all cases, you will want to work with a dental equipment pro-vider to help you establish a specific growth plan for your practice. You

will need to understand not only your initial equipment needs, but how your practice will grow and what you will need to purchase in the future.

Another important member of your team is the general contractor that will build-out your space. It is critical that the contractor you choose has extensive experience in construct-ing dental office spaces. You will want to know not only what the cost will be, but how long it will take to complete the work. A contractor can tour you through recently completed projects, so you can view his work. Working with an inexperienced contractor can be one of the most expensive mistakes you can make.

An experienced real estate attorney is another crucial team member. It is highly preferable if the attorney also has experience reviewing dental leases. The attorney needs to be comprehensive, but realistic and efficient in his lease review. The attorney can also help you with set-ting up a corporate entity or partner-ship, if you need it.

Develop a VisionYou probably won’t have all the details nailed down as you start the process, but it is a good idea to think about what you want your practice to be and where you want it to be locat-ed. You need to think about where you want to live and work, who you want your patients to be and what type of procedures you want to per-form. Think about whether this will be your only practice, or possibly the first of many locations. This informa-tion will help produce criteria that will enable your real estate broker to identify alternatives that best meet your needs. The broker can also play a big role in developing your vision by providing demographic informa-tion, competition studies, traffic

studies, etc. It is also helpful to think about the image of your practice. Do you want to be in a high-traffic retail location or in a lower-visibility profes-sional office building?

Evaluate Your OptionsThe key to successfully negotiating the terms of a new lease is having options. Your broker should play a vital role in developing a negotiat-ing strategy that will maximize your options and consequently maximize your negotiating leverage. Hav-ing options produces a competitive environment which will put you in a position to make the best deal. You are not only negotiating the rental rate and improvement allowance, but also such items as: lease term, park-ing, signage, exclusivity, sublease and assignment, security deposit, and other key lease components.

Most dental professionals dread dealing with office space issues. The process can be confusing, particularly if you are setting up an office for the first time. Fortunately, by following these key recommen-dations, you can find the right office space for your practice and suc-cessfully negotiate your lease.

Theauthor,EvanReynolds,ispresi-dentofTheReynoldsCompany,ahealthcarerealestateservicesfirmandTDAPerksProgrampartner,thatspecializesinhelpingTexasdentalprofessionalswiththeirof-ficespaceneeds.ThecompanyisheadquarteredinDallas,andhasofficesinAustinandHouston.FormoreinformationregardingTheReynoldsCompany,pleasevisit:thereynoldscompany.com,orcall:(972)231-8900.Formoreinforma-tionregardingotherTDAPerksPro-grams,pleasevisittdaperks.com,orcall(512)443-3675.


Your Practice is as unique as your thumbprint...

We assist with acquisition terms and conditions, thefinancing process, and other practice transition issues

in order to effect a timely and orderly transition.

L. Norton Hindley III, ASA

2202 Timberloch Place, Suite 218The Woodlands, Texas 77380

281-367-1955 • FAX 281-363-9296 • [email protected]

http://www.thehindleygroup.com

The Hindley Group, LLC

This resource and reference book, which draws on the experience and expertise of 12 collaborators, will help you evaluate your business practices and determine where you are and how to get where you want to be. Please visit www.yourpracticeasset.com for information and resources referenced in the book.

For a listing of available practices and associateship opportunities, visit our website at www.thehindleygroup.com.

The Hindley Group, LLC, announces the release of

Getting Down to Business —Success in Each Stage of Your Dental Career

While you’re at tda.org, be sure to check out the following:

. Update your Profile

. Pay your Dues

. Read current/past issues of TDA Today

. Review TDA References

. Check out the Calendar of Events

. Look up peers in the Directory

New Topics have been added to the Third Party web tool (member homepage)

Members can also sign up for a Personal Web Page or link to an existing website.


Alexander, Jack WillafordLamesa, Texas

October 30, 1917 – April 11, 2010

Good Fellow, 1971

Life, 1982

Fifty Year, 1993

Daggett, John RobertSan Antonio, Texas

September 10, 1937 – May 31, 2010

Life, 2003

Goettsche, Harley H. Amarillo, Texas

May 5, 1915 – January 26, 2010

Good Fellow, 1973

Life, 1982

Fifty Year, 1988

Golf, JackHouston, Texas

September 29, 1922 – April 28, 2010

Good Fellow, 1978

Life, 1987

Fifty Year, 1998

Hill, Gary RexDeer Park, Texas

August 22, 1946 – November 14, 2009

Good Fellow, 2000

In MemoriamThose in the dental community who have recently passed

In Memory of:

John Edwards By Don R. Deaver, D.D.S.

Gerald Maikoetter

By Charles A. Robertson, D.D.S.

Jim McNeill By Charles A. Robertson, D.D.S.

Billye Cooke


Ms. Joan Walters By Dr. & Mrs. Russell Owens

Dr. Al Densmore

By The Seventeenth District Dental Society

Eddie Meyer By Robert C. Cody, D.D.S.

Jim Pettus


Kimmy Till By Charles A. Robertson, D.D.S.

In Honor of:

Mr. Joe McCombBy The Corpus Christi Dental Study Club

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


Protecting & Defending

Dr. Gwen Corbett, a Fortress Dentist. When you choose Fortress Insurance

Company for your professional

liability coverage, you can be con-

fident that your practice is protected.

We are owned and operated by

dentists and only insure dentists.

Aggressive claims defense, valuable

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customer service are why dentists

all over the country have selected

Fortress. Our local agents are

responsive and knowledgeable

too. To get Fortress protection, call

Kyle Wallace at Bell Insurance Group,

800-521-2355 X4871. Tell him

Dr. Corbett sent you.

Over 14,000 dentists trust Fortress with their professional liability insurance. www.dds4dds.com

I live in Baton Rouge, Louisiana. It is a great city full of

cajun culture and a love of LSU.

I grew up in the local dental community. My father was a

general dentist here for 35 years and my mom ran the office.

I practice endodontics with Drs. Simon and Bond at Root

Canal Specialists of Baton Rouge. It’s a top notch practice.

Our patients are our priority.

I specialized in endodontics because I really liked the focus.

Our patients are often in pain and afraid.

It’s rewarding to relieve them of both.

I earned my pilot’s license in 2006

and I also enjoy triathlons and racing.

Balancing it all with a baby is a

challenge. I appreciate that dentistry

gives me flexibility.

I recommend Fortress professional

liability coverage. I like the personal

service and the newsletters with the case

studies. My agent appreciates my

busy schedule and takes care

of my needs right away.


August 20103 – 6The American Academy of Esthetic Dentistry will hold its 35th annual meeting at the Ritz-Carlton Kapalua in Maui, HI. For more information, please contact Ms. Jennifer Hopkins, AAED, 737 N. Michigan Ave., Ste. 2100, Chicago, IL 60611. Phone: (312) 981-6774; FAX: (312) 981-6787; E-mail: [email protected]; Web: estheticacademy.org.

13 & 14The TDA Smiles Foundation will hold a Texas Mission of Mercy in Waco. For more information, please con-tact the TDA Smiles Foundation, 1946 S. IH 35, Ste. 300, Austin, TX 78704. Phone: (512) 448-2441; Web: tdasf.org.

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: www.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: asdato-day.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.C

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28 – 30The Hispanic Dental Association will hold its annual meeting in Chicago, IL. For more information, please con-tact 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: (31) 787-3670; E-mail: [email protected]; Web: perio.org.

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.

Ca

len

da

r of E

ven

tsThe TexasDentalJournal’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.


Clinical HistoryFor more than 4 weeks, this 21- year-old man experienced a painful, ulcerated enlargement of the right retromolar area. A course of broad spectrum antibiotics was not suc-cessful in relieving his symptoms and the lesion continued to enlarge under that treatment. At initial examination a dark red, moderately firm, friable mass was seen to measure 3 x 4 x 2 cm (Figure 1). It was fixed to the underlying tissues and showed extensive but superficial necrosis with focal areas of hemorrhage. The patient had anesthesia of his right lower lip and chin, and was having difficulty swallowing. A pantograph revealed only a distal-angular, partial bony impaction of the lower right third molar (Figure 2). There was no cervical lymphadenopathy and the patient’s medical and social histories were unremarkable. Incisional biopsy showed chronic inflammation of fibro-vascular tissue, beneath a surface ulcer bed of fibrinoid necrotic debris. One week after the biopsy, the patient returned with a complaint of continued and more rapid growth of the lesion, increased chin numb-ness, chills, and increased difficulty with swallowing. He had an oral temperature of 102.7°F and the right retromolar mass had enlarged to the point that it was preventing the teeth from occluding and produced a visible extraoral swelling. A CT scan revealed only homogenous soft tis-sue edema on the right side, without bone erosion or encroachment of the airway (Figure 3). Bacterial and fun-gal cultures showed only normal oral bacterial flora; HIV Elisa assay and skin TB test were negative; and the complete blood count was normal. A second biopsy specimen, larg-er and deeper, was obtained for ad-ditional microscopic evaluation and immunostaining. The larger sample

Nagi M. Demian, D.D.S., M.D., As-sistant Professor, Stephen Schoolman, D.D.S., Resident, Department of Oral & Maxillofacial Surgery, and Jerry E. Bouquot, D.D.S., M.S.D., F.I.C.D., F.A.C.D., Professor and Chair, Depart-ment of Diagnostic Sciences, Universi-ty of Texas Dental Branch at Houston, Houston, Texas. BouquotSchoolman

revealed diffuse sheets of somewhat immature lymphocytic cells admixed with larger, more open, ovoid cells consistent with histiocytes (Figure 4). Occasional pleomorphism and hyperchromatism of tumor cell nuclei suggested a possibility of leukocytic malignancy and a battery of immunohistochemical studies were used to evaluate for lymphoma. The majority of lesional cells were reactive to CD68 and nonreactive to lymphoma markers CD3, CD5, CD20 and CD79a, as well as the carcinoma marker cytokeratin (Figure 5). This suggested that the lesional cells were proliferating or immature histiocytes, not lymphocytes or epithelial cells. Moreover, tumor cells were nonreactive to S100 protein, which marks the histiocytes of Langerhans cell disease. The patient was hospitalized for treatment of fever and dehydration, and was discharged with no fever and improved oral symptoms 2 days later, with-out specific treatment for the oral mass. Five days after discharge, the mass was less than 10 percent of its maximum size and the partially impacted right mandibular third molar crown was partially visible, with a small rim of necrotic bone distal to it. After an additional 4 weeks, no signs or symptoms remained and the impacted molar was extracted without incident (Figure 6). Two years later, there was no recurrence of the mass or the symptoms.What is the final diagnosis?

See page 704 for the answer and discussion.

Figure 1.Largefungating,ulcerativemassatinitialexamination.

Oral and Maxillofacial Pathology

Case of the Month


Figure 2.Pantographshowspartialbonyimpactionofrightmandibularthirdmolar,withnoobvioustumordestructionofthebone.

Figure 3.CTscandemonstratednobonyinvolvementbythetumor,onlydiffuse,nonspecificsofttissueenlargement,consistentwithedema.

Figure 4.Histopathologyrevealedsheetsoflymphocyticandhistio-cyticcellswithscatteredlargeepithelioidcellsshowingopennuclei(arrows).

Figure 5.CD68immunoreactivitywasstrongagainstthelesionalcells.

Figure 6.Oneweekafterbiopsythemasshasdiminishedtothepointwhereatthemolarisvisibleonceagain.

Figure 7.Fiveweeksafteronsetthemasshasalmostcompletelydisappeared.


SPDDSEmployees Bene�t Trust

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• Employer determines the amount of employee contribution and waiting periods

To obtain rates or more information, please call1-800-658-6810 or visit us on the Web at www.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.comwww.spddsebt.com

SPPDS Employee Benefit Trust is a Texas licensed, multiple employer welfare arrangement, governed by ERISA,providing self-funded health coverage for dentists, their employees, and dependents. AD-9


The late Victorian era (1890 – 1915) produced some of the most elegant dental cabinets in all of his-tory. Many of these cabinets had large hinged sections that spun out for access to myriad small drawers. During this era, a smaller dental supply company came up with a novel idea: ask dentists what they re-ally needed in a cabinet! The cabinet you see (Figures 1, 2) was the result; its revolving drawers allowed for easy access to dental supplies and equipment. This

cabinet was patented in 1905 by the A.C. Clark Company of Chicago, IL. This company also sold dental spittoons, brack-et tables (Figure 3), and a variety of office furnish-ings. It was started by Albert Charles Clark, who was born in Mattoon, Illinois, February 7, 1868. In 1884, he came to Chicago for work. His first job was as a day laborer, sorting scrap iron in the North Chicago Rolling Mills Company, for the sum of $1.50 a day. Following that, he had a 5-year stint in the insurance business; and from 1890 to 1892 was a salesman in a dental supply house. In 1892, he decided to venture on his own, selling furnishing and fixtures to dentists. His most notable achievement was the revolv-ing octagonal cabinet (Figures 4, 5). Historically important because of its design, it is prominently displayed at the Smithsonian. Reported in print, but not confirmable, was that only 125 of the octagonal cabinets were produced. Later on, Mr. Clark became an Illinois legislator. He was instrumental in helping pass a parks bill, which at that time connected Calumet, Illinois, to the Sanitary District of Chicago.

Dental ArtifactsThe Clark Revolving Dental Cabinet

Kim Freeman, M.A., D.M.D., M.S.

Figures 1 and 2Figure 3

Figures 4 and 5


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WATS LINE SEE WEBSITE 800-583-7765 www.tda.org


Atypical Histiocytic Granuloma (Pseudolymphoma)Oral and Maxillofacial Pathology Case of the Month (from page 698)

Oral and Maxillofacial Pathology

Diagnosis and Management

DiscussionThe routine microscopic appear-ance of this lesion was strongly suggestive of a lymphocytic lym-phoma, but immunostains showed that it was actually a benign, lymphohistiocytic reactive lesion sometimes confused with lym-phoma, i.e., a pseudolymphoma. This look-alike lesion has a confus-ing array of different diagnostic names, including benign lym-phoproliferative disease, recurrent ulcerating lymphohistiocytic lesion, atypical histiocytic granuloma, benign lymphoid polyp, lymphoid pseudotumor, lymphocytic pseudo-tumor and atypical lymphohis-tiocytic infiltrate (1-6). Atypical histiocytic granuloma seems to be the terminology preferred currently, although the pseudotumor name is still popular in dermatology. It was first described by none other than Kaposi in 1891 (7).

The oral pseudolymphoma is a de-cidedly uncommon reactive lesion of unknown origin and is similar to lesions arising from the orbit, skin (sometimes referred to as sarcomatosis of Spiegler-Fendt), gastrointestinal tract, lungs, nasopharynx, larynx, and breast (2, 7). Enlarged lymph nodes with a similar pseudolymphomatous reaction have occasionally been reported in patients taking a wide variety of drugs, especially diphe-nylhydantoin, sulfonamides, and allopurinol (7). The drug-induced pseudolymphoma is a much more

serious entity, possibly a Type IV hypersensitivity reaction, which results in death from liver, cardiac damage or true lymphoma de-velopment in up to 10 percent of cases (7). A few cases have also been reported in association with titanium implants, infections (Bor-relia, herpes simplex), hepatitis vaccinations, and collagen injec-tions (7).

Pseudolymphoma not related to drug use runs a much more benign course and its true etiology is almost completely unknown, even though its microscopic features are identical to the drug-associated lesions (4-6). In the mouth, this disease has been reported to oc-cur on the gingiva, lips, alveolar mucosa and lateral tongue (lingual tonsil region), but the posterior hard palate is the most likely site of involvement (2, 3, 5). It most frequently occurs in older women and presents as an asymptomatic soft to firm non-ulcerated mass. It is occasionally bilateral and may be associated with cervical lymph-adenopathy. Clinical laboratory investigations are almost always normal.

After an initial rapid growth, the oral pseudolymphoma behaves in a benign manner and spontaneous regression has been the typical outcome. A small number of pa-tients have developed recurrences after local excision, but none have shown evidence of a malignant process with long-term follow-up (1, 3, 6).

The oral pseudolymphoma does not require aggressive therapy of the type necessary for malignancy or systemic histiocytic disease and, for this reason, the use of immunohistochemistry is essential in order to rule out lymphoma and Langerhans cell disease (4, 5). In the present case, the primary tumor cell was shown to be an im-mature histiocyte, not a dysplastic lymphocyte or the unique histio-cyte of Langerhans cell disease. With that determination, follow-up evaluation was elected and since the mass began shortly to diminish without treatment, it was allowed to heal on its own.

If a pseudolymphoma does not fol-low such a behavior and continues to enlarge, conservative surgical excision or intralesional injection of corticosteroids can be performed, or rituximab may be given, but the lesion seems most often to regress spontaneously without treatment, almost always within 3-8 weeks (1-3, 7, 8). The present case followed a typical behavior, with complete resolution of the lesion within 5 weeks and with no recurrence after 2 years of follow. Removal of the underlying impacted third molar did not stimulate additional tissue pro-liferation. This case was, however, atypical in that it presented with local symptoms and was associ-ated with an underlying infection of a partially impacted tooth. The infection was, presumably, largely responsible for the symptoms, since the pseudolymphoma is typically


asymptomatic. The extensive surface ulceration of our lesions was also atypical, but was perhaps explained by the location in the posterior mandible, with subsequent trauma from opposing dentition.

This case very nicely illustrates the diagnostic and man-agement dilemma associated with pseudolymphoma. The diagnostic criteria are not well defined and the diagnosis is never easy. The lesion may become large very, very rapidly, causing considerable alarm, and it can be easily misdiagnosed at the microscopic level as either a systemic disorder (Langerhans cell disease), an innocuous inflammatory hyperplasia (which was the first biopsy diagnosis in the present case), or a malignancy (lymphoma). Prior to the advent of immunohistochemis-try techniques, there were, undoubtedly, individuals with this lesion who were treated for lymphoma. Fortunately, pseudolymphoma is a relatively rare condition and so the dilemma is unlikely to arise in a general practitio-ner’s office. Nevertheless, he or she must be ever alert for the odd lesion which does not seem to follow the normal presentation of more well established, better known entities in oral pathology. References

1. Kabani S, Cataldo E, Folkerth R, et al. atypical lymphohistiocytic infiltrate (pseudolymphoma) of the oral cavity. Oral Surg Oral Med Oral Pathol 1988:66:587-92.

2. De Vicente Rodriguez JC, Santos Oller JM, Jun-quera Gutierrez LM, Lopez Arranz JS. Atypical his-tiocytic granuloma of the tongue: case report. Brit J Oral Maxillofac Surg 1991; 29:350-352.

3. Del Rio E, Sanchez Yus E, Requena L, Garcia Puente L, Vazquez Veiga H. Oral pseudolymphoma: a report of two cases. J Cutan Pathol 1997:24:51-55.

4. Jham BC, Binmadi NO, Scheper MA, et al. Follicu-lar lymphoid hyperplasia of the palate: case report and literature review. J Craniomaxillofac Surg 2009; 37:79-82.

5. Shin JB, Seo SH, Kim BK, Kim IH, Son SW. Cu-taneous T cell pseudolymphoma at the site of a semipermanent lip-liner tattoo. Dermatol 2009; 218:75-78.

6. Yamakawa PE, Andrade EH, Watanabe-Silva CH, Dos Santos Neto LL. Lingual tonsil pseudolympho-ma and obstructive sleep apnea. Braz J Otorhino-laryngol 2009; 75:469-471.

7. Albrecht J, Fine LA, Piette W. Drug-associated lymphoma and pseudolymphoma: recognition and management. Dermatol Clin 2007; 25:233-244.

8. Witzig TE, Inwards DJ, Habermann TM, et al. Treat-ment of benign orbital pseudolymphomas with the monoclonal anti-CD20 antibody rituximab. Mayo Clin Proc 2007; 82:692-699.

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THANKSTDA would like to extend a special thank you to Districts 2, 5, 7, and 9 for their support

and assistance in this year’s TEXAS Meeting

Dr. Mark AlbrittonDr. Courtney AlexanderDr. Barton AllenDr. Kevin AltieriMs. Melena ArmentorDr. Josh AustinMr. Grady BaslerDr. Robert BeattyDr. Doug BeckerMs. Mona BejaranoDr. Kyle BessMs. Sylvia BradfordMs. Charletta BriggsMs. Bonnie BrooksDr. Monica BrownDr. Jason BrowningMs. Sharon BryantMs. Tina BurchfieldDr. Rene CasavantesDr. Jeremy ChanceDr. Jim ChancellorDr. Pat ChancellorDr. John ChandlerMs. Terri CloyMs. Gayle Marie ConnellDr. Ralph CooleyMs. Ann CottonDr. Taylor CottonMs. Nancy CrouchMs. Beth DaigleDr. Tommy DavisDr. Andy DoerflerMs. Mary DoerflerDr. Ingrid DuebbertDr. Richard Dyck

Dr. Paul Kennedy, IIIDr. Trisha KimesDr. Greg KunzDr. Galen Trey LacyDr. Galin LathamMs. Christi LawsonDr. Edwardo LorenzanaMs. Danya LoughDr. Anne LyonDr. Scott MakinsMs. Bridget MariottDr. Rise' MartinDr. Lisa MastersDr. Celeste Narro GonzalezMs. Rachel NewmanMs. Claudia OelfkeDr. Katie Olson TriskaDr. Elizabeth PalacioMs. Annalynn PappasDr. Jayu PatelMs. Brenda PhillipsDr. Jim ReismanMs. Kyra ResweberDr. Sue Ellen RichardsonDr. Ron RisingerDr. Jim RootDr. Kelly SawyerDr. Craig ScastaDr. Meredith ScottDr. Jeffrey SiebertDr. Sam ShowalterDr. Felicia SimpsonDr. Mark SmithDr. Robert Smith Ms. Connie Sonnier

Ms. Linda FambroughDr. Cindy FlanaganDr. Brandon FleshmanDr. Lawrence FreidmanDr. Leslie FullertonDr. Clay FuselierDr. David GarrettDr. Jathen GarrettDr. Terri GermanDr. Kathy GibsonDr. Bill GlennMs. Paula GlennDr. Whitney GomezDr. June GoodallDr. Tor GotunDr. John HackbarthDr. Kelly HaleMs. Jenny HallDr. Robert HallDr. Shirley HamamcyMs. Stephanie HammondMs. Tracy HargaveDr. Tommy HarrisonDr. Jennifer HathawayDr. Kimber HolmesDr. Milton HowardMs. Darlene HowdenDr. Maria Lopez HowellMs. Robin HubierDr. Mary Dawn HurstDr. Tom HurstDr. Joe HutchinsMs. Amber InfanteMs. Mary Kay JamesDr. Robert Kelly

Ms. Thelma SwearingenMs. Dodie TaubertMs. Sophia TeelMs. Jennifer ThigpenDr. Melissa TuckerDr. Karen TroendleDr. Herb WadeD’Ette WaldropDr. Karen WaltersDr. Gary WeeksMs. Lucy WeeksDr. Jay WelchDr. Mike WestwoodMs. Connie WilliamsDr. Thomas F. WilliamsDr. Jon WilliamsonDr. Grant WolfeMs. Stacy WolffordDr. David WoolweaverDr. Stephen WrightDr. Tom WrightDr. Bonita WynkoopDr. Stan Zebrowski


B r i e f s

IMPORTANT: Ad briefs must be in the TDA of-fice by the 20th of two months prior to the issue for processing. For example, for an ad brief to be included in the January issue, it must be received no later than November 20th. Remittance must accompany classified ads. Ads cannot be accepted by phone or fax. *

Advertising brief rates are as follows: 30 words or less — per insertion…$35. Addi-tional words 10¢ each.

The JOURNAL reserves the right to edit copy of classified advertise-ments.

Any dentist advertis-ing in the Texas Dental Journal must be a member of the American Dental Association.

All checks submitted by non-ADA members will be returned less a $20 handling fee.

* Advertisements must not quote revenues, gross or net incomes. Only generic language referencing income will be accepted. Ads must be typed.

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Practice Opportunities

MCLERRAN AND ASSOCIATES:

AUSTIN: High grossing, family practice located in retail center with seven op-eratories was recently remodeled. Near major highway. High growth area. Prac-tice boasts solid, well-established patient base. ID #1-0110.

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 excel-lent 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.

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice. Modern, new finish out in retail location 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 Medicaid oriented practice grossing high six figures on part-time work week. Excellent oppor-tunity. ID #100.

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

SAN ANTONIO: High gross and net in-come general family practice located in

high income area in very visible retail of-fice center. The seven op office is in excel-lent condition, has a modern design, and is equipped with almost new equipment, all digital X-rays, and is fully computer-ized. Practice grossed seven figures last year. Price slashed! ID #094.

SAN ANTONIO, NORTH WEST:Excellent four-chair general family prac-tice 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 over-head 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 office. 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 freeway; perfect starter office. Terrific pricing. ID #009.

SOUTH TEXAS BORDER: General prac-titioner with 100 percent ortho practice. Very high numbers, incredible net. ID #021.

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

SAN ANTONIO: Four operatory general family practice located in professional


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office building off of busy thoroughfare in affluent north central side of town. Very nice equipment and decor. Excellent op-portunity. 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 build-ing on busy thoroughfare. Practice has grossed in seven figures for last 3 years. Great location with super upside poten-tial. ID #055.

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 CENTRAL: Six operatory general practice located in high growth area. All operatories have large windows with great views. Very nice equipment, solid patient base, great hy-giene program. Priced to sell. ID #1-0112.

NEW! SAN ANTONIO, NORTH CENTRAL: Three operatory office in retail/office cen-ter with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #1-0111. NEW! CENTRAL TEXAS: Well-established, FFS family practice in five op office lo-cated in growing community. Office has been recently updated, boasts a commit-ted staff and strong hygiene program, and has seen increasing revenue in the high six figures the last 3 years. ID#1-0108.

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.

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

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.

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

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

NEW! SAN ANTONIO, NORTH CENTRAL: 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.

SAN ANTONIO, NORTH SIDE: Eight oepratory, high grossing, fee-for-service


family practice in historic, free-standing building. Affluent neighborhood. Huge patient base and super hygiene program. ID #104.

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.

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 Gugliemo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotiations. See www.dental-sales.com for pictures and more complete in-formation.

HOUSTON AREA PRACTICE OPPORTU-NITIES! MCLERRAN & ASSOCIATES: CONROW: 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 opportunity for success now and well into the future. #H105. HOUSTON: Established crown and bridge/removable practice with digi-tal X-rays, great new patient flow, pro-duction in high six figures. PPO and fee-for-service only. Tremendous cash flow. #H109. HOUSTON: Buy-in opportunity with premier group practice. Requires existing patient base close to Texas Medical Center aera. Beautiful 12 opera-tory, high tech office with low overhead. Partner financed. #H115. 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 TRI-

ANGLE: Eight op general family practice grossing seven figures plus. Modern, open concept design in a highly residen-tial area, strong new patient flow with high net. #H107. HOUSTON: Established general and family practice inside 610 for transition. #H112. HOUSTON: Beauti-ful four operatory general practice, very new equipment, digital X-rays, grossing in mid six figures. Located in premier Houston neighborhood. Fee-for-service only. #H106. Contact McLerran & As-sociates in Houston: Tom Gugieimo and Patrick Johnson, (800) 474-3049 or (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotia-tions. 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. Retiring surgeon; outright sale or transition; seven-figure gross. Seller will work for buyer on lim-ited basis. We have the best sources for 100 percent buyer funding. Gary Clin-ton 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 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA SOUTH TEXAS / BROWNSVILLE / HARLINGEN AREA: Excellent practice with flexible transi-tion. Primarily fee-for-service and Delta Dental. High operating profits; more than seven figures in collections. Lovely office. Some ortho easily expanded to larger per-


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centage of practice. Outright sale. Seller will transition / work for new owner as needed. We have the best sources for 100 percent buyer funding. Gary Clin-ton 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 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

GARY CLINTON / PMA BRYAN / COL-LEGE STATION PRACTICE FOR SALE. Transition/outright sale. Retiring 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 In-stitute 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 con-flict of interest/dual representation. Au-thorized closing agent/escrow agent for numerous financial institutions. 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 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/transi-tion. High collections/net; five operato-ries, full hygiene. We have the best sourc-es 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 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 dentist. Will continue to work as needed 1 day per week. We have the best sources for 100 percent buyer funding. Gary Clin-ton 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 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 buy-ers! 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/tran-sition as follows: Austin, San Antonio, DFW area, and Houston. Have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practic-es. 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 questions. 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 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. 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 of-fice. Plenty of patient to work 5 days a week; exceptional value. S-2 San Angelo —Excellent well-established restorative practice. Very nice equipment. Dentist relocation. Transitional/outright sale. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the Institute of Business Ap-praisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every appraisal/tran-sition/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 comparables to ensure accuracy of ap-praisal (specialty and general). Very con-fidential. DFW: (214) 503-9696; WATS: (800) 583-7765.

ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O-1 North Dallas — Fast growing, highly desirable suburb; digital equipment; doctor relocating; will transi-tion. O-2 West Central Texas mid-sized to larger community — Ideal transition; pro-

fessional referral based; traditional fee-for-service, referral, highly productive. Gorgeous building with room for two in this planned 50/50 partnership; within 5 years complete buy-out with owner work-ing 1-2 days as needed. O-3 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 In-stitute 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 con-flict of interest/dual representation. Au-thorized closing agent/escrow agent for numerous financial institutions. 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.

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 Ap-praisers, 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 finan-cial institutions. 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.


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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 Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I person-ally handle every appraisal/transition/sale. No conflict of interest/dual rep-resentation. Authorized closing agent/escrow agent for numerous financial institutions. Certified appraisals based upon the comparables. More than 2,000 comparables to ensure accuracy of ap-praisal (specialty and general). Very con-fidential. 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 front-age road; high visibility. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the In-stitute 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 con-flict of interest/dual representation. Au-thorized closing agent/escrow agent for numerous financial institutions. 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 MCKINNEY/ FRISCO AREA: Exceptional premier

restorative practice; seven figure gross re-quiring experienced dentist. Newer equip-ment; attractive facility. We have the best sources for 100 percent buyer funding. Gary Clinton is senior member of the In-stitute 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 con-flict of interest/dual representation. Au-thorized closing agent/escrow agent for numerous financial institutions. 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 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 Busi-ness Appraisers, Inc. “For over 37 years, you’ve seen the name ... a name you can trust.” I personally handle every ap-praisal/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 comparables to ensure accuracy of appraisal (specialty and general). Very confidential. 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 re-


tirement 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 are an older doctor who needs to re-complete his retirement package after the stock market drop, and want to practice in a less competi-tive more relaxed environment, this is a must-see opportunity. Contact The Hind-ley Group 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. Building also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. (Ginju-palli).

WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with moderate revenues and high profit mar-gin on 4 days per week. Due to limited competition and a large facility, there is ample room to grow in this community that is home to Baylor University. All ortho cases are being completed, unless purchaser would like to expand new cas-

es. No Medicaid being seen, but good op-portunity with enhanced state fee sched-ule. Experienced staff and steady new patient flow. Wonderful mentor. Build-ing also available. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com. (McGregor).

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

ASSOCIATESHIPS: EAST TEXAS GEN-ERAL DENTAL PRACTICE — Small but busy practice generating mid-range revenues 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 ENDO-DONTIST ASSOCIATESHIPS — Periodon-tal associateship with pre-determined buy-in for very active, multi-office peri-odontal practice. Endodontist associate also needed in this practice. Outstand-ing mentor and cohesive staff. If you are the right person, thsi is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRACTICE — Associateship with pre-determiend buy-in and partnership terms. Nine operatories. Strong mentor


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and experienced staff. Excellent rev-enues and profit margin. Large Medicaid component. 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 & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA — Six general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); five specialty practices available (two ortho, one perio, two pedo). FORT WORTH AREA — Two general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA — One general dentistry practice. CENTRAL TEXAS — Two general dentistry practices (north of Austin and Bryan/College Sta-tion). NORTH TEXAS —One orthodon-tic practice. HOUSTON AREA — Three general dentistry practices. EAST TEXAS AREA — Two general dentistry 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 listings, please visit our website at www.adstexas.com or call ADS Wat-son, 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 comput-

erized using Dentrix software. Highly productive practice with excellent collections. Staff is young, friendly, energetic and loyal with excellent clini-cal and managerial skills. Continued growth each year with minimal adver-tising, low overhead. Full-time CDT in office produces crown and bridge as well as removable prosthodontics. All lab equipment included 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. Den-tal 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 wtthin 1 hour of three major cities. The office building can be leased or pur-chased separately and is spaciously designed with four operatories, doctors’ 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 wanting to relocate and become part of an estab-lished practice with a reputation for providing comprehensive, quality den-tal care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krum-holz, (409) 762-4522.

EL PASO: FULL- OR PART-TIME ASSOCIATE NEEDED. Would be sole practitioner at location. Three opera-tories for DDS plus one for hygienist, equipment less than 1 year old. Past compensations up to five figures per week. No administrative responsi-bilities. Call (702) 510-7795 or e-mail [email protected].

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 pedi-atric 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 Tyier 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.


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Our office is located in beautiful East Texas and provides all phases of qual-ity dentistry in a friendly and compas-sionate 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 avaialble. Our knowl-edgable staff will support and enhance your growth and earning potential while helping create a smooth transi-tion. Intereted 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-enuein 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 mainte-nance 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 mo-tivated 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 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 behav-ior managment using oral conscious sedation as well as IV sedation. For more information, please visit our web-sites at www.wyliechildrensdentistry.com and www.parischildrensdentistry.com. Please e-mail CV to [email protected].


SOUTHWEST FT. WORTH — GENER-AL DENTAL PRACTICE WITH BUILD-ING FOR SALE OR LEASE: This very successful, well-established practice has an excellent patient base with referrals from near and far. The seller is retiring immeidately 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! Appraisal 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 loca-tion will be opening soon. Join our outstanding 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/benefts, 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 lifestyle, yet quick access to metropolitan Hous-ton. 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 (8.00) 930-8017.

DALLAS / ROCKWALL: Seeking full- and part-time endodontists. Expand-ing a busy, TEAM-oriented, modern practice with a well-established referral


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base. Must have strong clinical and people skills. E-mail [email protected].

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 pa-tients. Experienced or new grad wel-come. Contact at [email protected].

HOUSTON MEDICAL CENTER GEN-ERAL PRACTICE: Practice dentistry the way you have always dreamed! Incredible opportunity for general den-tist to work as an associate and transi-tion 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 wills stay for introductions and successful 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 physicans practicing in the Medical Center. State-of-the-art clinical and business systems through-out, including professional manage-ment, contemporary equipment, and an in-house dental laboratory staffed by three talented lab techs. See our web-site, www.ddsassociates.com, for more information, 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 opportunity for a general dentist who surgically places implants. Opportunity to become a partner. Loca-tion pictures are avaialable. Call Sherri, (972) 562-1072 or (214) 697-6152.

DENTIST FOR JCAHO-ACCREDITED COMMUNITY HEALTH CENTER IN SOUTH TEXAS. Texas license or eli-gible. Full-time or part-time. Competi-tive compensation package, and great working hours. Contact Nuestra Cli-nica 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 servcies 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].

PART-TIME ASSOCIATE NEEDED IN ALLEN: Established two doctor prac-tice moving to a beautiful new building. Must have a least 2 years experience. E-mail resume to [email protected].

PEDIATRIC DENTIST OPPORTUNITY in a well-established, fast-paced dental practice located in El Paso. Tremendous career opportunity for an associate seeking mentorship or affiliation with a senior pediatric dentist in a full-time or part-time position. As well, the prac-tice requires a personable, caring, and


energetic individual who is looking for an enterprising opportunity. For further information, please visit our website at www.iamallsmiles.com. Please forward CV to [email protected].

SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national aver-age for general dentists; future poen-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 responsbilities. Full- and part-time positions with com-petitive 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].

FANTASTIC OPPORTUNITY FOR GENERAL DENTIST to learn and incorporate orthdontics into career; no experience required. Become a part-ner/owner, full-time or part-time while building your general dental practice concurrently. All training and business support provided. Easy and affordable financing. Call now, (469) 232-3100.

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. Allen 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.


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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 infor-mation.

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 COVERAGE (LOCUM TENENS): Professional temporary coverage of your dental practice by a colleague during maternity and disabil-ity leaves, vacation, or just some short-term relief. Short-notice coverage is our specialty. Flat daily rate. Free quotes. No obligation, ever. A few “superstars”

on our team seek full-time positions. All inquiries treated with absolute confidentiality. Since 1996, the nation’s largest team of distinguished dentists. Register online at www.doctorsperdiem.com; (800) 600-0963.

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 pa-tients treated and booked for recall, all for a flat daily rate not a percent of production. Nation’s largest, most distinuished team. Short-notice cover-age, personal, maternity, and disability leaves our specialty. Free, no obligation quotes. Absolute confidentiality. Trust-ed integrity since 1996. Some of our team seek regular part-time, perma-nent, or buy-in opportunities. Always seeking new dentists to join the team. Bread and butter procedures. 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

ESTABLISHED DENTAL ASSISTING SCHOOL searching for general dental office to lease on 1 weekend day and 1 weeknight in Plano and Austin. Ongo-ing 12-week course. Lease payments of $1000-$1500 / month for minimal light use of the office. Please call Dr. Peter Najim, (800) 509-2864, [email protected].


LOOKING TO HIRE A TRAINED DEN-TAL ASSISTANT? We have dental as-sistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at (800) 383-3408; Web: www.schoolofdentalassisting-plano.com.

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.


Your Patients Trust You. Who can YOU Trust? The Professional Recovery Network (PRN) ad-dresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional diffi culties. We provide impaired dental profes-sionals with the support and means to confi den-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

PRN Staff

Donna Chamberlain, LCSW, CAS Director . . . . . . . . . . 512-615-9176

Paige Peschong, LMSW Social Worker . . . . . 512-615-9155

Courtney Bolin, MSW Social Worker . . . . . 512-615-9182

Professional Recovery Network12007 Research Blvd. Suite 201

Austin, TX 78759www.rxpert.org

Perks’ Group PurchasingEquals Energy SavingsPerks Group Members Pay Only a Low Million kW-h Rate!*TDA Perks Program has partnered with JLT Energy Consultants, a company that develops master programs with multiple energy providers to provide special rates for large groups of individuals. This means that through TDA Perks Program, TDA members living in deregulated areas now have access to lower-tier energy prices.

Following are some of the features of the TDA Perks Program contract:•Rather than an offi ce paying a rate based on its own usage, each offi ce under the Perks Program will be quoted as if the offi ce used 1 million kW-h annually.

To Qualify for TDA Perks Group Electricity Program:1. You must be a TDA member.

2. *Your area must be deregulated to permit competition.

3. Your current contract must be expired or expiring. When your contract expires, you can join other TDA members who qualify for a lower-tier rate, and save thousands of dollars per year. If your offi ce uses 80,000, 90,000 or less than 250,000 kW-h, it can sign a new contract to pay the same rate as those using 1-million to 2-million kilowatt hours of electricity per year. Your new rate will effectively give you a savings equal to free electricity for the last two months of every year.

•If you sell or move your business, your contract can either be taken to your new location, or terminated without penalty.

•If the price of electricity goes down during the term of your agreement, you can request “blend and extend” to take advantage of these lower rates.

•The Contract is for a FIXED rate per kilowatt, regardless of usage.

•The contract can be for one year up to four years; each dentist offi ce has a choice, and is only responsible for his/her own contract. Learn more: tdaperks.com

For more information, call JLT Energy:

(682) 224-1385


Professional Recovery Network

pu Junep 630

TDJ July 2010.indd 722 6/29/10 11:08 AM


Perks’ Group PurchasingEquals Energy SavingsPerks Group Members Pay Only a Low Million kW-h Rate!*TDA Perks Program has partnered with JLT Energy Consultants, a company that develops master programs with multiple energy providers to provide special rates for large groups of individuals. This means that through TDA Perks Program, TDA members living in deregulated areas now have access to lower-tier energy prices.

Following are some of the features of the TDA Perks Program contract:•Rather than an offi ce paying a rate based on its own usage, each offi ce under the Perks Program will be quoted as if the offi ce used 1 million kW-h annually.

To Qualify for TDA Perks Group Electricity Program:1. You must be a TDA member.

2. *Your area must be deregulated to permit competition.

3. Your current contract must be expired or expiring. When your contract expires, you can join other TDA members who qualify for a lower-tier rate, and save thousands of dollars per year. If your offi ce uses 80,000, 90,000 or less than 250,000 kW-h, it can sign a new contract to pay the same rate as those using 1-million to 2-million kilowatt hours of electricity per year. Your new rate will effectively give you a savings equal to free electricity for the last two months of every year.

•If you sell or move your business, your contract can either be taken to your new location, or terminated without penalty.

•If the price of electricity goes down during the term of your agreement, you can request “blend and extend” to take advantage of these lower rates.

•The Contract is for a FIXED rate per kilowatt, regardless of usage.

•The contract can be for one year up to four years; each dentist offi ce has a choice, and is only responsible for his/her own contract. Learn more: tdaperks.com

For more information, call JLT Energy:

(682) 224-1385

724 Texas Dental Journal l www.tda.org l July 2010“The Hartford” is The Hartford Financial Services Group, Inc. and its subsidiaries. ©2009 The Hartford.

Insure wIth tDA FInAnCIAL serVICes InsurAnCe ProgrAm AnD the hArtForD

running a successful dental practice isn’t easy. Attending to patients, handling paperwork, dealing with a hundred little details that need your attention – there are a number of challenges. Finding the right insurance shouldn’t be one of them. the tDA Financial services Insurance Property and Casualty Program features the hartford’s spectrum® business owners’ policy. In addition to financial strength, excellent service and dependable claim handling, the program includes the following features:

• Electronic Funds Transfer

• 12 Equal Payments (No large down payment!)

If you don’t have your Property, Liability, or workers’ Compensation insurance placed through the tDA Financial services Insurance Program, there has never been a better time to switch.

Contact us today at (888) 588-5420 or [email protected]

the tDA Financial services Insurance Program is administered by the higginbotham & Associates brokerage firm.

july 2010

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