February 2011

February 2011y

TEXAS DENTALJournalClinical Decision Making:

Fitting Evidence Into the Picture

Dental School

Knowledge

Marketing

Information

Local

Opinion

Leaders

Professional

Guidelines

Continuing

Education

Patients

Clinical

Experience

Recent

Lawsuits

Study Club

Information

Texas Dental Journal l www.tda.org l February 2011546142142 Texas Dental Journal l www.tda.org l February 2Texas Dental Journal l www.tda.org l February 2

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.

144 Texas Dental Journal l www.tda.org l February 2011

ContentsTEXAS DENTAL JOURNAL Established February 1883 Vol. 128, Number 2, February 2011

ON THE COVER Evidence-Based Dentistry Evidence-based dentistry combines a dentist’s treatment decisions with his or her clinical expertise and experience, available research, and the patient’s needs. The skill is a lifelong learning process, ever-changing, and dependent on the dentist’s search for more knowledge and evidence. Cover concept by Dr. John D. Rugh, a professor in the Department of Developmental Dentistry and Director of the Evidence Based Practice Program at the University of Texas Health Science Center at San Antonio Dental School in San Antonio, Texas.

ARTICLES — EVIDENCE-BASED DENTISTRY

155 Principles of Evidence-Based Dental Practice (EBDP) Hoda Abdellatif, B.D.S., Dr. PH.; Paul C. Dechow, Ph.D.; Daniel L. Jones, D.D.S., Ph.D. write up to come

167 Three PubMed Skills to Support Evidence-Based Dentistry S. Thomas Deahl II, D.M.D., Ph.D. write up to come

177 The Evidence-Based Initiative at Baylor College of Dentistry Daniel L. Jones, D.D.S., Ph.D.; Robert J. Hinton, Ph.D.; Paul C. Dechow, Ph.D.; Hoda Abdellatif, D.D.S., Ph.D.; Ann L. McCann, RDH, Ph.D.; Emet D. Schneiderman, Ph.D.; Rena D’Souza, D.D.S., Ph.D. write up to come

183 Teaching Evidence-Based Practice at The University of Texas at Houston Dental Branch Richard D. Bebermeyer, D.D.S., M.B.A. write up to come

187 Teaching Evidence-Based Practice at the University of Texas Health Science Center at San Antonio Dental School John D. Rugh, PH.D.; William D. Hendricson, M.A., M.S.; Birgit J. Glass, D.D.S., M.S.; John P. Hatch, PH.D.; Thomas S. Deahl, D.M.D., PH.D.; Gary Guest, D.D.S.; Richard Ongkiko; Kevin Gureckis, D.M.D.; Archie A. Jones, D.D.S.; William F. Rose, D.D.S.; Peter Gakunga, D.D.S., M.S., PH.D.; Debra Stark, D.P.H.; Bjorn Steffensen, D.D.S., M.S., PH.D. write up to come

193 The Challenges of Transferring Evidence-Based Dentistry Into Practice Richard T. Kao, D.D.S., Ph.D. write up to come

201 The ADA’s Center for Evidence-Based Dentistry: A Critical Resource for 21st Century Dental Practice Julie Frantsve-Hawley, R.D.H., Ph.D.; Arthur Jeske, D.M.D., Ph.D. write up to come

207 ADA Champions of Evidence-Based Dentistry Conference Joshua Austin, D.D.S. write up to come

211 How Effective is That Treatment? The Number Needed to Treat S. Thomas Deahl II, D.M.D., Ph.D. write up to come

Texas Dental Journal l www.tda.org l February 2011 145

MONTHLY FEATURES

148 President’s Message

149152 The View From Austin

206 TDA 140th Annual Session 2010 TEXAS Meeting Photo Contest

213 Oral and Maxillofacial Pathology Case of the Month

214 TEXAS Meeting Preview

217 Oral and Maxillofacial Pathology Case of the Month

Diagnosis and Management

218 Value for Your Profession

220 In Memoriam / TDA Smiles Foundation Memorial & Honorarium

Donors

221 Calendar of Events

224 Advertising Briefs

240 Index to Advertisers

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


EDITORIAL STAFF

Stephen R. Matteson, D.D.S., EditorNicole Scott, Managing Editor

Barbara S. Donovan, Art DirectorPaul 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 mail-

to TEXAS DENTAL JOURNAL, 1946 S. Interregional Highway, Austin, TX 78704.Annual subscriptions: Texas Dental Association

-

orders, add 8.25% sales tax.Contributions: Manuscripts and news items of inter-est to the membership of the society are solicited. The Editor prefers electronic submissions although paper manuscripts are acceptable. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. 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 state-ments of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any

or services described in their articles. Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such product or of the claims made of it by its manufacturer.


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Texas Dental Journal l www.tda.org l February 2011 147 Texas Dental Journal l www.tda.org l August 747


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

Decision Points

Decision Points, the autobiographical memoirs of President George W. Bush, was published by Crown Publishers in 2010. For those in leader-ship, regardless of your political persuasion, it is an enlightening read. President Bush states that his hope is “that this book will serve as a resource for anyone studying this period in American history,” and secondly “to give readers a perspective on decision making in a complex environment.”

President Bush was forced to make decisions in the period following 9/11 that were far bigger than any decisions the rest of us will ever be required to make. He had to decide for instance, how to allow the intelligence community to seek out those terrorists already within our borders without the destruction of the civil liberties of the American people. He also had to make the decisions about entering into wars in Iraq and Afghanistan.

While he got advice from all quarters, in the end,

decisions has been re-examined many times.

While the decisions as president of the TDA are nothing in comparison to the decisions a presi-dent of our country must make, they are frequent and often affect many people. I am always pleased to have your input on these matters.

As dentists, striving to serve our patients and to deliver to them the best of care that the art and science of dentistry has to offer, we all daily make decisions affecting the welfare of others. We are fortunate to have science backgrounds and to have the opportunity to “co-diagnose” with our patients.

This special issue of the Texas Dental Journal is focused on Evidence Based Dentistry (EBD). In the decisions that we make in our practices, EBD is a valuable tool. While EBD will not account for the individual nuances that each of our patients

-dation upon which we, in conjunction with the

Articles in this issue will explain the principles of EBD, how it is being presented in Texas dental schools, and how we can incorporate EBD into

Enjoy your Journal!


HOUSE OF DELEGATES: In accordance with Chapter IV, Section 70, paragraph A of the Texas Dental Association (TDA)

of the House will convene at 8:00 a.m. on Thursday, May 5, 2011, in Ballroom B on the street level of the San Antonio Conven-tion Center in San Antonio, Texas. The second meeting of the House will be at 8:30 a.m. on Saturday, May 7, 2011, in Ballroom B. The Sunday, May 8, 2011, meeting will be in the Marriott Rivercenter Hotel, starting at 8:30 a.m.

REFERENCE COMMITTEE HEARINGS: Reference Committees will meet on Thursday, May 5, 2011, in the Convention

minutes after the adjournment of the House of Delegates, whichever is later. Reference Committee E will start at 12:00 noon.Reference Committee B will start at 1:00 p.m. Reference Committee C will start at 1:30 p.m. Reference Committee D will start at 2:00 p.m. The agendas for these meetings will be sent to the Delegates and Alternate Delegates prior to the meetings.

REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be e-mailed in PDF format to all participants andthese reports may be downloaded from any location with Internet access. Printed reports will be available on Friday, May 6,

location.

CANDIDATES FORUM: As a reminder, the TDA / ADA Candidates Forum will be held on Friday, May 6, 2011, from 2:00 p.m.

DIVISIONAL CAUCUSES: Divisional Caucuses (Northwest, Northeast, Southwest, Southeast) will be held at 5:15 p.m. on

DELEGATE BOOK: In accordance with TDA Bylaws, the Delegate Book will be sent 30 days prior to the Annual Session. The supplement to the Delegate Handbook, containing the agenda and subsequent reports, will be sent after the spring TDA Board of Directors meeting, April 1-2, 2011. Delegates and alternates will receive their House book in a searchable PDF format.

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

The View From Austin

“Doctor, look at this new restorative material my company is selling. It holds its color longer, seals the margins perfectly, is easy to handle. Research shows this is the best product on the market, and just for you, I can give you a great deal on the price.”

Quite often, we hear these types of messages at our dental meetings and from salespersons about new products in dentistry. Being a skeptical bunch, we are leery of such tactics, but also want to adopt proven new technology in our practices; so who to believe? Experts at continuing education courses? Colleagues in our study clubs or dental societies? Mailings from commercial sources? Articles in journals? Online infor-mation sources? What was taught in dental school, our own experience in practice?

The Texas Dental Journal requires authors to disclose -

ated with products in their manuscripts, as do most

with information that they can use to assess the valid-ity of statements in these articles. The TDA also re-quires similar disclosures from providers of courses at its annual meeting. I believe that cautious readers and course attendees take these disclosures seriously and use this information when deciding if new technologies or techniques should be adopted in their practices. It comes down to this: Should we make changes in our practices or not?

Still, there remains the question of validity; and how do I, the practitioner, know that what I am reading or be-ing told is the truth? Enter evidence-based dentistry, a.k.a. best practice. The American Dental Association

Evidence Based Dentistry“Evidence-based dentistry (EBD): An approach to oral health care that requires the judicious integration of

evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical ex-pertise and the patient’s treatment needs and prefer-ences.”

I think of it in two parts:

validity of a particular material or technique? 2. Is the information important enough for me to

make this change in my practice?

This issue of the Texas Dental Journal is devoted to EBD and includes information on how to search for the evidence using PubMed, the Cochrane Collaboration, and the ADA website on this material. These sources

and providing the level of evidence.

The ADA Council on Dental Accreditation (CODA) has recently updated its curriculum standard on this topic:

“Standard 2-21: Graduates must be com-petent to access, critically appraise, apply,

-ture as it relates to providing evidence-based patient care.

Intent: The education program should introduce students to the basic principles of clinical and translational research, including how such research is conducted, evaluated, applied, and explained to pa-tients.”


In response to these standards, authors at Baylor College of Dentistry-Texas A&M Health Sci-ence Center, the University of Texas Dental Branch at Houston, and the University of Texas Health Science Center at San Antonio Dental School have kindly provided reports on their efforts to provide instruction on evidence based dentistry.

The ADA has also sponsored a “Evidence-Based Dentistry Cham-pions Conference” in which dental practitioners from around the coun-try attended training sessions with the intent that they would promote this subject in their dental commu-nities. Dr. Josh Austin of San An-tonio participated in this program and has kindly provided a report on his experience. In addition, the ADA has trained dentists to be reviewers of EBD articles submit-ted for publication in the Journal of the American Dental Association. Table 1 is a talley of ADA EBD champions and EBD reviewers in Texas (courtesy of Erica Vassilos, MPH, [email protected], Manag-er, ADA Center for Evidence Based Dentistry, Division of Science.)

It should also be noted that the scope of dental research is some-what limited in that the number of meta-analysis and systematic reviews is low compared with that in medicine. The goal of EBD is to identify the best available

to provide practitioners with the lat-est available information. Clearly stating the level of evidence is a part of these efforts so dentists can weigh the value and importance of the information that is presented. For example, laboratory reports and individual case studies are of low value for clinical decision-mak-ing but can be important for the

The EBD Champions from Texas, outlined by city, from

City Number of EBD Champions

Colleyville, TX 1

Dallas, TX 2

Fort Worth, TX 1

Houston, TX 4

Pasadena, TX 1

San Antonio, TX 5

The ADA EBD Reviewers from Texas, outlined by city:

City Number of EBD Reviewers

Austin, TX 1

Converse, TX 1

Dallas, TX 1

Houston, TX 3

Plano, TX 1

San Antonio, TX 1

Table 1.

further development of research projects, while systematic reviews of the literature are of greater value to guide diagnosis and treatment planning. It is also important to understand that the research evidence at any point in time will only be what is available at that time, and that continuous moni-toring of the literature will reveal new knowledge as it becomes available.

upon the “dentist’s clinical expertise and the patient’s treatment needs and preferences.” EBD provides input into such decisions and is not intended for use by third parties for reimbursement procedures, or is an attempt to direct dentists to make changes in practice procedures.

The Editor is grateful to all contributors to this issue on EBD and hopes that the information contained will be of value to the readers.

Reference: http://ebd.ada.org.


Principles of Evidence-BasedDental Practice (EBDP)

Hoda Abdellatif, B.D.S., M.P.H., Dr. PH.,Paul C. Dechow, Ph.D.,Daniel L. Jones, D.D.S., Ph.D.

AbstractIn an effort to improve patient care, there has been a grow-ing trend across the nation and the world to embed the principles of evidence-based dentistry into mainstream caredelivery by private practicing dentists. Evidence-baseddentistry is an essential toolthat is used to improve the quality of care and to reducethe gap between what weknow, what is possible, and what we do. An evidence-based health care practice is one that includes the decision

and incorporate high-quality,valid information in diagnosis and treatment. The evidence is considered in conjunctionwith the clinician’s experi-ence and judgment, and the patient’s preferences, values, and circumstances. Thisarticle introduces the basic skills of evidence-based den-tistry. Their practice requires a discipline of lifelong learningin which recent and relevant

-lated into practical clinical applications.

KEY WORDS: Evidence-based dentistry, evidence-based practice, hierarchy ofevidence, steps in evidence-based dentistry.

Tex Dent J 2011;128(2):155-164.

Dr. Abdellatif is an assistant professor, Department of Public Health Sciences, Baylor College ofDentistry-Texas A&M Health Science Center (TAMHSC).

Dr. Dechow is a professor and vice chair, Department of Biomedical Sciences, Baylor College of Dentistry-Texas A&M Health Science Center (TAMHSC).

Dr. Jones is a professor and chair, Department of Public Health Sciences, Baylor College of Dentistry-Texas A&M Health Science Center (TAMHSC).

Corresponding Author: Dr. Hoda Abdellatif, Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Dallas, Texas 75246. Phone: (214) 828-8164; Fax: (214) 874-4555;E-mail:[email protected].

IntroductionTo some the phrase “evidence-based dentistry” ap-pears odd insofar as the juxtapostioning of the words “evidence-based” and “dentistry” implies that not all dental care is based upon evidence. Those bothered by the phrase include dental practitioners who believe that the training they’ve received in dental school wasbased upon current evidence and that that evidence

-fessional careers. Those bothered by the phrase also include dental patients who believe that their dental

of health care — well-recognized to be scholarly chal-lenging — delivers the best possible care known to the

Abdellatif Jones


Unfortunately, dental care today is often not based upon the most current evidence, and the training requirements and infrastructure of modern dentistry has lacked mechanisms for assuring the incorpora-

-dence-based dentistry” is not simply a response to a lack of evidence in dental care, as the traditions and clinical experience of modern den-tistry have led to a high level of care. Rather the phrase denotes a new methodology — based on a revolution in information infrastructure, clinical research design, and biostatistics — that enables all practi-

clinical studies and analyses, and to possess the intellectual tools to interpret this information for modern patient care.

Evidence-Based Dental Practice (EBDP) is a thoughtful integration of the best available external evidence from systematic research, coupled with individual clinical expertise (1). As practitioners face healthcare questions and with the approach of EBDP, they are able to evaluate the relevance and quality of the evidence as it may apply to their spe-

current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating

was originally developed in cer--

ciples apply to all health care arenas, including dentistry. The American Dental Associa-

-dence-based dentistry” as “an approach to oral health care that requires the judicious integration of systematic as-sessments of clinically relevant

the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.” Simply stated, evidence-based dental practice is “the integration of the best research evidence with clinical expertise and pa-tient values” (Figure 1).

Figure 1

Principles of EBDP


EBDP Approach

method for evidence-based prac-tice, let’s ask: why is evidence-based practice important?

Explosion of literature. Health-care literature, with clinically

at so great a rate that it is impos-sible for individual clinicians to keep up, especially across a

According to Neiderman, dental clinicians would need to iden-tify, obtain, read, and appraise more than one article per day, 365 days per year, for the rest of their professional lives in order to keep-to-date with just articles

addressing therapy. This is an impossible task (4).

Unmet information needs. Practitioner information needs are not currently being met. For every three patients seen, two questions are generated. Due to lack of time and/or weak search skills, only 30 percent of physi-cians’ information needs were met during the patient visit, usually by another physician or other health professional (6).

Implementation delay. Re-

in being implemented into clini-cal practice. It has been reported

that the diffusion of new knowl-edge among health care workers is a slow process (7,8). Accord-ing to Balas, it takes an average of 17 years for clinical research to be fully integrated into every-day practice (9).

Despite the formidable advances in information technology, re-search design, and biostatistics that have enabled the revolution in evidence based practice, a sound method for EBDP is relatively simple and can be easily learned through practice and awareness, as can any other competency leading to effect modern clinical practice. What is this method?

Step 1: AskingConverting the clinical question to an answerable question

Step 2: AccessingSearching to identify pertinent clinical research studies, systematic reviews, guidelines, and other evidence-based resources to answer the question

Step3: AppraisingCritically evaluating the evidence to assess its validity and relevance

Step 4: ApplyingMaking the decision based on sound evidence, professional expertise, and patient preferences

Step 5: AssessingEvaluating the results and the process


Where do the questions come from? Important clinical questions arise from daily encounters with patients in the practice setting. These questions often relate to therapy (e.g., which material is superior or what drug should be pre-scribed?), diagnosis (is this test accu-rate and reliable?), prognosis (what is

this patient’s likely clinical course over time or what is the expected longevity of this restoration?), or

causation (what is the etiol-ogy of this condition or is this treatment harmful?).

best available evidence, the clinician must ask a well-designed clinical question with all the compo-nents that will lead to the most rel-evant clinical research literature. A clear question will help one identify key words for use in a search of online databases.

the type of question: background or foreground. The type of question helps to determine the resources needed to answer the question.

“Background” questions are usually asked because of a need for basic in-formation or general knowledge about a disease or disease process. They are not asked because of a need to make a

-tient.

“Foreground” questions are focused to

clinical decisions or actions.

A well-built focused clinical question includes the following four components (PICO) (10):

Principles of EBDP

Step 1: Formulating the QuestionPatient’s disease or problem Intervention (exposure to treat-

ment, risk factor, diagnostic test) Comparative intervention (if appli-

cable — not always present) Outcome

The framework constructed through a “PICO” question provides the necessary components for asking an answerable online query.

The following approach will help the framing of a good question:

-tion (P). It may be helpful to phrase the question in this form: “How would I describe a group of pa-tients similar to this one?”

-tient or population; it could be an exposure to a disease, a diagnostic test, a prognostic factor, a treat-ment, or a risk factor.

intervention. It may be appropri-ate to compare with no disease or treatment, but usually inter-ventions for comparison will be a placebo, a different prognostic fac-tor, different diagnostic method, or absence of a risk factor. In the case of treatment, the comparison is often to the “standard of care.”

-


Here is an example question that includes all four PICO components: “In patients with

Patients with oral lesions

Toluidine mouth rinse

Oral biopsy

Detect oral cancer

undiagnosed oral lesions, can a toluidine blue mouth rinse, when compared to an oral biopsy, ef-

fectively detect oral cancer and/or precancerous lesions?

What is the Patient’s disease/ problem?

What is the Intervention?

What is the Comparison intervention?

What is the Outcome?

Applying the PICO method is a systematic way to identify important concepts in a clini-cal scenario, and formulate a question for online searching. However, often one does not have an intervention for comparison. Also, different types of EBDP resources require different levels

the types of available resources, one might not search with all the

Remember, no matter what resources are available, one should always start by applying a PICO question to the clinical scenario so that the search has the potential to lead to relevant

to formulating PICO questions is available at http://medinformatics. uthscsa.edu/EviDents/.

Remember that minutes spent properly formulating the ques-tion will save hours of time in searching.

Once you have formed your PICO question, understanding the type of question (therapy, diagnosis, prognosis, or causation) is also important in your search for evidence.

Step 2: Database/Resource SearchingHaving successfully formulated the clinical question related to the patient’s prob-

the question. There are several types of information resources that can be con-sulted, and these generally are categorized as (i) general information (background)

consulted in that order depending upon the particular situation.

General Information (Background) Resources

The clinical question may fall outside one’s specialty area or in-volve a situation which is rare for a provider. A comprehensive overview of the area may be necessary. In such a case, back-ground resources (e.g., textbooks and other reference material)

foreground question (PICO). Background resources provide detailed information, but seldom include the most current re-search on the topic. They often will include references to clini-cal research literature, from which one can judge the currency of the information.


For example: a patient presents with a cracked tooth. If you need to refresh your knowledge of the clinical presentation, diagnosis and treatment of a cracked tooth, a background resource would be the best place to start.

Filtered Resources

A second step in seeking an answer to a clinical question is

resources to see if the question has recently been investigated by a clinical expert or subject spe-cialist, and if the evidence has been systematically compiled and synthesized into recommendations or guidelines. It often can be the case that the question has already been addressed in an evidence-based manner through clinical studies and associated systematic reviews. Because the literature has been searched and results

be very useful to a clinician, sav-ing time and providing the assur-ance of skilled review. The caveat, however, is that, relative to the vast variety of possible clinical

may only include a small fraction.

The conclusions produced by these resources still need to be evaluated by the clinician for

patient, but are very helpful and -

source exists. There are many evi-dence-based review resources that synthesize and critically appraise current healthcare literature such as the ADA EBD Database (ebd.ada.org), the Cochrane Collabora-tion of Systematic Reviews, the National Guideline Clearinghouse,

Principles of EBDP

the Database of Abstracts of Re-views of Effectiveness (DARE), and the Journal of Evidence-Based Dental Practice (11-16). The TRIP (Turning Research into Practice)

-source that allows health profes-

quality material available online to support evidence-based practice (17). It simultaneously searches evidence-based sources of system-atic reviews, practice guidelines, and critically-appraised topics and articles.

These resources provide a variety of information backed up with links to the literature that was used to formulate the clinical recommendations. Synthesized EBDP resources are easy to use and help quickly connect practi-tioners with evidence-based an-swers to their clinical questions.

By using these EBDP resources, clinicians can make evidence-based decisions about patient

-cient manner.

Evidence is often not available via

--

erature) is needed to answer the -

tered resources address the ques-

and new research may be avail-able that addresses the question.

resources need to be consulted. These resources provide the most recent information, but it is up

to the clinician to evaluate each study found to determine its va-lidity, relevance, and applicability to the patient. Effectively search-ing and evaluating the studies

takes more time and skill, which

-cal questions. PubMed is con-sidered the database of choice for the health sciences, as it provides nearly complete access to primary and secondary litera-

literature searches performed in PubMed and other databases such as Ovid Medline and CIN-

clinical research.

Making Search Decisions

-tion on your topic answer your question? For example, are you looking for presenta-tion information, a list of dif-ferential diagnoses, or types of therapies? Try a recent background resource, such as a text book, a reference handbook, or a reliable pro-fessional internet resource.

the best course of action (for diagnosis, treatment/preven-tion, prognosis, or etiology/harm) and want to incorpo-rate recent, valid evidence into your decision? Consult a

answer to your question in a

want to continue your inqui-ry by checking the primary clinical research literature?


-lenging task. However, simply treating one’s patient in the same manner as 10 or 20 years ago may be inadequate or in the worst case, may be malpractice. After identifying an article or resource that seems appropriate to your question (step 2), you must criti-cally appraise the information.

If the study is from a primary source — one that provides original data on a topic with no commentary — you should do a “validity” (closeness-to-truth) check. There are three basic questions used to guide the critical analysis process (1):

1. Are the results of the study valid?2. What are the results?3. Are the results applicable to my patient?

research design, methods, and manner in which the study was executed. A study without valid design, methods, or manner of execution yields little information, and the associated research article may be of little value. However, interpretation of clinical

research is often highly technical so study groups or seeking expertise from clinical research experts may be needed in order to adequately evaluate a primary clinical research article.

After concluding that a study described in an article is valid, then the second issue simply relates to understanding whether the results from the study are important, and whether they can be used in a way clini-

results, one needs to take into consideration the patient’s needs and preferences as well as evaluating the patient’s circumstances.

Fortunately, a number of different appraisal tools are available on the internet for download and use. Several evidence-based groups provide critical appraisal checklists of these questions (18, 19). One of these groups is CASP, the Critical Appraisal Skills Programme, which has developed tools to help with the critical appraisal of research articles related to diagnosis, therapy, harm, and prognosis.

The Evidence Pyramid provides an excellent short graphic review of which types of research articles, if done well, provide the greatest evi-dence. As you move up the pyramid the amount of available literature decreases, but increases in relevancy to the clinical setting (Figure 2).

When evaluating the evidence, you need to keep in mind the “quality” of the individual studies and the “consistency” of evidence across all the studies being evaluated. The “quantity” of studies can be another

Effectively searching and

evaluating the studies

found in unfiltered re-

sources takes more time

and skill, which is why

filtered resources are the

first choice for answer-

ing clinical questions.

PubMed is considered the

database of choice for

the health sciences, as it

provides nearly complete

access to primary and

secondary literature.

Step 3: Critical Appraisal


factor to be consider but is of a lesser weight in the determin-ing the evidence — in clinical research, the best research (well designed, controlled, and with adequate sample sizes or power) greatly exceeds in importance large numbers of lesser studies,

question.

Once the review of the evidence is completed and the validity and relevance of the study deter-mined, you need to communicate

your patient and decide how the

apply to your question (step 4).

To reach your conclusion regarding the applicability of the evidence, you may consult questions related to diagnosis, therapy, harm, and progno-

sis. Keep in mind that you must interpret the information based on the research methodology and evaluation criteria described, on your skill and experience, and on patient needs/preferences. Your professional expertise becomes

(few systematic reviews or rigorous primary clinical re-

professional expertise and/or the evidence is weak, other professional expertise is sought, such as reliance upon peer specialists. The patient’s needs and preferences are

EBDP is patient-centered care and includes respect for patient autonomy. The most a practitioner can do is to give advice on optimal care and then let patients make their

own health care decisions.

Principles of EBDP

Figure 2

Step 4: Applying the Evidence


In the process of executing EBDP, you have developed a clinical question (step 1), sought out answers to verify and support your clinical decision (steps 2 and 3),

The last step in this process is to evaluate the effectiveness and

You may ask questions such as:

Remember that all of these questions require thoughtful action and keeping up-to-date with the current literature.

ConclusionThe above discussion may seem to many as very prescriptive — a sequence of steps to be followed that will lead to an answer. “Where is the art of health care?” one may ask. “By following this sequence, what’s to distinguish my delivery of dental care from another who follows the same steps?” The response to this cri-tique involves recognizing that while the sequence is quite logical, it is subject to

For example, a slightly different PICO question may lead to a different published evidence, and ultimately to a different decision regarding a presenting patient.

latest and most relevant clinical research.

The other comment that should be made in conclusion is that the set of skills of EBDP (i.e., the generic steps to be pursued to arrive at the best evidence) are re-ally quite straightforward, and will easily become second-nature to those who pur-

-tation of primary clinical research literature, continued study can in short order lead to greatly increased understanding of the nuances of clinical research and its interpretation. Unfortunately for many providers, it is not a set of skills that is discoverable by one’s self, and it is one in which the newer dental graduates will be increasingly conversant as the skill set is now being added to the curriculum of dental schools. Learning EBDP requires explicit communication, presentation, and practice. Although there are many dental care providers today who are with-out EBDP skills, leading to practice that is not evidence-based, regular courses are now being offered by the ADA, and various other dental and medical profes-sional organizations that will provide introductions to this skill set, and eventually greater competency throughout the various health care professions.

Step 5: Re-evaluating the Evidence


References

1. Sackett DL, Strauss S, Rich-ardson WS. Evidence-based Medicine: how to practice and tech EBM. New York: Churchill Livingstone; 2000.

2. The Centre for Evidence-based Medicine. Finding the best evidence. Available at: http://www.cebm.net/in-dex.aspx?o=1023. Accessed October2nd, 2010.

3. Neiderman R, Badovinac R. Traditional dental care and evidence-based dental care. J dent res1999; 78: 1288-91.

4. Neiderman R, Chen L, Muurzyn L. Benchmarking the dental randomized con-trolled literature on Medline. Evid Based Med 2002; 3:5-9.

5. Alper BS, Hand JA, Elli-otSG, Kinkade S, Hauan, MJ, Onion DK, Sklar BM. How much effort is needed to keep with the literature relevant for pimary care? Journal of the Medical Library Association 2004; 92(4): 429-37.

6. Covell DG, Uman GC, Man-ning PR. Information needs

being met? Annals of Inter-nal Medicine 1985; 103(4): 596-99.

7. Rogers EM. Diffusion of In-novations. Fourth Edition, The Free Press, New York, 1995.

8. Cain M. and Mittman R. Diffusion of Innovation in health care. Available from: URL: http://www.chcf.org/publications/2002/05/diffusion-of-innovation-in-health-care

9. Balas A E. Information sys-tems can prevent errors and improve quality. J A M I A 2001; 8(4): 398-99.

10. Richards D. Asking the right question right Evidence-Based Dentistry 2000; 2: 20 - 21

11. The American Dental Asso-ciation. Center for Evidence-Based Dentistry. Available from: URL: http://ebd.ada.org. Accessed September 15th , 2010

12. The Cochrane Collaboration. Oral Health Review Group. Available from: URL: http://www.cochrane.org/reviews/en/topics/84_reviews.html. Accessed October 10th, 2010.

13. National Institute for Health Research. Centre for Re-views and Dissemination. Available from: URL: http://www.crd.york.ac.uk/crd-web/. Accessed October 10th, 2010.

14. The Journal of Evidence-based Dental Practice. Else-vier. Available at: http://journals.elsevierhealth.com/periodicals/ymed. Accessed October 10th, 2010.

Principles of EBDP

15. The national guideline clear-ing house. Available from: URL: http://www.guideline.gov . Accessed October 20th, 2010.

16. The Database of Abstracts of Reviews of Effectiveness (DARE). Available from: URL: http://www.crd.york.ac.uk/crdweb/ . Accessed October 20th, 2010.

17. Turning Research into Prac-tice (TRIP) database. Avail-able at: http://www.trip-database.com/. Accessed November, 11th, 2010.

18. The Centre for Evidence-Based Medicine. Critical appraised sheets. Avail-able from: URL: http://www.cebm.net/index.aspx?o=1157 . Accessed September 2010

19. CASP, Critical Appraisal Skill Programme. Appraisal Tools. Available from: URL: http://www.phru.nhs.uk/Pages/PHD/CASP.htm . Ac-cessed September, 2010.


Three PubMed Skills to Support

Evidence-Based DentistryAbstractThe National

Library of Medicine’s

PubMed database

can powerfully

assist dentists in

evidence-based

practice. Three

useful PubMed

skills can improve

clinician’s search: (1)

Use of MeSH terms;

(2) Use of Limits;

(3) Use of Clinical

Queries.

KEY WORDS:PubMed Medical

Subject, Headings,

Evidence-Based

Dentistry

Tex Dent J 2011;128(2):167-173.

IntroductionPubMed at http://www.ncbi.nlm.nih.gov/pubmed can pow-erfully assist the clinician seeking the best evidence. Peer-reviewed journals contain the highest-quality evidence for decision-making in clinical practice, and PubMed indexes mostof these journals and their contents. PubMed, a database of the U.S. National Library of Medicine, contains millions of citations of journal articles and other publications, many with abstracts, and is updated four times per week. PubMed is the electronic equivalent of the (now-discontinued) print publication Index Medicus, which clinicians may remember using during their university education.

Over 800 dental journals, including the Texas Dental Journal, are indexed in PubMed, along with many medical and pharmacy journals which may con-tain articles relevant to dentistry. Over 5,000 journals are currently indexedin this database. PubMed’s principal component is Medline, which coversreferences in the biomedical literature back to 1947.

Although the dentist has many search options today, including databases such as Google and Bing, PubMed covers principally peer-reviewed clinical

reducing the amount of extraneous information the clinician must scan.

S. Thomas Deahl II, D.M.D., Ph.D.

Dr. Deahl II is n adjunct associate professor, Department of Developmental Dentistry, The University of Texas Health

Contact Information: Department of Developmental Dentistry, UTHSCSA Dental School, 7703 Floyd Curl Drive, San

Science Center at San Antonio, San Antonio, Texas, and The Institute for Natural Resources, Concord, California.

Antonio, TX 78258. Telephone: (210) 567-3500. E-mail [email protected]

materials discussed in the manuscript.

Deahl II


A full tour and explanation of PubMed is beyond the scope of a single article. Readers desiring a full tour may take the free-of-charge tutorial, a full version of which takes at least 2 hours, at http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/

PubMed contains hyperlinks from citations to full-text jour-nal articles whenever they are available. For many citations in PubMed, only the abstract is available. If the clinician desires to read the full-text article which is unavailable online, he or she should contact a biomedical

Three PubMed Skills

Figure 1. Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

library to obtain an interlibrary loan of the document.

PubMed could be used, in aca-demic settings, for an extensive review of the literature on a par-ticular topic. The evidence-based clinician, however, usually does not want an extensive literature review but instead wants to

three citations on a topic, read their abstracts, and in some cases peruse the full-text article. The three skills discussed in this article support this goal.

The PubMed user faces two

is that the database contains too many citations to inspect individually. PubMed adds 2,000 to 4,000 references each day, and over 712,000 citations were added in 2009. Therefore,

needed to narrow the list of cita-tions to only a few which may be perused individually. The second challenge is that the narrowing process, if conducted by the user injudiciously or too aggressively could screen out some of the most pertinent citations.


A well-designed PubMed search on a clinical problem should yield only a handful of citations, but should contain the very best, most pertinent citations. This article discusses three methods to help the busy clinician more

to support clinical practice. Readers should consult their biomedical library’s reference librarian (this may be done by telephone or email) for additional help in searching PubMed.

Evidence-Based Skill #1: Use Mesh terms Although PubMed users may simply enter any terms into the search box at the top of the home page (see Figure 1), the use of MeSH terms may improve the ef-fectiveness of the search. MeSH (an acronym for MEdical Sub-ject Headings) is the controlled vocabulary used by National Library of Medicine indexers. Indexers assign relevant MeSH terms to each citation as it is en-tered into PubMed. Some of the assigned terms, though very rel-evant to the central topics of the citation, may not appear in the article’s title nor in the abstract. PubMed users who employ MeSH terms while searching may oc-casionally retrieve highly relevant citations that they would not retrieve without using MeSH.

The basic strategy is to search the MeSH database for the best MeSH terms, and then use the MeSH terms to search PubMed. A video tour of the MeSH da-tabase begins at http://www.nlm.nih.gov/bsd/viewlet/mesh/searching/mesh1.html



Step 1: In the PubMed home page,click on “MeSH Database” (Figure 1, see circled hyperlink).

Step 2: In the resulting screen, enter a desired term into the search box. Note in Figure 2 that we have entered “parotid tumors.”

Step 3: Click on the “Go” button to the right of the search box.

Step 4: Peruse the available term(s) on the subsequent screen. Note in Figure 3 that the MeSH term is “Parotid Neoplasms.” Check the term(s) desired, then click on the drop-down menu “Send to search box with “AND”” as shown in Figure 3.


Three PubMed Skills


Step 5: On the resulting screen, click on “Search PubMed” to search the PubMed database us-ing the selected MeSH term(s), as shown in Figure 4.

Step 6: Note the search results, as shown in Figure 5. Note in Figure 5 that we have retrieved over 6,400 citations, too many to review. Retrieving a large num-ber of articles raises the need for the next skill covered here, which is using PubMed Limits.

Evidence-Based Skill #2: Using PubMed Limits “Limits” allows PubMed users

evidence, such as “systematic re-view” or “randomized controlled trial”. The “Limits” function is found on the PubMed search page (see Figure 5, hyperlink circled). Click on the “Limits” hy-

perlink and peruse the resulting screen (see Figure 6). Citations may be limited by Type of Ar-ticle, Species, Language, or other criteria. Limits most useful for

on questions about therapy and prevention include “Meta-Analysis” and “Randomized Controlled Trial” in the “Type of Article section, and “Systematic Review” in the “Subsets” section of the Limits page. Selecting a Limit (as we have done, circled, in Figure 6) and then clicking on the “Search” button returns





Source: National Library of Medicine at http://www.ncbi.nlm.nih.gov

Three PubMed Skills



results as shown in Figure 7, a much more reasonable number of results to review.

For a tutorial on using Limits, see http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/020_210.html.

Evidence-Based Skill #3: Using Clinical Queries“Clinical Queries” is a PubMed tool that helps the user to quick-

-ing to the topic of interest. This tool is found at http://www.ncbi.nlm.nih.gov/pubmed/clinical as circled in Figure 8. Clicking on the “Clinical Queries” link re-turns the screen shown in Figure 9. On this screen, enter the term of interest (as we have done with “Parotid neoplasms”, choose the Category (Therapy, as shown circled; Diagnosis is also avail-able from a drop-down menu) and choose the scope (Broad or Narrow, as shown circled). Then click on the “Search” button.

This returns the screen shown in Figure 10. Note that the left-hand column shows a list of citations from Clinical Studies; the middle column shows a list

-atic Reviews; and the right-hand column shows a category less often relevant to dental practice, Medical Genetics.

A tutorial on using Clinical Que-ries is found at http://www.nlm.nih.gov/bsd/disted/pubmedtu-torial/020_570.html.



This brief introduction to the powerful PubMed is intended to encour-age the evidence-based clinician to search for the latest, best informa-tion for clinical practice. An hour or two exploring other aspects of

the best evidence quickly.


141st ANNUAL SESSION OF THE TEXAS DENTAL ASSOCIATION

Dr. Roger LevinDr. Donald LewisDr. David LittleDr. Eduardo LorenzanaDr. Kaneta LottDr. Denis LynchMs. JoAn MajorsMr. Orlando MartinezDr. Joseph MassadMr. Chris MaurerDr. Thomas McDonaldDr. Thomas McGarryDr. John Carl McManamaDr. Dale MilesDr. John MolinariMs. Virginia MooreDr. Jaimee MorganDr. Anita MurckoDr. Mark MurphyDr. Dan NathansonDr. Stephen NiemczykDr. Linda NiessenDr. David OstreicherDr. Ray PadillaMr. Chris PageDr. Edwin ParksMr. Tim PendergrassDr. Stan PresleyDr. Steve RatcliffMs. Karen Cortell ReismanMr. Matt RobertsDr. Jose Luis RuizMr. Randy SaundersDr. Stephen SchmittDr. Richard SchwartzMs. Laurie SempleDr. Jeffrey ShermanMs. Pam SmithMs. Tina SteinDr. William SteinhauerDr. John SvirskyDr. Keith ThorntonDr. Karen TroendleDr. Michael UnthankDr. William van DykDr. Clark WhitmireMs. Gail WilliamsonDr. Robert WinterDr. James WoodDr. Benjamin Young

Dr. Linda AltenhoffDr. Robert AndertonMs. Nancy AndrewsMr. Thomas AngeloniMs. Karen BakerMs. Lois BantaMr. Kirk BehrendtMs. Judy BenditDr. Scott BenjaminMs. Jen BlakeDr. Lee Ann BradyMs. Rosemary BrayDr. Lynne BrockDr. Steve BuckleyDr. Alan BudenzMr. Timothy CarusoMr. Paul CashMs. Debbie CastagnaMr. Bruce ChristopherDr. James CollDr. Sarah ConroyMr. Aquileo CortesMs. Karen DavisDr. Robert DewDr. Gary DeWoodDr. M. Franklin DolwickDr. Wendell EdginDr. Robert EdwabDr. Clarence FellerDr. Paul FeuersteinDr. James FondriestMs. Cynthia FongMs. Ellen GambardellaDr. Mitchell GardinerDr. Henry GremillionMs. Susan GunnDr. Kelly HalliganDr. Timothy HemptonDr. Maria HowellDr. Randy HuffinesMr. Sam HughesDr. Richard HuntDr. Peter JacobsenDr. Arthur JeskeMs. Rita JohnsonMs. Sheri KayDr. Martha Ann KeelsDr. Mark KleiveDr. James KohnerDr. Doug LambertDr. Brian LeSage

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The Evidence-BasedDentistry Initiative at Baylor College of DentistryDaniel L. Jones, D.D.S., Ph.D., Robert J. Hinton, Ph.D., Paul C. Dechow, Ph.D., Hoda Abdellatif, B.D.S., M.P.H., Dr. PH.,

Ann L. McCann, RDH, Ph.D., Emet D. Schneiderman, Ph.D., Rena D’Souza, D.D.S., Ph.D.

Jones Hinton Abdellatif

IntroductionThe NIH-NIDCR R25 Oral Health Research Edu-cation Grant initiative at the Texas A&M Health Science Center-Baylor College of Dentistry (BCD),designated “CUSPID”, is based on the theme that“Clinicians Using Science Produce Inspired Den-tists”. CUSPID complements the recent advances

AbstractThis report describes the impact of an R25 Oral Health Research Education Grant awarded tothe Texas A&M Health ScienceCenter-Baylor College of Dentistry(BCD) to promote the applica-tion of basic and clinical research

encourage students to pursue careers in oral health research. At Baylor, the R25 grant supports a multi-pronged initiative that employs clinical research as avehicle for acquainting both stu-dents and faculty with the tools of evidence-based dentistry (EBD). New coursework and experiencesin all 4 years of the curriculum plus a variety of faculty develop-ment offerings are being used to achieve this goal. Progress

nascent “EBD culture” charac-terized by increasing participa-tion and buy-in by students and faculty. The production of a newgeneration of dental graduates equipped with the EBD skill set as well as a growing nucleus offaculty who can model the impor-tance of evidence-based practice is of paramount importance for the future of dentistry.

KEY WORDS: evidence-baseddentistry, curriculum, clinical re-search, faculty development

Tex Dent J 2011; 128(2):177-180.

Dr. Jones is a professor and chair, Department of Public Health Sciences, TAMHSC-Baylor Col-lege of Dentistry, Dallas, Texas.Dr. Hinton is a professor, Department of Biomedical Sciences, TAMHSC-Baylor College of Den-tistry, Dallas, Texas.Dr. Dechow is a professor and vice chair, Department of Biomedical Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas.Dr. Abdellatif is an assistant professor, Department of Public Health Sciences, TAMHSC-BaylorCollege of Dentistry, Dallas, Texas.Dr. McCann is an associate professor and Director of Assessment, TAMHSC-Baylor College of Dentistry, Dallas, Texas.Dr. Schneiderman is an associate professor, Department of Biomedical Sciences, TAMHSC-Baylor College of Dentistry, Dallas, Texas.Dr. D’Souza is a professor and chair, Department of Biomedical Sciences, TAMHSC-Baylor Col-lege of Dentistry, Dallas, Texas.

Send correspondence and reprint requests to: Dr. Daniel L. Jones, Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Dallas, TX 75246; Phone: (214) 828-8350; Fax: (214) 874-4555; E-mail: [email protected]

Supported by NIH-NIDCR grant DE018883 (to Dr. Robert J. Hinton and Dr. Daniel L. Jones).

McCann Schneiderman D’Souza


at BCD in competency-based education and the development of a strong research infrastructure. These research advances

increase in researchers supported by the NIDCR Research Infrastructure Enhancement Program (R24 and U24) awards to BCD; (ii) formal collabora-tion with the University of Texas-Southwestern Medical Center (UTSW) in Dallas; (iii) a comprehen-sive training program (T32 award) to develop dental student and faculty re-searchers for successful dental academic research careers. Collaboration with UTSW is a key part of the T32 grant, but also includes participation by BCD faculty and students in an NIH Roadmap K12 award for multidisciplinary training of Clinical Re-search Scholars, and a CTSA (Clinical and Trans-lational Science Award — U54) to develop a strong infrastructure for clinical and translational sciences at UTSW and BCD.

EBD Initiative at Baylor

The basic goal of CUSPID is to incorporate critical thinking and formal instruction in evidence-based dentistry into a competency-based curriculum. The principal strategies are to (i) create a theme throughout the dental curriculum centered on the knowledge,

to critically evaluate new information and advances in treatment, and to participate in dental practice research networks; (ii) begin a Dental Scholars Program to provide selected dental students with additional training and experiences in clinical and translational research; and (iii) implement a faculty development program to

incorporation of new information and technologies into oral health-care. We emphasize the evaluation and interpretation of clinical research as it relates to practice, and development of the skills needed to achieve its integration into clinical dentistry. For most

applicability to future practice, where they will continue to exercise these skills as they seek out the newest advances.

Curricular ThemeDevelopment of courses/experiences in each year of the curricu-lum is central to the EBD initiative, and courses are introduced in-crementally, 1 year at a time, laying the foundation in the D1 year and reinforcing this concept in subsequent years. We designed the EBD curriculum to become progressively more small group-driven, with clinical faculty taking an increasingly prominent role, and with EBD becoming integral to clinical instruction and practice. In Fall 2008, a D1 course titled Introduction to Evidence-Based Den-tistry & Clinical Research made its debut. The year-long course, consisting of large group lectures/interactive sessions and small group discussions, has two primary aims: 1) to provide a founda-tion of knowledge necessary for the effective practice of EBD; 2) to begin to develop the practical skills needed for such practice. Foundational knowledge includes applied clinical epidemiology, biostatistics and some areas of modern dental and craniofacial research. The development of practical skills emphasizes how to evaluate clinical studies, how to formulate a focused clinical re-

evaluate evidence to answer that question. The small group ses-sions consist of biweekly meetings of around 8-10 students with one or two faculty to discuss an assigned paper on a clinically-relevant topic, using a standardized article review format. In the D2 EBD course (Application of Evidence-Based Dentistry I), each student participates in small group sessions several times per semester to further practice analysis of clinical research articles. Each student


prepares a Critically Appraised Topic (CAT) report based on a clinical scenario written by BCD clinical faculty, and pres-ents this report orally to the group and course faculty. An important feature of this course is the pairing of an EBD core faculty member with a clinical faculty member for each small group session. This approach has proven very successful in providing a clinical perspec-tive on the evidence presented, especially in the CAT. We an-ticipate that extension of these experiences into the D3 and D4 years will feature an increasing integration of EBD into course-work and chairside interactions in clinical dentistry. The intro-duction of EBD into the D3 cur-riculum began in the fall of this year, and includes integration into the weekly case conferences students have with their group leaders and other students.

Faculty DevelopmentWe have adopted a multi-pronged approach that offers faculty development experi-ences to accommodate different levels of interest and expertise.

“Clinical Colloquium” In May 2009, a series of clini-cal updates on evidence-based topics of interest to clinical faculty was inaugurated. These seminars followed by Q&A sessions are intended to stimu-late discussion among clini-cal faculty on subjects of wide clinical interest, with the hope of increasing familiarity with an evidence-based approach.

Expanded Scope of “Research Day”

presentations by D2 students of the best of the Critically Appraised Topics (CATs), clinical case presentations by D3 and D4 students, and a keynote lecture on a clinical research topic.

Summer EBD Fundamentals Course for Clinical FacultyFor those clinical faculty with a previous research background or a desire to learn more about EBD, we have provided opportunities for more formal and intensive training. In recognition of the need for EBD ‘champions’ (clinical faculty who will carry the EBD ef-fort into the D3-D4 years), core EBD faculty have created a course that meets twice weekly for 8-9 weeks. The course covers the basic tools of EBD (PICO, PubMed searching, fundamentals of statistics, research design, levels of evidence, Critically Appraised Topics).

Funding for Off-campus EBD Workshops and Conferences The R25 grant provides funds to support attendance by faculty (and students) at EBD/ critical thinking-themed conferences and workshops.

The Dental Scholars TrackThe Dental Scholars track was created for a few select dental students who express interest and aptitude for a career in patient-oriented re-search and/or dental academics. Three entering D1 students from the

-ticipated in faculty-mentored research projects in Summer 2009. The students attended college seminars featuring speakers on developmen-tal biology of the craniofacial region and craniofacial surgery, preceded by a journal-club discussion of one of the speaker’s articles. Activities in ensuing years will include elective courses in teaching and dental academia, attendance at clinical research workshops, participation in


an academic fellows program and teaching pract-icum and rotations in clinical research. Each dental scholar receives a 25 percent reduction in tuition for years D2-D4 and will be afforded special recognition as a graduate with honors in scholarship at the graduation ceremony.

OutcomesStudent reviews of the D1 EBD course indicate an appreciation for the applicability of the skill set being taught as well as the small group ses-sions that encourage them to work in teams to review articles. The D2 EBD course, which is entirely small group-based, is regarded even more highly.

Faculty development efforts have energized sub-sets of the clinical faculty. We are encouraged by the willingness of a core group, mostly com-prised of restorative (D3) and general dentistry (D4) faculty, to acquire EBD tools via the sum-mer course for clinical faculty. The attendance and informal feedback from faculty regarding our Clinical Colloquium speakers indicates the program is having the intended effect: knowledge transfer that also heightens appreciation for the importance of evidence in clinical decision-making.

The aims of this grant, if achieved, will result in a graduating dentist who is better equipped to

-mation to which he/she will be subjected and to decide whether and/or how to incorporate this information into the treatment of patients. In addition, the training of dental school faculty in the principles and practices of EBD will enrich them professionally while enabling them to serve as role models for students. Finally, providing a clinical/translational research-based track may induce a small subset of DDS students to choose careers in academic dentistry and/or clinical research.

EBD Initiative at Baylor



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Teaching Evidence-Based Practice at The University ofTexas Dental Branch at HoustonRichard D. Bebermeyer, D.D.S., M.B.A.

Bebermeyer

Introduction

In 2002, the American Dental Association (ADA) de-

based dentistry,” or EBD: “an approach to oral health

care that requires the judicious integration of sys-

evidence, relating to the patient’s oral and medical

condition and history, with the dentist’s clinical exper-

tise and the patient’s treatment needs and preferences

(1).” More recently, in August of 2010, the ADA’s

Commission on Dental Accreditation adopted new Ac-

creditation Standards for Dental Education Programs

(2). This change evolved over the past 3 years, with

input from all constituents. Among the new stan-

dards is an emphasis on evidence-based practice.

must be competent in the use of critical thinking and

AbstractThis brief report outlines the current curriculum for evi-dence-based practice at TheUniversity of Texas DentalBranch at Houston (UTDB). This curriculum is now based on the American Dental As-sociation’s Commission on Dental Accreditation 2010Accreditation Standards for Dental Education Programs. Evidence-based practice isintroduced to students in the

learn to be clinically effective through use of the components of evidence-based practice, in-formation search and retrieval, critical thinking (appraisal), and through information resourceevaluation and then application to the patient or population. Planned innovations in curricu-lum include further implementa-tion of evidence-based deci-sion-making in clinical courses, including development of theclinical prescription as a meansof demonstrating competencein asking and answering clinicalquestions, and of the portfolioas a means of demonstratingoverall competence.

KEY WORDS: evidence-based practice (EBP);education, dental

Tex Dent J 2011; 128(2):183-185.

Dr. Bebermeyer is professor and chairman, Department of Restorative Dentistry and Biomaterials; The University of Texas Dental Branch at Houston; Houston, Texas, 77030. Phone: (713) 500-4286; Fax: (713) 500-4108; E-mail: [email protected]

Please address all reprint requests to: Richard D. Bebermeyer, D.D.S.


problem-solving, including

their use in the compre-

hensive care of patients,

-

that “graduates much be

competent to assess, criti-

providing evidence-based

Discussion

relationship of science, and rel-evant research, to dental prac-

there has been increased em-

on the use of best evidence for

1990’s as the entering student’s

-ing all students on e-mail or

-

and pursues the effective uses of dental data, information, and

problem solving, and decision

Teaching EB Practice at UTDB

-

a combination of formats in-cluding lecture, on-line learning modules and interactive case-based learning in the Simula-

information search and retrieval; -

-

this course include general den-tists, a biomedical informatician,

In preparation for using this --

dents are given simulated clinical

-

Med and Cochrane Oral Health -

the evidence can be applied to

In addition, the cases involve

to integrate these aspects of

in their courses, it became ap-parent that the levels of appli-

--

sia and Biomaterials report that

is also used in some post-doc-

-

--

critical appraisal of research and

appraisal instruments or forms

-

to assess overall competence of -

teaching and measuring overall


composing a portfolio of cases, photographs, and materials progresses through the stages of gathering and processing new information, criti-

relevant to each student’s work and life, and is most likely to retain the student’s interest in education. The student must decide on how to practice effectively and on how to proceed with life-long learning. With portfolio learning, the student must set learning goals, identify learning resources (books, online learning, web databases, continuing

-ing is proceeding, list and document achievements, and use what s/he has learned to plan into the future. It is notable that the portfolio can be used in documenting overall competence, and may well replace human subjects in clinical dental licensure examinations, as has been recently implemented in California.

Conclusion

This brief report outlines the current curriculum for evidence-based dentistry at The University of Texas Dental Branch at Houston. This curriculum is based on the American Dental Association’s Commis-sion on Dental Accreditation 2010 Accreditation Standards for Dental Education Programs. Evidence-based practice is introduced to stu-

the 4 years. Students learn to be clinically effective through use of the components of evidence-based practice, information search and re-trieval, critical thinking (appraisal), and through information resource evaluation and then application to the patient or population. Planned innovations in curriculum include further implementation of evidence-based decision-making in clinical courses, and use of the portfolio as a means of demonstrating overall competence. The clinical prescrip-tion may be implemented as a means of clinical decision support, and of demonstrating competence in forming and answering clinical questions, relying on each student’s use of best evidence rather than simply expert opinion.

References

1. American Dental Association, policy statement on evidence-based dentistry. Available at: http://www.ada.org/1754.aspx. Accessed Nov. 18, 2010.

2. American Dental Association, Commission on Dental Accredita-tion; Accreditation Standards for Dental Education Programs. Available at: http://www.ada.org/sections/educationAndCareers/pdfs/predoc.pdf. Accessed Nov. 18, 2010.

3. Grant, WD. An Evidence-Based Journal Club for Dental Residents in a GPR Program. J Dent Ed 2005; 69(6);681-6.

4. Critical Appraisal Skills Programme; Tools for appraising research. Available at: http://www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme. Ac-cessed Nov. 18, 2010.


James L. Dunn,

Trustee

DDR Dental TrustServing Texas Dentists for more than 40 Years

800-930-8017


Teaching Evidence-Based Practiceat the University of Texas Health Science Center at San Antonio Dental SchoolJohn D. Rugh, Ph.D.; William D. Hendricson, M.A., M.S.; Birgit J. Glass, D.D.S., M.S.; John P. Hatch, Ph.D.; S. Thomas Deahl II, D.M.D., Ph.D.; Gary Guest, D.D.S.; Richard Ongkiko; Kevin Gureckis, D.M.D.; Archie A. Jones, D.D.S.; William F. Rose, D.D.S.; PeterGakunga, D.D.S., M.S., Ph.D.; Debra Stark, D.P.H.; Bjorn Steffensen, D.D.S., M.S., Ph.D.

IntroductionOne of the most serious challenges facing all health profes-sionals is dealing with the explosion of new biomedical in-formation and products. The exponential increase in newknowledge and the useful half-life of knowledge (7-10 years)

to-date. The number of articles published annually in peer-reviewed dental journals has grown from 6,212 in the year 1970 to 13,600 in 2009. Adding to the problem is the in-

AbstractThe overarching goalof the Evidence-BasedPractice Program at SanAntonio is to provide ourgraduates with life-long learning skills that will en-able them to keep up-to-date and equip them withthe best possible patient care skills during their 30-40 years of practice. Students are taught to(1) ask focused clinical questions, (2) searchthe biomedical researchliterature (PubMed) for the most recent and highest level of evidence,(3) critically evaluate theevidence and (4) make clinical judgments aboutthe applicability of theevidence for their pa-tients. Students mustdemonstrate competency with these “just-in-time”learning skills throughwriting concise one-page Critically Appraised Top-ics (CATs) on focused clinical questions. The school has established an online searchable library of these Critically Appraised Topics. This library provides studentsand faculty with rapid, up-to-date evidence-based answers to clinical ques-tions. The long-rangeplan is to make this online library available to practi-tioners and the public.

Tex Dent J 2011;128(2):187-190.

Dr. Rugh, professor,Department ofDevelopmental Den-tistry and Director of the Evidence Based Practice Program,UTHSCSA, San Antonio, Texas. Mr. Hendricson, assistant dean for educational and faculty development,UTHSCSA, San Antonio, Texas.Dr. Glass, professor, Department ofComprehensive Dentistry and AssociateDean for Academic Affairs, UTHSCSA, San Antonio, Texas.Dr. Hatch, professor, Department of De-velopmental Dentistry and Department ofPsychiatry Behavioral Medicine DivisionSTRONG STAR Multidisciplinary PTSD Research Consortium, UTHSCSA, San Antonio, Texas.Dr. Deahl , adjunct associate professor, Department of Developmental Dentistry, UTHSCSA, San Anto-nio, Texas, and The Institute for Natural Resources, Concord, California.Dr. Guest, professor, Department of Comprehensive Dentistryand Assistant Dean for Predoctoral Clinics, UTHSCSA, San Antonio, Texas.Mr. Ongkiko, database administrator, UTHSCSA, San Antonio, Texas, and Instructor at the University of the Incarnate WordADCaP, San Antonio, Texas.Dr. Gureckis, associate professor, Department of Comprehen-sive Dentistry, UTHSCSA, San Antonio, Texas.Dr. Jones, associate professor, Department of Periodontics,UTHSCSA, San Antonio, Texas.Dr. Rose, assistant professor, Department of Comprehensive Dentistry, UTHSCSA, San Antonio, Texas.Dr. Gakunga, assistant professor, Department of Developmental Dentistry, UTHSCSA, San Antonio, Texas.Dr. Stark, evaluation specialist in the Academic Center for Excellence in Teaching, UTHSCSA, San Antonio, Texas.Dr. Steffensen, professor, Department of Periodontics, professor, Department of Biochemistry and Associate Dean for Research, UTHSCA, San Antonio, Texas.

Rugh Hendricson Glass Deahl II Guest

Gakunga Stark Steffensen

Ongkiko Gureckis Jones Rose


crease in marketing jour-nals and Internet based sources of information … and misinformation.

One recent strategy, used in medicine, of dealing with the

keeping up-to-date involves a “just-in-time learning” approach (1,2). This approach entails learning skills that will allow

knowledge related to a patient’s

at the point of care (Figure 1). This “just-in-time learning” ap-proach is in contrast to passively reading three to four journals each month, attending weekend CE courses, and memorizing large quantities of information

Teaching EB Practice at SA

Figure 1

that may or may not be useful. The strategy assumes the clini-cian has a solid basic science and clinical foundational knowl-edge base with which to interpret and put into perspective the new knowledge.

With the aid of a 4-year NIH Edu-cation Research grant, the Uni-versity of Texas Health Science Center at San Antonio Dental School is implementing and eval-uating a “just-in-time learning” evidence-based practice (EBP) model. Students are taught four evidence-based practice skills enabling them to:

1. Ask focused questions (in a PICO format),

2. Use a systematic PubMed

highest level of evidence,3. Critically evaluate the evi-

dence and4. Make clinical judgments

about the applicability of the evidence for their patients.

These skills are taught in the context of having students pre-pare Critically Appraised Topics (CATs) that are one-page sum-maries of the four-step process mentioned above (Figure 2). The overarching goal is to provide students with life-long learning skills that will enable them to keep up-to-date during their ex-pected 30-40 years of practice.

The four evidence-based prac-tice skills are introduced in the freshman year in parallel with foundational basic science and

The San Antonio EBP/CATs program emphasizes a “just-in-time learning” modelas a strategy to help graducates keep up-to-date after graduation.


Figure 2

preclinical courses. An 18-hour sophomore course in the fall se-

four EBP skills. Each student must then demonstrate the EBP/CAT skills in the spring of the sophomore year by writing a CAT on a focused clinical question under the guidance of a faculty mentor. The student and faculty mentor edit and ultimately pub-lish the completed CAT on the UTHSCSA’s online searchable CAT Library. A PubMed learn-ing lab rotation in the junior year requires the student to demon-strate correct PubMed search strategies for six focused clinical questions. The skills are rein-forced in the context of formal clinically relevant case presenta-tions required of each student in the spring of the junior year.

The same EBP/CAT skills are taught in seven of the school’s residency programs during a 26-hour research methods course. The residents then apply the EBP/CAT skills, in the Interdisci-plinary Biomedical Core Course. This course provides a founda-tion in the principles of basic sci-ences for the clinical disciplines. To satisfy the criteria for comple-tion of the course, each resident is required to write a CAT. The CAT is focused on the broad area of dental basic science, pertain-ing to a clinical question, or disease mechanism. The CAT is reviewed by a member of the Biomedical Core Course faculty and published in the UTHSCSA’s CATs Library.

San Antonio’s EBP initiative in-cludes a formal faculty develop-ment program on evidence-based practice, which emphasizes the four EBP skills and the prepara-tion of CATs. To date, 32 hours of faculty EBP workshops have been provided. Sixty-two (62) faculty members have completed training in EBP/CATs writing and are serving as student CAT mentors.

The goal is to integrate these EBP skills into all levels of the cur-riculum and into direct patient care activities with the faculty. One General Practice Group is testing the use of the formal CAT protocol to investigate and report clinical problems and questions during the weekly group meet-ings. The implementation has been challenged by recent state


budget cuts and associated restructuring of departments within our school to help achieve

believe that these disruptions are temporary and expect full imple-mentation by summer of 2012.

Another important goal of the project was to create a search-able online CATs library, which has now been established and includes 200 CATs developed by our students, residents and fac-ulty. This online library provides students and faculty with rapid, up-to-date, evidence-based an-swers to clinical questions. The library includes a mechanism for faculty and practitioners to

library is searchable by keywords and currently is accessible by our dental students and faculty on the schools “intranet”. Ulti-mately the online library will be available to practicing dentists and educators worldwide, as well as to the public. We anticipate the library will reach 500 CATs by the fall of 2011. An impor-tant aspect of this searchable evidence-based knowledge center is that the individual CATs will be updated every 2 years. CATs will be reassigned to students to be rewritten, with faculty over-sight, in light of recent publica-tions and/or practice guidelines. The updated CAT will go through the same review and approval process as the original CATs to ensure that it is based on the best available and most recent evidence. Our CATs library will be modeled after the searchable online CAT libraries that have

Teaching EB Practice at SA

been established in several medi-cal schools.

Future plans are to encourage practicing dentists, students, and faculty from other schools to contribute and/or comment on the CATs. These CATs will undergo the same review pro-cess for quality. We also envision providing continuing education credit for dentists using the CATs library. In addition we are plan-ning to offer continuing educa-tion programs dealing with EBP “just-in-time-learning” skills.

We hypothesize that this com-prehensive, school-wide col-laboration among student and faulty in the preparation and review of CATs will strengthen skills associated with critical appraisal of the literature and foster more rapid integration of

dental school curriculum and dental private practice. The goal is to have these “problem-based” or “just-in-time learning” skills

-ation to enable young clinicians to keep up-to-date and deal with the plethora of new knowledge, products and procedures they will face during their practice ex-periences. Our 4-year NIH grant includes funding for a compre-hensive outcomes assessment of the program that will allow us to assess its effectiveness. Initial outcomes have been very en-couraging, and we look forward to assessing the impact on our students practice behaviors 5-10 years after graduation (3-6).

This program is supported by an Education Research Grant from the NIDCR, NIH/1R25DE018663 to Dr. John D. Rugh (PROJECT DI-RECTOR/PRINCIPAL INVESTIGA-TOR), Endowed Clinical Professor-ship funds to Dr. Kevin Gureckis

UTHSCSA.

References

1. Ebell MH, Shaughnessy A. Infor-mation mastery: Integrating con-tinuing medical education with the information needs of clinicians. Journal of Continuing Education in the Health Professions, 23:S53-62, 2003.

2. Harden RM. A new vision for distance learning and continu-ing medical education. Journal of Continuing Education in the Health Professions, 25(1):43-51, 2005.

3. Wallmann E, McLin S, Rugh JD, Hendricson WD, Hatch JP. EBP Course Increases Knowledge, At-

Students. Journal of Dental Research, Issue 89 (Special Iss B):IADR/AADR 88th General Session, Barcelona, Spain, 2010. (www.dentalresearch.org).

4. Hendricson WD, Rugh JD, Hatch JP, Stark DL, Deahl T, Wallmann ER. Validation of an Instrument to Assess Evidence-Based Practice Knowledge, Attitudes, Access and

-ment. Journal of Dental Educa-tion, 75(2): 131-144, 2011.

5. Rugh JD, Hendricson WD, Hatch JP, Glass BJ. Keeping Up-to-Date: The San Antonio CATs Initiative. Journal of the American College of Dentists, Vol. 77:2, 2010.

6. Rugh JD, Hatch JP, Hendricson WD. Assessing Outcomes of Re-search Methods Courses, Journal of Dental Research, Issue 89 (Spe-cial Iss A):673, AADR 39th Annual Meeting, Washington, D.C., 2010.

(wwwdentalresearch.org).



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The Challenges of TransferringEvidence-Based Dentistry IntoyPracticeRichard T. Kao, D.D.S., Ph.D.Reprinted by permissiony of thef California Dental Association. Copyright 2006.

Kao

IntroductionThe dental profession is committed to providing theg bestpossible dental care for patients. This is proving tog be morecomplex duex to a virtuala “information explosion” on newtherapies, techniques, and materials; increased consumerunderstanding ofg treatmentf possibilities and therapeu-tic outcomes; and changing socio-demographicg patterns.Though the profession advocates the importance of evi-fdence-based dental disease prevention and treatment, prac-titioners have been slow to implement this concept.

In 2003, the California Dentala Association (CDA) formulated an evidence-based dentistry actiony plan that included the formation of af taska force tomonitor evidence-based dentistry effortsy and implement programs to educateCDA members on this methodology. The challenges of transferringf evidence-gbased dentistry intoy clinical practice were key issuesy addressed by they task

paper. Possible solutions for eliminating barriersg against evidence-based carewill also be explored.

AbstractThe goal ofevidence-baseddentistry is to helppractitioners pro-vide their patientswith optimal care.This is achievedby integratingsound researchevidence withpersonal clini-cal expertise andpatient values todetermine the bestcourse of treat-ment. Thoughclinicians embracethis concept, itsimplementationin clinical practicehas been slow. Inthis paper, bar-riers against theimplementation ofevidence-basedcare are examinedand possible solu-tions are offered.

Tex Dent J 2011;128(2):193-199.

of Dentistry. He also is past chair, Task Force on Evidence-based Dentistry, California Dental Association, and has a privatepractice in Cupertino, California.

Send correspondence and reprint requests to: Dr. Richard T. Kao, 10440 S. De Anza Blvd., Suite D-1, Cupertino, CA,95014.


What Is Evidence-based Dentistry and How Do Den-tal Practitioners Interpret It?The CDA Task Force on Evi-dence-Based Dentistry recom-

based dentistry drawn from the “Oral Health in America” report by the U.S. Surgeon General, which is philosophically consis-tent with the American Dental

Evidence-based dental practice is the integration of an individual practitioner’s experience and ex-pertise, with a critical appraisal of relevant available external clinical evidence from system-atic research, and with consid-eration for the patient’s needs

stresses the importance of three elements: a dentist’s expertise and clinical judgment, relevant clinical evidence that is present in the literature, and the in-formed patient’s preference. In a dental practice that incorporates an evidence-based approach, the practitioner’s experience is pri-mary since it is his responsibility to consider all three components

of treatment. Ideally, evidence-based treatment is characterized by the intersection of these three elements.

Barriers Against Evidence-based CareThough the concept appears fundamentally simple and reasonable, clinicians have been slow to implement evidence-based dentistry. For clinical practitioners, evidence-based dentistry as a concept is not unlike the logical and common-sense patient-oriented approach that was advocated in the 1980’s and 1990’s as comprehensive care. The

on the body of evidence present in the literature. This difference has deterred the implementation of evidence-based care. It has been sug-

peer-reviewed, published, and appropriately analyzed dental research (3,4). This paper will examine barriers that clinicians encounter in their attempts to incorporate evidence-based dentistry into clinical practice.

Challenges of Transferring EBD


Barrier

One of the main concerns clini-cians have is the challenge of keeping up with a constantly ex-panding knowledge base. No one knows exactly how many dental research articles are published in a single year. In 1998, it was estimated that approximately 10,000 dental research articles were published in English (5). Considering the fact there is an equal amount of research pub-lished in foreign languages, this number may safely be doubled.

It is inconceivable for private practitioners to even consider analyzing this overwhelming volume of research. Therefore, most rely on systematic reviews. Unfortunately, the number of systematic reviews that ad-dress clinical topics in dentistry is small, but growing (6). The Cochrane Library lists only three reviews that met the minimum criteria for systematic reviews published in 1993. However, in 1999 there was an exponential increase to 484 reviews. System-atic reviews not only identify all relevant information contained

the key question, inclusion and exclusion criteria, and literature search parameters, and evalu-ate the quality of the study and information obtained. When sys-tematic reviews are structured appropriately, multiple studies may be combined to potentially provide clinical insight. Further scrutiny of these reviews indi-cates that these reviews may not

be clinically relevant or available to practitioners.

A recent survey was performed of systematic reviews from 1966 to December 31, 2002, on MED-LINE and the Cochrane Library’s Database of Abstracts of Reviews of Effectiveness (7). A total of 592

process, clearly delineated inclu-sion and exclusion criteria, and a re-examination of the raw or synthesized data from all in-cluded studies were eliminated. Furthermore, reviews not pub-lished in English were excluded. Using these criteria, 131 system-

96 of which had direct clinical relevance. These 96 reviews covered a wide range of dental topics; however, 17 percent of them concluded that the evi-

the key question. An additional 50 percent hedged in answering the key question, noting that the supporting evidence was weak or limited in quantity. It was con-cluded that despite the growing number of systematic reviews, more than one-half of these are unable to answer the key clinical question due to weak studies.

An additional problem with sys-tematic reviews is their inability to inform practitioners about new dental materials and techniques, such as the ever-evolving implant design materials, tooth-colored re-storative materials, and adhesives. Both the names and formulations of these products are changing

sort them out. Further complicat-ing this situation are savvy sales representatives who often provide slick marketing pieces with ques-tionable claims. Some practice consultants even view these sales representatives as the key provid-ers of information about advances in dental services, products, and technology (8). In the absence of reliable systematic reviews and

-cians are forced to depend on either clinical trial and error or commercial market information.

Further confounding clinicians is the fact that the few relevant systematic reviews published in journals often are interspersed with weaker studies and case reports/series. Consequently, in addition to being inundated with non-refereed journals and marketing information, clini-cians perceive there is a dental

are unable to distinguish the presence and importance of valid published systematic reviews. Additionally, there are few good systematic reviews that de-

clinically relevant procedures. -

menting evidence-based care is that the amount of relevant clinical evidence is so poor or the questions are so unrelated to clinical issues that it appears that evidence-based dentistry is not used. The challenge for evidence-based dentistry advo-cates is to ensure the increase in the number of systematic reviews

clinically relevant key questions.


Guideline or Treatment Algorithm Barrier

Despite their limited number, clinicians question whether these systematic reviews can lead to conclusions that will result in clinical practice guidelines (7). Practitioners are then concerned

adhere to such guidelines. Al-though dentists’ adherence to clinical practice guidelines has not been studied extensively,

-herence have been examined (9). These studies have shown that there are several impediments, such as unawareness of the ex-istence of guidelines, personal disagreement with the guide-

-pected results, practice inertia, and other external barriers. In the independent and often iso-lated dental practice environ-ment, these same barriers may

Patient-Related Barrier

Patient preferences can be a barrier to adherence to evidence-based care. Patient decisions about care are based on two major factors: personal

With increased dental advertis-ing and ready access to infor-mation on the Internet, today’s patients are well-informed con-sumers. Commercial marketing of esthetic and implant den-tistry procedures and results have resulted in more demand

for these services. Though there are longevity and survival studies for esthetic materials, the nature of these materials is changing so rapidly it is not clear whether this information is still germane to the various generations of composites, ad-hesives, veneer materials, and implants entering the market-place. When such an informa-tion void exists, it is easy to be

and non-refereed publications. In the face of growing patient demand, non-existent evidence,

associated with these services,

provide evidence-based care.

-tention since approximately 69 percent of patients have dental insurance (10). Practitioners are understandably concerned that the insurance industry may misuse information to

and dictate the types of proce-dures and treatment that will be covered. This fear stems from dental carriers’ history of regulating covered services and terms of re-treatment. Instead of informing the public that these regulations are based on purchase-service utilization analyses, third parties fre-quently suggest in their denials that provided services are not

based. Additionally, outcomes assessment in terms of patient satisfaction has largely been ig-nored by the insurance indus-try. Though patient satisfaction

can be quite high for esthetic procedures such as esthetic crown lengthening, bleaching, veneers, and dental implants, these procedures are generally

carriers have given the public

parameter of care through their regulations and coverage, even though their decisions may often be contrary to evidence obtained from well-designed, peer-reviewed studies and pa-tient preferences.

Internal and External Barriers Faced by Clinicians

based dentistry emphasizes the importance of a dentist’s ex-pertise and clinical judgment. Though these are largely based on past clinical experiences,

clinician’s decision.

Awareness and familiarity with the evidence remain one critical problem. It is clear that most clinicians either do not have access to or are not capable of evaluating the primary litera-ture. Though there are numer-ous articles that inform clini-cians on the art of evaluating the literature, most clinicians are still heavily dependent on systematic reviews (7,11-18). As previously mentioned, there are presently a limited number of reviews, with the majority

recommendations due to weak or limited supporting evidence (7). Faced with these system-



intuition is to decide if the key question is clinically relevant. Even with relevant reviews, clinicians may not agree with a

-sonal experiences or expected outcomes.

There are also internal barri-ers which may prevent adop-tion of evidence-based den-tistry. Clinicians may fall prey to practice inertia and not be motivated to change. Altering therapeutic regimens in a small practice may require behav-ioral adaptations among the staff. At times, clinicians still practice in the same fashion as they were taught in their earlier training. Though this is inappropriate given the rate of change in clinical dentistry and availability of continuing edu-cation courses, this neverthe-less does occur. Additionally, many of the procedures and

Though a more conservative

may be evidence-based, clini-cians still need to deal with the temptation of providing a more

driven by both business pres-sure associated with running a practice and the need to make a living.

External factors not under the clinician’s control also impact evidence-based dentistry. For example, necessary access to certain equipment or changes in facility design may be cost-prohibitive, making adherence to certain aspects of evidence-

staff support, poor reimburse-ment, escalating practice op-erational costs, and increased liability.

When such an information void exists, it is easy to be influenced by marketing jargon and non-refereed publications. In the face of growing patient demand, non-existent evidence, and significant economic gains associated with these services, it is difficult for clinicians to provide evidence-based care.

Embracing Evidence-based CareEvidence-based dentistry have been the buzzwords for the type of quality dental care promoted by academicians and dental policymakers for the past decade. Yet, this practice philosophy has not been read-ily embraced by clinicians. This paper has revealed barriers against universal acceptance of evidence-based care, but what are some possible solutions?

Evidence-based care has much potential in improving patient care. more about patient ex-pectations and outcome sat-isfaction for dental care. Until each of the four stakeholders learn to appreciate the weak-ness, strengths, potentials, and barriers toward implementation for all concern, the growth and


implementation of evidence-based care will be slow.

Academicians and evidence-based dentistry advocates must begin to appreciate that evi-dence-based dental care entails more than randomized con-trolled trials, refereed journals, meta-analysis, and systematic reviews. These have little mean-ing for the clinician trying to provide dental care. The pro-fession must be able to frame answerable questions based on clinical problems. To do so ret-rospectively through systematic reviews has been a failure to date (7). The National Institute of Dental and Craniofacial Re-search recently committed $75 million over the next 7 years to establish three practice-based research networks (19). The proposed objective of the prac-tice-based research networks is to accelerate clinical trials and studies of important issues in oral health care. Though it is of concern that these centers have been awarded funds with-out any evidence of their ability to develop these networks or

addressed, the practice-based research networks may be a golden opportunity to develop the informational-evidence ele-ment of evidence-based den-tistry.

Instead of conducting sys-tematic reviews or performing meta-analysis on disjointed studies presently in the lit-erature, the practice-based research networks may provide

a prospective mechanism for addressing issues of clinical approaches and effectiveness in a real-world environment. The challenge to academicians and evidence-based dentistry advocates will be to design answerable questions based on clinical problems that can be tested in this network. The ex-perts in clinical dentistry have always been the practitioners. Academicians and evidence-based dentistry advocates should partner with astute cli-nicians so basic problems can

these problem areas be identi-

not by bureaucrats, ivory tower academicians, or statisticians. If the questions are appropri-ately framed, practice-based research networks can generate important and timely informa-tion to guide the delivery of dental health care and improve patient outcomes. More impor-tantly, this information is more likely to be accepted, adopted, and translated into daily prac-tice by clinicians.

Another step for removing pa-tient-associated barriers to evi-dence-based dentistry would be for the dental insurance indus-try to educate its subscribers on the nature of its business. While it is acknowledged dental

oral health, it is important for insurance carriers to educate subscribers on the limitations

-tions are based on a business model utilizing employer-paid


insurance premiums to provide -

ployees. When treatment falls

(i.e., cosmetic dentistry, im-plants, etc.), patient preferenc-es should be respected. In lieu of denials and commentaries, carriers should acknowledge the patient’s preference and the treatment as an accepted option despite the fact that it is not covered by insurance.

Given the sheer volume of

it will be a challenge for our dental educators, journal edi-tors, and public policymakers to provide an effective infor-mation transfer. Though an increasing number of schools and residency programs are instituting curricula for teach-ing the principles and practice of evidence-based care, suc-cess has been limited (20). It is questionable as to how much of the evidence-based decision-making process is utilized after training. If evidence-based den-tistry is to succeed, it is critical that these problems associ-ated with the dissemination of the evidence-based systematic reviews be evaluated. Addition-ally, evidence-based dentistry teaching strategies need to be developed. This task falls to dental educators, dental asso-ciations, and journal editors.


ConclusionDespite the barriers that have prevented evidence-based dentistry from being readily embraced by dental clinicians, there should be no mystery or fear surrounding this concept. This logical, common-sense, patient-oriented approach is not different from the compre-hensive care that was the pop-ular in the 1980’s and 1990’s. The difference is that we are in an enviable position where

of information that can help us in our patient care decisions. In evidence-based dentistry, there is a “conscientious, explicit and judicious use of current best evidence” to be used in clini-cal decision-making (21). This information is an adjunct, not a substitute for clinical judg-ment and patient preferences. When used in concert, it has the potential to provide optimal treatment.

References

1. U.S. Department of Health and Human Services. Na-tional call to action to pro-mote oral health in Ameri-ca: a report of the surgeon general. Available at http://www.surgeongeneral.gov/topics/oralhealth/national-calltoaction.htm (Accessed April 13, 2006.)

2. American Dental Asso-ciation, ADA positions and statements: ADA policy on evidence-based dentistry. Available at www.ada.org/prof/resources/ positions/statements/evidencebased.asp. (Accessed April 13, 2006.)

3. Antczak-Bouckoms A, Symposium: The Cochrane collaboration: Creating a registry of clinical trails (ab-stract). J Dent Res 74(Spec. Issue A):69, 1995.

4. Kugel G, Squier C, Fact vs.

the dental curriculum (ab-stract). J Dent Res 77(Spec. Issue):106, 1998.

5. Niederman R, Badovinac R, Tradition-based dental care and evidence-based dental care. J Dent Res 78:1288-91, 1999.

6. The Cochrane Library, Database of abstracts of re-views of effectiveness. Avail-able at www.nicsl.com.au/cochrane/guide_data.asp. (Accessed April 13, 2006.)

7. Bader J, Ismail A, Survey of systematic reviews in dentistry. J Am Dent Assoc 135:464-73, 2004.

8. Levin RP, The hidden resource to your practice. Implant Dent 14:210, 2005.

9. Cabana MD, Rand CS, et al, Why don’t physicians follow clinical practice guidelines? A framework for improve-ment. JAMA 282:1458-65, 1999.

10. Evidence-based care and risk assessment. Insurance Solutions newsletter. Is-sue:4-15, May-June 2002.

11. Richards D, Lawrence A, Evidence-based dentistry. Br Dent J 179:270-3, 1995.

12. Sutherland SE, Evidence-based dentistry: Part I. Getting Started. J Can Dent Assoc 67:204-6, 2001.

13. Sutherland SE, Evidence-based dentistry: Part IV. Research design and levels of evidence. J Can Dent As-soc 67:375-8, 2001.

14. Sutherland SE, Evidence-based dentistry: Part V. Critical appraisal of the dental literature. J Can Dent Assoc 67:442-5, 2001.

15. Newman MG, Improved clinical decision-making using the evidence-based approach. Ann Periodontol 1:i-ix, 1996

16. Hamilton J, Assessing ‘Real Science’: Poor studies, industry ties taking toll. J Calif Dent Assoc 32:29-39, 2004.

17. Richardson WS, Wilson MC, et al, The well-built clinical question: A key to evidence-based decisions. ACP J Club 123:A12-3, 1995.

18. Guyatt GH, Haynes RB, et al, Users’ guides to the medical literature XXV : Evidence-based medicine. Principles for applying the user’s guides to patient care. JAMA 284:1290-6, 2000.

19. Pilstrom BL, Tabak L, The National Institute of Dental and Craniofacial Research: Research for the practicing dentist. J Am Dent Assoc 136:728-37, 2005.

20. Hatala R, Guyatt G, Eval-uating the teaching of evidence-based medicine. JAMA 288:1110-2, 2002.

21. Sackett DL, Rosenberg WMC, et al, Evidence-based medicine: What it is and what it isn’t. BMJ 312:71-2, 1996.


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The American DentalAssociation’s Center ForEvidence-Based Dentistry:A CriticalA Resource For 21stCentury Dentaly PracticeJulie Frantsve-Hawley, R.D.H., Ph.D.Arthur Jeske, D.M.D., Ph.D.

Frantsve-Hawley Jeske

Introduction-

cally-structured educational model, dentists have aspecial responsibility toy their patients to provide carethat is evidence-based, and to be able to effectivelycommunicate the evidence for dental treatments totheir patients, so that patients can make informeddecisions about their care. This principle is effec-tively enunciatedy by they American Dental Associa-

dentistry” (EBD) as follows: Evidence-based dentistryd(EBD) is) ans approachn toh oralo healthl careh thate requirestthe judiciouse integrations ofn systematicf assessmentsc

patient’s orals andl medicald conditionl andn history,d withthe dentist’se clinicals expertisel ande thed patient’se treat-sment needst ands preferences.d

AbstractThrough its website (http://

www.ada.org/prof/re-

sources/ebd/index.asp), the

American Dental Associa-

tion’s Center for Evidence-

Based Dentistry offers

dental health professionals

access to systematic re-

views of oral health-related

Clinical Recommendations,

which summarize large bod-

the form of practice recom-

mendations, e.g., the use

of professionally-applied

feature of the site of great

practical importance to the

practicing dentist is the

Critical Summary, which

is a concise review of an

individual systematic re-

view’s methodology and

importance and context

of the outcomes, and the

strengths and weaknesses

of the systematic review and

its implications for dental

practice.

Tex Dent J 2011; 128(2):201-

205.

Dr. Frantsve-Hawley is the director of the ADA CenterA for Evidence-Based Dentistry.

Dr. Jeske is a professor, Department of Restorative Dentistry and Biomaterials, University of TexasDental Branch at Houston.


Recognizing the importance of and need for accessible, high-quality information on evidence-based dentistry, and the fact that dental research doesn’t do any good if it doesn’t reach the clinician, the ADA created the Center for Evidence-Based Dentistry (EBD) to connect the

daily practice of dentistry. The EBD website (http://ebd.ada.org) provides on-demand access to systematic reviews, summaries and clinical recommendations

Figure 1

ADA EBD: Crititical Resource

that translate the latest schol-

format.

ADA members and stakeholders determined that they needed one centralized online resource to

information. The resource that emerged should provide concise, clinically relevant information for the dental profession. The website, illustrated in Figure 1, was supported by a grant from the National Library of Medicine

and the National Institute for Dental and Craniofacial Research (grant number G08 LM008956). The EBD website was launched in March, 2009, is open-access, and provides current, clinically

information in a user-friendly format (Figures 1, 2).

All dental professionals world-wide can now access the EBD website for information for dental and health care professionals and, as a next phase, the ADA


will develop content for the gen-eral public. Key features of the EBD website include:

A database of systematic reviews. The database has over 1,300 systematic reviews and is updated monthly.Critical Summaries of sys-tematic reviews. One-page synopses of the key elements of a systematic review with clinical implications written by practicing dentists trained in critical assessment of published studies. Sample summary can be seen at http://ebd.ada.org/System-aticReviewSummaryPage.aspx?srId=51de1696-175d-44ff-87af-565d7fe0fba4 Clinical Recommendations. These provide useful tools that can be applied in mak-ing evidence-based clinical treatment decisions.

Figure 2

Links to many other useful resources. This is a central resource for EBD informa-tion, and has links to many outside resources including; tutorials, glossaries, and databases Clinical Questions. If you have a clinical question that isn’t covered here, you can submit it through the website for consideration of future systematic reviews or studies.

A panel of world renowned EBD Experts provides oversight for the EBD website, including train-ing and overseeing the dentists that write the Critical Summa-ries. Panel members include:

Dr. James Bader, University of North Carolina

-ty of Dundee; Cochrane Oral Health Group

University School of Dental Medicine

-sity of Alberta

Commonwealth University -

sity of Washington

Minnesota -

sity of Toronto -

housie University -

versity of New Mexico

Austral de Chile

University

of Pittsburgh


A wealth of scien-

available at the EBD website, including “Frequently Asked Questions”, systematic reviews and Critical Summaries of those systematic reviews, ADA Clinical Recom-mendations for EBD, all with easy-to-use topic selection features (Figures 3–5). Finally, the EBD website of-fers the dentist the capability to suggest clinical ideas based on questions that arise in dental practice that require science-based answers (Figure 6).

The dental profession can take great pride in the leadership role in evidence-based den-tistry that the ADA has taken with the estab-lishment of the Center for Evidence-Based Dentistry and the EBD website. Application of

-tion provided in this endeavor will continue to strengthen our profession, maintain our high professional standards, and enrich and improve the care of all of our patients.

Figure 3

Figure 4

ADA EBD: Crititical Resource


Figure 5

Figure 6


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ADA Evidence-Based Dentistry Champions ConferenceJoshua Austin, D.D.S.

Austin

IntroductionAs a young private practitioner, I can still re-

member my course on dental evidence during

dental school. During the spring semester of our

-

ence Center at San Antonio Dental School (UTH-

SCSA), Dr. John Rugh ran “Clinical Judgement

and Evaluation.” We were all just trying to sur-

vive the onslaught of microbiology, physiology,

and pharmacology. We knew little of dentistry

inlay wax. We had no idea that dental evidence

would shape the way we practice dentistry for

the entirety of our careers.

Throughout dental school, we were always told, “Here at UTH-SCSA, we teach our students to practice evidence-based dentist-ry.” It was told to us countless times by professors and deans.It was always said with conviction and meaning. Because of thisobvious emphasis from our educators, we as students never really admitted that we weren’t absolutely sure what evidence based dentistry meant. We just knew it had to be good.

During dental school, there are few issues practicing evidencebased dentistry. Lectures are almost always cited with the most recent and classic literature. Clinical procedures are per-formed with professors well-versed and even published in the

Dr. Austin is in private practice in San Antonio, Texas; and chair of the TDA Committee on the New Dentist.


literature. The disconnect with evi-dence based dentistry comes when the dental student graduates and en-ters practice. It is at this time many practitioners lose their link to the evidence. Thankfully, the American Dental Association (ADA) is helping to rejuvenate its members’ interest in evidence based dentistry.

Time becomes the biggest enemy in the average private practice. Today’s practicing dentists are completely overwhelmed with payroll, staff is-sues, patient management, and pa-tient care. By the end of a busy day of practice, the last thing a dentist wants to do is sit and read a peer-reviewed journal. Dentists today need

and created its Center for Evidence-Based Dentistry website.

The Center for Evidence-Based Dentistry website is extremely well laid out. In-formation is easily accessible, searchable, and broken down into categories. It is

the procedures we perform on a daily basis. Within 5 minutes, a dentist can gain great overviews on the current literature pertaining to the desired topic.

The only problem was that I wanted more. I wanted to know more about evidence itself. What is a systematic review? What is a meta-analysis? Where do these studies come from? What makes for a good study? How can I utilize this more in my practice? I had questions, so I turned to the ADA for answers.

The ADA informed me of a new program they were launching called “The Evi-dence-Based Dentistry Champions Conference.” Coming from San Antonio, we know a few things about champions (sorry, Mavs and Rockets fans). The idea of the conference intrigued me. I applied with the ADA and received word a few weeks later that I had been accepted into its new program and would attend the May 2009 Evidence-Based Dentistry Champions Conference.

The conference took place Thursday through Saturday at the ADA headquar-ters in Chicago. Thursday’s opening session gave attendees an update on levels of dental evidence and resources to locate it. Part of the session was devoted to rehashing some of the topics we all explored in our dental evidence class from dental school. The presenters broke down the differences, strengths, and weak-nesses of the study types. A clear linear ascension from weak evidence to strong

ADA EBD Conference

Participants attend the ADA’s Evidence-Based Dentistry Champions Conference in May 2009 in Chicago, IL.

Photo courtesy ADA News. ©2010 American Dental Association.


evidence was drawn and made very clear. In addition, we received a les-son on the use of the Pub-Med web-site to locate data and studies. After Thursday, we each had a refreshed background in levels of evidence which included skills for decipher-ing strong evidence from weak evidence. With the use of Pub-Med, we each then had a tool to use for the location of new evidence.

Friday brought an emphasis on why evidence and literature is important to dentistry. The ADA brought several speakers in from educators to private practitioners, all to help drive home the idea that evidence is critical to the practice of dentistry. With the background we re-learned on Thursday, we were shown the ADA’s Center for Evi-dence Based Dentistry website and how to use it. The ADA had practitioners who had reviewed literature and written some of their clinical recommendations speak on the process and use of these clinical recommendations.

and using evidence in practice on a daily basis. These obstacles were surpris-ingly universal to almost all dentists in the room. Each table seemed to echo the same obstacles and frustrations to utilizing evidence based dentistry in practice. Afterwards, we examined strategies to overcome these obstacles. Many of these strategies involved using resources and tools already in place that are free to ADA members.

As the conference moved to Saturday, the topics changed focus from using evi-dence-based dentistry in practice to spreading information to our colleagues. The

-ing the methods and strategies we had previously learned with other dentists. This may be done at a study club, table clinic or, as I did, at a component society general membership meeting. The conference gave me all the tools I needed to pass this information on to others.

There are worse things to do in the world than spend 4 days in Chicago in May. A visit to Wrigley Field to see the Cubs play would normally be the highlight of such

-dence-Based Dentistry Champions Conference stole the show from Wrigley Field.

the information and skills I desired after spending 3 days at the ADA.

It would be untruthful for me to claim that my entire practice has changed since attending this conference. Practicing evidence-based dentistry is a much more subtle shift. Being a more recent graduate, much of my training is still accepted and supported by literature. There are, however, regular instances in which I must look into the literature to answer a clinical dilemma faced in my practice. With the tools I learned at the ADA Evidence-Based Dentistry Champions Conference, I

maximize the level of patient care I provide.

Dr. Leslie Winston of Proctor and Gamble speaks at the ADA’sEvidence-Based Dentistry Cham-pions Conference in May 2009 in Chicago, IL.

Photo courtesy ADA News. ©2010 American Dental Association.


Photographer: Leanna R. Sims-Gowan of Mabank, TexasTitle: “Old Lock”

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


How Effective is That Treatment? The Number Needed to TreatS. Thomas Deahl II, D.M.D., Ph.D.

IntroductionAs you consider adopting a new treatment (or a new preventive agent) in clinical practice, you should ask a series of questions. Among the most important ques-tions you can ask are as follows:

words, is the evidence valid)?

worth my efforts to adopt (in other words, how ef-fective is this treatment)?

Applying these critical questions is especially important today asmarketing of dental equipment, instruments, and materials increas-ingly complete, for the dentist’s attention, with the results of long-term clinical studies.

At least these three questions should be answered before adopting a new treatment or preventive agent. This article aims to help you ad-

we best describe the relative effectiveness of a new treatment (com-pared to some other treatment we are already using)? This article

AbstractThe Number Needed to Treat (NNT) is a tool useful for comparing therelative effectiveness oftwo or more therapeutic or preventive interven-tions. The NNT may be presented by authors ofa clinical research article,or, if not provided, may becalculated by the reader ifthe authors have reportedoutcomes as positive or negative per research subject. The NNT is simply calculated as theinverse of the absolute risk reduction. The NNT ismost meaningful when re-

interval and when describ-ing clinical trials of highervalidity such as random-ized controlled trials and meta-analyses of suchtrials. Several example NNTs from the dentaland medical literature arereported.

KEY WORDS: Evi-dence-based dentistry, number needed to treat, effectiveness, clinical trials

Tex Dent J 2011;128(2):211-219.

Deahl II

Dr. Deahl is an adjunct associate professor, Department of Developmental Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas, and The Institute for Natural Resources,Concord, California.

Send correspondence to S. Thomas Deahl II, DMD, PhD, Department of Developmental Dentistry, UTHSCSA,7703 Floyd Curl Drive, San Antonio, Texas 78258. Phone: (210) 567-3500; E-mail [email protected].

This article has been peer reviewed.


describes a handy clinical tool called the Number Needed to Treat, abbreviated “NNT,” that helps us compare effectiveness in a useful way.

of evidence-based medicine in 1988 and has been advocated and reported in both the British and American literature since then (1–5).

How to Calculate the NNTLet’s assume we have two treatments to compare. We read a journal article in which the new treat-ment (Agent Blue), has been compared in clini-cal research to an older and widely used (Control) treatment with regard to the cure of a particular disease. The journal article we read informs us that the researchers have taken 100 patients who have the disease we want to treat, and randomized them to two groups of 50 each (Group 1 and Group 2). The two groups are represented in the “Before Treatment” column of Figure 1, with each patient represented by an “x.”

Before Treatment Treatment After Treatment

x x x x x x x x x x o o o o o o o o o o 11 “cures”Group x x x x x x x x x x o x x x x x x x x x in 50 patients 1 x x x x x x x x x x Control x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 39/50 = 0.78 x x x x x x x x x x x x x x x x x x x x still diseased

x x x x x x x x x x o o o o o o o o o o 33 “cures”Group x x x x x x x x x x o o o o o o o o o o in 50 patients 2 x x x x x x x x x x Agent Blue o o o o o o o o o o x x x x x x x x x x o o o x x x x x x x 17/50 = 0.34 x x x x x x x x x x x x x x x x x x x x still diseased

x = patient with the diseaseo = patient without the diseaseo = patient without the disease, helped by Agent Blue, who would not have been helped by Control treatment

Figure 1.

One hundred percent of patients in both groups have the disease. Now let’s administer the old Con-trol treatment to all Group 1 patients, and the new Agent Blue to all Group 2 patients, as shown in the “Treatment” column of Figure 1.

At the end of the study, an examiner checks all of our patients to see which ones still have the dis-ease and which ones do not. Those who still have the disease are indicated with an “x,” and those who have been cured are indicated with an “o,” as shown in the “After Treatment” column of Figure 1. Those in Figure 1 who represent cures above and beyond the Control rate of treatment are repre-sented by o. The NNT is inversely proportional to these Agent Blue-dependent cures, indicated by “o”s, among the entire group. The smaller the NNT, the fewer “x’s” we will need to treat with Agent Blue to get one “o.”

In this example, Agent Blue outperforms Control. We note that the Control resulted in 11 out of 50 “cures.” So the Control group is left with a disease rate of 39 / 50 = 0.78 (that is, 78 percent still have the disease). We note that Agent Blue resulted in

How Effective is That Treatment?


33 out of 50 “cures”, so these patients are left with a disease rate of 17 / 50 = 0.34 (34 percent still have disease).

How can we describe these results? We could calcu-late the Relative Risk Reduction (RRR), which is the (Control disease rate minus the Experimental disease

Control Disease Experimental Relative Risk

Rate (CDR) Disease Rate (EDR) Reduction (RRR)

Agent Blue vs. 39 / 50 = 0.78 17 / 50 = 0.34 (0.78-0.34) = 0.56

Control 0.78

What the NNT MeansThe problem with the RRR is that even trivial results in a large study could give a similar risk reduction. Imag-ine that we have Agent Green, a new preventive agent, to be administered to 5,000 healthy people for the next 5 years, and with this we hope to reduce the risk for a particular disease. We’ll compare its effectiveness to a Placebo, given to another 5,000 healthy people, during the same 5 years. At the end of the 5-year period we

Agent Green group. Again, we calculate a RRR of 0.56. See the calculation of this in Table 2. This is bother-some, as we sense that although, yes, the Agent Green agent does reduce the likelihood of disease better than Placebo; we’d be much less impressed with it than with Agent Blue in the earlier example.

Table 1. Relative Risk Reduction for Agent Blue vs. Control Treatment

Control Disease Experimental Relative Risk

Rate (CDR) Disease Rate (EDR) Reduction (RRR)

Agent Green vs. 39 / 5000 = 17 / 5000 = (0.0078-0.0034) = 0.56

Placebo 0.0078 0.0034 0.0078

Table 2. Relative Risk Reduction for Agent Green vs. Placebo

rate) divided by the Control disease rate (0.78 – 0.34) / 0.78 = 0.56. This RRR means that Agent

is a 56 percent reduction in the risk for continued disease, compared to the Control treatment. This is summarized in Table 1.

The Number Needed to Treat (NNT) overcomes this problem by taking into account the absolute proportions of the sample cured by each treat-ment (or control, or placebo).

Agent Blue. We subtract the Experimental dis-ease rate (0.34) from the Control disease rate (0.78) and then take the inverse of the difference: (1 / 0.78-0.34) = 2.3. For discussion purposes we can round 2.3 up to 3. This means that we would need to treat about 3 patients with Agent Blue in order to obtain 1 cure more than could be ob-tained with the Control treatment. Applying the same calculations to the preventive Agent Green results reveals an NNT of 227. So, although Agent Blue and Agent Green have identical RRRs, they have drastically different NNTs. These cal-


culations and results are shown in Table 3.

NNTs of treatments in dentistry are shown in Table 4. Note that they range from 2 (for single dose acetaminophen for preventing postoperative dental pain at 4 – 6 hours after the procedure) to 25 (for prophylactic amoxicillin for preventing single-implant fail-ure within 3 months or more of dental implant placement). Note that the fourth column of Table 4 lists not just the NNT, but also

(CI). This is given to remind us that the NNT calculated from any given article is an estimate of the true NNT, and that the true NNT is 95 percent likely to lie within

-dence interval (6).

Relative Risk Absolute Risk Number

Control Experimental Reduction Reduction Needed

Disease Disease Rate (RRR) = (ARR) = to Treat

Rate (CDR) (EDR) CDR - EDR CDR - EDR (NNT) =

CDR 1 / ARR

Agent Blue vs. (0.78-0.34) 0.78-0.34

Control 39 / 50 = 0.78 17 / 50 = 0.34 0.78 = 0.44 = 2.3

= 0.56

Agent Green 39 / 5000 = 17 / 5000 = (0.0078-0.0034) 0.0078-0.0034

vs. 0.0078 0.0034 0.0078 = 227

Placebo =0.56 = 0.0044

The last row of Table 4 states NNH rather than NNT. NNH is the “Number Needed to Harm,” and is calculated using the risk of a particular adverse outcome,

treatment. NNH is calculated in a way analogous to the NNT, but uses the rates of “adverse event(s)” rather than “cure” or “case of disease prevented.” Of course, we would like the NNH to be a large number and the NNT to be a small number, which would mean that we would have to treat few patients in order to get a cure, but we would have to treat many patients in order to get an adverse event. NNH can only be calculated if the authors have measured the proportion of patients in each group (treat-ment and control) who have experienced an adverse event. NNH have rarely been reported

in the dental research literature. The NNH of 2, for retro-second molar periodontal defects follow-ing third molar removal, reported in the last row of Table 4 is one of the few examples. An ex-ample of NNH from the medical literature relevant to dentistry is as follows: the NNT for treating

ug/day is 2.9 (95 percent CI 2.4 to 3.4) (7). At this dose the NNH for oral candidiasis is 90 (27 to 750), meaning that we’d only expect about one case of oral candidiasis for every 90 patients

-

is increased to 1000 ug/day, the NNH for oral candidiasis is only 23 (14 to 75).

If we have a clinical research paper giving us both NNT and NNH, we could use both to calcu-

Table 3. Relative Risk Reduction Compared to NNTs



Treatment Number of NNT Reference

[study type] studied Acetominophen Acute postoperative dental pain 2690 2.7 (9)Single dose [SR 4 to 6 hours after procedure (2.5 to 3.0)of RCTs]

Prophylactic Prevention of single-implant 316 25 (10)amoxicillin failure within 3 months or more (13 to 100)[SR of RCTs] of dental implant placement

varnish applied in adolescent patients (CI not

[RCT] orthodontic treatment Guided tissue Gaining at least one extra site 737 8 (12)regeneration, with with 2mm or more attachment, (5 to 33)or without graft in periodontal infrabony pockets.materials (vs. open

[SR of RCTs] Systemic antibiotic Prevention of alveolar osteitis 2932 13 (13)prophylaxis in third (9 to 26)molar surgery[SR of RCTs]

Systemic antibiotic Prevention of surgical wound 2398 25 (13)prophylaxis in third infectionmolar surgery [SR of RCTs] (15 to 73)

Third molar surgery Acquiring periodontal defect on 40 NNH (14)[RCT] distal of second molar 2 postoperatively, within 6 months of third molar extraction

Table 4. Some NNTs from Recent Research in Dentistry

Explanation: NNT: Number Needed to Treat NNH: Number Needed to HarmSR of RCTs: Systematic review of several randomized controlled trials.RCT: a single randomized controlled trial

reside most of the time. In other words, the true NNT is likely to be somewhere within this range.


late a ratio called the Likelihood of Help vs. Harm, abbreviated LHH. The LHH is simply the ratio of the NNH to the NNT, and is the likelihood that the patient will be

(vs. comparison) Endpoint CI, when [study type] provided)

Calcium and Prevention of one hip fracture 20 (15)vitamin D supplementation (13-57)for 3 years (placebo) Triple therapy for Cure of peptic ulcer 1.1 (16)6-10 weeks (vs. (1.6-2.1)histamine antagonist) [RCT] Finasteride for Prevent benign prostatic 39 (17)

(vs. placebo) [RCT] avoid an operation

Duloxetine 80-120 mg/day 50 percent improvement in 7 (18)for 8 to 9 weeks (vs. placebo) symptoms of major depression (5 to 18)[9 pooled clinical trials]

[RCT] and B in adults over age 60 in provided) the winter of 1991-1992 NNH 10 for local reaction

Herpes zoster vaccine Prevention of shingles for three 175 (20)(vs. placebo) years after vaccination in subjects (CI not[RCT] age 60 or over provided)

Prevention of shingles for three 231 years after vaccination in subjects (CI not age 70 or over provided)

Prevention of post-herpetic 1087 neuralgia for three years after (CI not vaccination in subjects 60 or over provided)

helped rather than harmed. In -

sented, the LHH for 100 ug/day is 90 / 2.9 = 30, meaning that for every 30 patients helped with their

asthma; approximately one patient would develop oral candidiasis.

NNTs of treatments in medicine are shown in Table 5.


Table 5. Some NNTs from Medicine


Note that the NNT can be calculated when the -

riencing either a “positive outcome” or a “negative outcome.” For example let’s suppose a study has reported that in a clinical trial of an analgesic, 32 of 100 patients given placebo experienced at least 50 percent reduction in pain, whereas 70 of 100 pa-tients given the analgesic “Agent Gray” experienced at least 50 percent reduction in pain. Note that in

“positive outcome” as the patient experiencing at least 50 percent reduction in pain, and they have measured each patient against this outcome. Even if the authors did not report an NNT for Agent Gray, a reader could do so by calculating the control disease rate (100 minus 32 patients taking Placebo are still in pain = 68 percent) and the experimental disease rate (100 minus 70 patients taking Agent Gray are still in pain = 30 percent). These control and experimental disease rates could then be used to calculate RRR, ARR, and NNT as shown in Table 6. It is interesting to note that in such articles, not only have the authors provided us with the infor-mation with which to calculate the helpful NNT, but they have in so doing also given us their answer to

result from this treatment?” In this example, a clin-

“pain reduction of at least 50 percent.” We readers are welcome to agree or disagree with the authors’ choice, but at least they have taken a stand on the

Why We Can’t Calculate an NNT for All New TreatmentsTo enable us to calculate an NNT, the article’s au-

what constitutes a successful outcome for each patient. At the end of the study they then measure the proportion of patients who attained this suc-cessful outcome, and compare them to the propor-tion who did not attain a successful outcome. For example, in the Agent Blue vs. Control example given earlier, 66 percent of patients taking Agent Blue were cured, whereas only 22 percent of Con-trol patients were cured. As another example, in which “cure” and “no cure” do not strictly apply,

-ing a particular threshold, such as “In this study of Analgesic Brown, we considered a patient as a treatment success if he or she reported pain reduc-tion of at least 60 percent at the end of the study. Any patient who reported less than 60 percent

failure.” Note how both of these examples provide us an understanding of exactly what proportion of patients reached success, even if the “success” is

threshold for “success” on a per-patient basis, but instead simply measure each patient on a continu-ous variable (such as % pain reduction per patient) and then report the mean (average) outcome for each group. For example, an article might report re-sults like these: “Patients treated with Agent Purple reported mean pain reduction of 72 percent, where-

Table 6. Example of an NNT Calculation from Provided Data

Relative Risk Absolute Risk Number

Control Experimental Reduction Reduction Needed

Disease Disease Rate (RRR) = (ARR) = to Treat

Rate (CDR) (EDR) CDR - EDR CDR - EDR (NNT) =

CDR 1 / ARR

Agent Gray (0.70 – 0.32) 0.70 - 0.32

vs. 70 / 100 = 0.70 32 / 100 = 0.32 0.70 = 0.38 = 2.6

Control = 0.46


as patients treated with placebo reported mean pain reduction of 37 percent.” NNTs cannot be cal-culated when patient outcomes, measured on a continuous scale, have been averaged for a group of patients. The authors in such a case apparently intend to let the readers decide for themselves how much of a change in the outcome

reader does not have the informa-tion needed to calculate the NNT.

In summary, the NNT is a useful concept with which to compare the effectiveness of various treat-ments or preventive agents. The NNT is useful when considered in the context of whether evidence is valid (true) and whether it is applicable to a particular patient. Note that the NNT is appropriate for treatments of disease (medi-cal, surgical, behavioral, and so forth) and for preventive meth-ods, but not for diagnostic tests.

Although the arithmetic for calculating NNT is simple, online calculators are available for your convenience. An example NNT calculator is available at www.ebem.org/nntcalculator.html.

Note that the NNT is only as good as the research on which it is based. NNTs are generally calcu-lated from the results of well-designed randomized controlled trials (RCTs) and combined reviews (meta-analyses) of such trials. NNTs of less-stringent study designs (cohort studies or case series) would not be worth calculating as they could convey


data. Therefore users should

of the research article (were the subjects randomized to treatment or control? Were the treating cli-nicians, the examining clinicians, and the patients all blinded to the treatments provided? Were there at least 30 patients per group? Was there at least an 80 percent completion rate in each group?) If the answers to any of these questions is “no,” then an NNT would be of little value.

Questions and Answers about NNTQ. Does NNT predict how my

particular patient will re-spond to a treatment?

A. No. Your patient will either respond or not. NNT does not tell you how likely YOUR patient is to respond. An NNT of 5 (95 percent CI 2 – 7) allows us to estimate that in a group of 5 patients treated with the same treatment, one of them will respond, but we cannot predict which patient will respond.

Q. Could a large NNT be used by a third-party payer to compare the effectiveness of various treatments, and to exclude certain treatments with large NNTs as not worth paying for?

A. This concern was raised in the medical literature soon

-

oped (8). If I were in charge of an insurance company, that’s exactly what I’d do, as-suming I were not collecting so much money that I could afford to pay for everything and anything. Furthermore, if I were a premium payer, I would want my premium dollars to go only to pay, for other policyholders, for treat-ments with a low NNT so that there would be some dollars left for me when I needed care. Therefore, if I were a clinician, I would be looking for treatments with low NNTs!

Q. Can NNT be used to evaluate diagnostic technologies, such as FOTI or 3DCT?

A. No. Tools other than NNT are used to evaluate diagnos-tic technologies. NNT is ap-plicable only to interventions of therapy and prevention.

Q. Is NNT the only indicator that I should rely on for compari-son of treatments?

A. No. NNT is helpful, but only as a statement of the results of research. You must also evaluate its validity (don’t bother applying NNT to non-randomized trials; NNT means little if study size was less than 30 patients per group, etc) and you must evaluate its applicability (even if a treatment has a low NNT, it does not mean much to my practice if the treatment is too expensive, or risky, or something my pa-tients are unlikely to comply with or agree to).


Q. I don’t recall seeing NNTs re-ported in the last few articles I’ve read. Are they commonly reported in journals?

A. Until recently, relatively few dental clinical research articles have provided NNTs. They have been very popular in the medical literature and are catching on in dentistry.

reporting numbers needed to treat from relatively valid articles in dentistry by typ-ing the following into the search box at PubMed www.ncbi.nlm.nih.gov/pubmed: (“number needed to treat” AND dentistry) AND (Meta-Analysis[ptyp] OR Random-ized Controlled Trial[ptyp])

References1. Laupacis A, Sackett DL, Rob-

erts RS. An assessment of clinically useful measures of the consequences of treatment. New England Journal of Medi-cine 318(26):1728-1733, 1988.

2. Moore A. What is an NNT? Monograph in the What Is? Se-ries. April 2009. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/NNT.pdf as accessed March 2, 2010.

3. Watt E, Burrell A. Implement-ing NNTs. Monograph in the What Is? Series. April 2009. http://www.medicine.ox.ac.uk/bandolier/painres/down-load/whatis/Imp-NNTs.pdf as accessed March 2, 2010.

4. Simon S. Number needed to treat. Monograph in the “Ask Dr. Mean” series. Children’s Mercy Hospitals & Clinics, July 2008. http://www.child-rens-mercy.org/stats/ask/nnt.asp as accessed March 2, 2010

5. Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine, 3rd edition. New York: Elsevier 2005.

6. Anonymous. Swot’s Corner: -

vals. Bandolier http://www.medicine.ox.ac.uk/bandolier/band18/b18-9.html as ac-cessed March 2, 2010.

7. Powell H, Gibson PG. Inhaled corticosteroid doses in asthma: an evidence-based approach. Medical Journal of Australia 178:223-225, 2003.

8. Black HR, Crocitto MT. Num-ber needed to treat: Solid science or a path to pernicious rationing? American Journal of Hypertension 11(8):128S-134S, 1998.

9. Derry C, Derry S, Moore RA, McQuay HJ. Single dose oral ibuprofen for acute postopera-tive pain in adults. Cochrane Database of Systematic Re-views (3):CD001548, 2009

10. Esposito M, Grusovin MG, Talati M, Coutthard P, Oliver R, Worthington HV. Interven-tions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Da-tabase of Systematic Reviews (3):CD004152, 2008

11. Stecksen-Blicks C, Renfors G, Oscarson ND, Bergstrand F, Twetman S. Caries-preventive

-nish: a randomized controlled

orthodontic appliances. Caries Research 41(6):455-9, 2007.

12. Needleman IG, Worthington HV, Giedrys-Leeper E, Tucker RJ. Guided tissue regenera-tion for periodontal infra-bony defects. Cochrane Database of Systematic Reviews (2)CD01724, 2006.

13. Ren YF, Malmstrom HS. Effec-tiveness of antibiotic prophy-laxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. Jour-nal of Oral and Maxillofacial Surgery 65(10):1909-21, 2007

14. Karapataki S, Hugoson A, Kugelberg CF. Healing follow-ing GTR treatment of bone de-

fects distal to mandibular 2nd molars after surgical removal of impacted 3rd molars. Jour-nal of Clinical Periodontology 27(5)325-32, 2000.

15. Chapuy MC, Arlot ME, De-bouef F. Vitamin D3 and calcium to prevent hip frac-tures in elderly women. New England Journal of Medicine 327:1637-42, 1992.

16. Moore RA. Helicobacter pylori and peptic ulcer. A system-atic review of effectiveness and overview of the economic

which is known to be effective. 1994 December. Bandolier http://www.medicine.ox.ac.uk/bandolier/bandopubs/hpyl/hpall.html as accessed March 2, 2010.

17. Anonymous. More on BPH. Bandolier 46, December 1997. http://www.medicine.ox.ac.uk/bandolier/band46/b46-4.html accessed March 2, 2010.

18. Cookson J, Gilaberte I, De-saiah D, Kajdasz DK. Treat-

major depressive disorder as assessed by number needed to treat. International Clini-cal Psychopharmacology 2006 September;21(5):267-72.

19. Anonymous. Prevention

and B. Therapeutics Letter, November/December 2000, Therapeutics Initiative, Univer-sity of British Columbia.

20. Shootsky SA. Live attenuated varicella-zoster vaccine: Is it worth it? UCLA Department of Medicine Clinical Com-mentary, February 20, 2007. http://www.med.ucla.edu/modules/wfsection/article.php?articleid=294 As accessed April 26, 2010.


Gilcrease, Walter LewisSan Marcos, Texas

November 20, 1931 – November 17, 2010

Grove, Arthur Henry

Sherwood, ArkansasNovember 25, 1926 –

December 5, 2010

In MemoriamThose in the dental community who have recently passed

Hardeman, Strotha E.

December 11, 2010

Ivy, Ralph Carroll

El Paso, TexasJune 30, 1920 –

November 18, 2010

Wells, Joe Edward

December 11, 2010

Dr. Norman SpeckDr. Diana Smith

Dr. Behzad NazariDr. Ronada Davis

Dr. Russell HilliardDr. Helen Jafari

Dr. Terry OttDr. Stephen LukinDr. John Glauser

Dr. Brian MartinezDr. David EmmersDr. John StockmanDr. Chester Barker

Dr. Rhil BuckleyDr. Byron J. HallDr. James Seale

Memorial and Honorarium Donorsto the Texas Dental Association Smiles Foundation

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

Dr. Stephen BuehlerDr. Frank GreiderDr. Annette Gemp

Dr. Matthew GempDr. Chris GowanDr. Mark Speck

Dr. Bradley WilsonDr. Mark Hiller

Dr. John WeatherfordDr. Arezo Zarghouni

Dr. Fadi SalhaDr. Raja Nasir

Dr. Jeffrey HooverDr. Stephen Cheff

Dr. Donald LeeDr. Ron Hill

In Memory of:

Jean CoffeyGeorge ElderAlice Volney

Marjorie LawlessCalvin Clayton

Roger SmithMargaret Lilly

R. Dean ClevelandTed Keck

Annie Kirk MurphyMaxine MoodyEdward Foster

In Memory of:

Dr. Lewis Gilcrease

The Honorable Jim White

Brad Hatten

In Honor of:

In Honor of:

Dr. Jorge QuirchDr. Jerry Long

Dr. Rhonda Davis


Clinical History

This case involves a 95-year-old male patient with a history of papillary and/or verrucous gingival lesions which had been removed several times.

prostate cancer and breast cancer, and he is cur-rently on tamoxifen.

Three biopsies had been performed in the past, all from either the right or left facial mandibular

-illary hyperplasia with lichenoid change” 3 years ago (Figure 1). The next biopsy was performed 3 months ago and was signed out as “verrucous hyperplasia with epithelial dysplasia, moderate” (Figure 2) The last biopsy was diagnosed 1 month ago as “epithelial dysplasia, severe” (Figure 3).

What is your diagnosis?

See page 225 for the answer and

discussion.

Oral and Maxillofacial Pathology

Case of the Month

John E. Kacher, D.D.S., director, JKJ Pathology —Oral Medicine/Oral Pathology, The Woodlands, Texas

Kacher

Figure 1. Appearance of original lesion as an exophytic growth of the right mandibular facial gingiva with a papillary/verrucous surface.

Figure 2. Second lesion presenting as a leukoplakic verrucous lesion on the anterior marginal mandibular gingiva.

Figure 3. Histology of third lesion, exhibiting a somewhat papillary surface with dysplastic changes that focally extend into the upper third of the epithelium.

Oral and


Preview

e a a te isti s Thriving Dentists

Behrendt

Kirk Behrendt, ACT Speaker & Coach

Traveling all over the world and observing thousands of dental prac-

tices operate; we have noticed some very clear trends that are be-

coming more obvious with every month that passes. Basically, there

are two distinct groups in dentistry. There are those who are thriving

in practice, and there are those who are starving in practice.

Years ago, you could be clueless as to how to run a business and still makemoney in dentistry if you had a dental license. That is simply not the case any

same challenges that every entrepreneur has to deal with in growing a business. Dentists who recognize this trend have embraced it to thrive in dentistry. Otherswho have resisted this trend tend to struggle for the oxygen to keep their practicebreathing. The time has come for dentists to whole-heartedly choose one of these two paths.

This month we examine the nine common characteristics of the thriving dentist:

1. They Have Purpose, Conviction, and Clarity of Vision. The thriving dentistcan tell you without hesitation where they are planning to go and what they

comes to sharing what they believe about dentistry. Procuring this purpose,

great leaders.

2. They Are Hungry in Learning. The thriving dentist has an intense appetite for learning. Continuing Education has never been an expense. It is actuallyexciting. They don’t hesitate to take their entire team to a course that seem-ingly has value. They know that they don’t know everything. Pete Dawson

e te s akeYour Practice Thrive In AnyEconomyFriday, May 6, 2011

8:30 AM – 11:30 AM

te s s i e Team To Sell More DentistryFriday, May 6, 2011

1:30 PM – 4:30 PM

The 12 Most Effective Dental Marketing Tactics Available Today Saturday, May 7, 2011

8:30 AM – 11:30 AM


at my age and experience I have never thought

new all the time from my students. It is very exciting.”

3. They Learn Best By Doing. While being hungry

in learning, they understand that the best way to truly learn is to DO. They know that the best way to learn how to swim is to jump right in. Adult learning is most effective experientially. Ken Blanchard said that the “biggest gap in the world is between knowledge and application.” Starving dentists see this gap in application with pessimistic achievability, while the thriving dentist sees it with optimistic achievability and a

-pose. They know that there are “no shortcuts” to becoming the best, and that it may include some great failures along the way.

4. They Have Great Support and “Touchable”

Mentors or Coaches. They have spent a lifetime surrounding themselves with the right people. They found mentors, coaches, or

-cant relationships with and share in a process of intimate learned experience. These mentors or coaches are “touchable” which means that they have an intimate working relationship that includes critical feedback (not just someone they met a few years ago that gets together with them for dinner once and a while). They also (con-sciously or unconsciously) have practiced what Michael Collins revealed in his book “Good to

and Others Don’t” in which he said, “Contrary to popular belief, people are NOT our greatest as-

asset.” Who they have become in dentistry has been an evolutionary process that has attracted, kept and appropriately nurtured great talent that

professionally. 5. Their Practice is Structured for Success.

They have very clear goals and monitor them constantly. The entire operation is very well

that is being served. Ambiguity is an enemy to their practice. Very rarely do you ask a team member in a thriving practice a question about

Thriving dentists

to make sure that the


how they do things and you are met with the reply “I’m not sure.” Predictability in daily business operations and predictability in the delivery of technical dentistry becomes the critical component to how high their

6. They Understand That “Dentistry is 51 Percent

si ess a e e t e i al This is great quote given to me by my friend Dr. Gary DeWood of the Pankey Institute that is so incredibly true. Know-ing how to do the dentistry is not nearly enough to run a successful practice. The thriving dentist knows that cash is to their business what oxygen is to their life. And that living in a surplus of cash is a byproduct

goal. The thriving dentist has developed a hungry awareness of how successful businesses (or prac-tices) work and would almost certainly be successful in any other profession for this reason.

7. They Are Excellent Communicators. Thriving

-cant relationships. They have done this not only in practice, but also in life. They understand that truly ef-fective communication has a lot to do with non-verbal messaging, intense listening, and sometimes talking. Some of the highest producing dentists that we coach actually do very little talking (in comparison to their patients) in their new patient experience. They have an incredible ability to get patients talking in a way that they feel excited about themselves. Patients most often end up being the driving force in treatment plans rather than the dentist and teams. The thriving dentist

that procures higher levels of trust and likeability. 8. They Look The Part. Thriving dentists have taken

the steps to make sure that the image and brand they

patients actually experience. They walk the talk. They are everything other patients say they are. They dress like patients would expect them to dress. The esthet-

to see. Their practice is usually in a great location. You see, people create an image of who you might be when they hear about you. How well you meet or

exceed the standards of that picture will greatly deter-mine how successful you are in living out your vision. You would hope that people don’t judge a book by its

recognize with “looking the part” is that our standards grow higher every month with every new shopping mall, high end coffee shop and brilliant restaurant that opens around us. Consumers’ expectations are grow-

the image of being “with or ahead of the curve.” 9. They Do a TON of Marketing.

of all understand that marketing is not just and exter-nal effort, but rather EVERYTHING THEY DO. Their internal operations and how they train patients to refer are very well choreographed. They are willing to take great risks when it comes to projecting their brand. Their website is top notch. Their image pieces (logo, stationary, etc) are very sharp. Their staff clearly

patient truly experiences in their practice. The lab they use is the best. They are involved with organized dentistry and most often respected by their peers. Marketing for them is doing everything they possibly can to increase the “top of mind” awareness for any-one who is considering their kind of services.

Where you are in dentistry is a choice. It may be con-scious or unconscious, but nevertheless, it is still a choice. If you are thriving in dentistry, and you read these nine characteristics, it probably supported the beliefs you al-ready have and act on. You have chosen to thrive. On the other hand, if you are starving and you read this article, you may have discounted a few of these character-istics as “things I should have done” or “things I can’t do”.

in the current state of your practice, because the future will only be a slight variation of what you have now. Choosing to thrive is something very few people do. We were given this great gift of choice. My hope is that you use it wisely and let it work its magic in your life.

Thriving Dentists


Proliferative Verrucous LeukoplakiaOral and Maxillofacial Pathology Case of the Month (from page 221)

Oral and Maxillofacial Pathology

Diagnosis and Management

Discussion

Proliferative Verrucous Leukoplakia (PVL) is a rare multifocal leukoplakia

-pathologic parameters. This disease typically begins with white plaques which slowly spread and tend to recur after biopsy. Both the clinical and histologic appearance occupy

hyperkeratoses to verrucous lesions that may demonstrate varying levels of dysplasia (1).

PVL has a strong female predilec-tion and is not associated with any traditional risk factors for oral cancer. The progression is relentless with eventual transformation into invasive squamous cell carcinoma. One study demonstrated that with a mean time of 7.7 years, 70.3 percent of patients developed oral cancer at a PVL site (2).

Other studies have demonstrated an association between PVL and infection with human papillomavirus, most notably type 16 (3). Due to

from a surgical approach, some tri-

als using drugs that inhibit viral RNA synthesis have been attempted (4).

The differential diagnosis for PVL based on clinical information in-cludes: verrucous hyperplasia with dysplasia, verrucous carcinoma, or atypical papilloma. It is important to note that clinical history plays a large part in diagnosis of PVL. This case was diagnosed based on the history of spreading verrucous leukoplakic lesions that recur, and histopatholo-

This particular patient is being referred to a major cancer center for potential enrollment in a drug trial.

References

1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Max-illofacial Pathology, 2nd edition. Philadelphia: WB Saunders Company 2002; 607-608.

2. Silerman S, Gorsky M. Prolifera-tive verrucous leukoplakia: A follow-up study of 54 cases: Oral Surg Oral Med Oral Pathol Oral Radiol Endod (1997) 84:2 154-157.

3. Palefsky J, Silverman S, et al. Association between prolifera-tive verrucous leukoplakia and infection with human papilloma-virus type 16: J. of Oral Pathol-ogy & Medicine (1995) 24:5 193-197.

4. Azfar, RS James, WD. Prolif-erative Verrucous Leukoplakia: Treatment & Medication. eMedi-cine Specialties -> Dermatology 12/16/2009.

Special thanks to Dr. Gayle Brad-shaw for sharing this case. Website: www.bradshawperiodontics.com


value for yourprofession

Provided by TDA Perks Program

Does Payroll Outsourcing MakeSense for Your Practice?

Brian Bauml, President, Netchex Central Texas, LLC

-

ally rewarding experience. As with every entrepreneurial endeav-

or, the positive aspects of running your own business are tem-

pered by the realities of hiring and

developing staff, keeping up with

the latest dental technologies and

techniques, submitting required

reporting to the government—on

time and accurately, managing

your receivables, and dealing with

the inevitable insurance reimburse-

ment headaches.

Although some of these issues are unique to a dental or medical practice, you wouldn’t be the only small business owner who wishes he had more time to focuson growing and managing his businessand could spend less time on activities

For many entrepreneurs, this is possible through outsourcing tasks that take uptheir time but don’t help their business


tired of all the headaches associated with paying your employees, it might be time to outsource your time tracking, payroll, and HR activities to a reliable, com-petent and time tested business partner.

Processing payroll is a high-risk, low-re-ward business activity. If you process payroll manually, you’ve got to keep track of payroll regulations and changes in withholding tables—a time-consuming task. Calculating the actual payroll amounts and deductions are equally tedious; and it’s very easy to make a mistake. Then, there’s the arduous chore of writing checks and making all the

state payroll taxes. It’s not uncommon for small busi-nesses to spend 2 to 3 hours processing each payroll, if they do it by hand or use payroll software.

Mistakes are costly. Employee morale dips when you give an employee a check or a W2 with errors. If payroll records are ac-cidently accessed by the wrong staff person, pay-rate

breached. Employees may forgive, but they might not

have to pay a payroll penalty. Every year, four out of ten

for payroll errors. When you add it all up, that’s billions

payroll penalties and the value of your time, processing payroll internally can be a very costly proposition.

Already Outsource?Even if you’re already outsourcing payroll, there may be room for improvement. Payroll services change over time, and there are new capabilities that are worth checking out. If you’ve already outsourced to a service bureau, CPA or bookkeeper, it’s worth consid-ering whether your provider is giving you everything you want at the best price point. Payroll service offer-ings today, including automated time and attendance tracking options and human-resource record keeping, are better than ever.

The Benefits of Web-Based Payroll ServicesEnhanced Control and AccessibilityThe internet has greatly improved the process of out-

service is enhanced control. With web-based payroll

services, you can enter and view payroll information from anywhere at any time, as long as you have Inter-net access.

and monitor your payroll, hours worked, and HR data. Employers have online access to payroll reports from

in real time, and calculations viewed instantly, guaran-teeing an accurate payroll every time. Employees can view and print their payroll records and W2s, alleviat-ing administrative burden that frequently arises when employees need proof of payment history for loan applications and other purposes.

Payroll can be processed whenever it’s convenient. Paychecks can be printed, signed, stuffed and deliv-ered or routed to your employee’s bank accounts elec-tronically via direct deposit. Once you enter your payroll data or import hours from an automated time clock, web-based payroll services can automatically calculate,

W-2s are automatically prepared at the end of the year

Save Time and MoneyBeyond increased control, online payroll services save small-business owners time and money. It only takes a few minutes to process payroll online, so your time could be freed up for more important things; like caring for your patients, expanding your practice, accelerat-ing receivables, recruiting the right new employee, or spending more time with your family.

How do the new payroll services save money? If a payroll service is processing thousands of payrolls for its clients, economies of scale allow it to work more

passed on to its clients. In addition, because new on-line payroll services don’t have the same cost structure as traditional ones, their prices can be as much as 15 - 25 percent lower. Moreover, many payroll services guarantee that you won’t incur a payroll tax penalty, which can represent considerable savings.

Other ConsiderationsOnce you’ve decided that outsourcing your payroll makes sense, it’s a good idea to gather information and ask questions that will help you select the best business partner. Consider the following:

1. What type of company you prefer: a large multi-national, publically traded company or a privately-held regional processor? Large companies offer


safety in numbers; but a small business might not get the attention it deserves. Large companies have deep pockets, but are shareholder-focused. Accordingly, they operate quarter-to-quarter, which can cause annual price increases

service levels. If you choose a regional processor, make sure payroll outsourcing is its core business; not a side one. Because losing even a small client has a large impact on a smaller company, customer service—by necessity—is a

customers. Smaller compa-nies tend to be more nimble, and can adapt more quickly to changes in technology, client requirements and expecta-tions. Look for a smaller pro-vider who has a track record of at least 5 to 7 years. Make sure it assumes liability in writ-

your taxes. Speaking of taxes, another desirable feature that offers employer peace of mind is a service provider’s ability to direct you to the IRS e-File website that documents what

on your behalf, and when they were submitted.

2. Request a copy of the pro-vider’s SAS70 document. This provides a written third-party review over the company’s policies and procedures, (in-cluding business continuity and security,) which publicly-traded companies must provide to third-party auditors in order to be in compliance with Sar-banes-Oxley reporting require-ments. Even better would be an SAS70II document, which not only describes policies and procedures, but also tests them in a production environment.

3. Ask a prospective company how its employees are trained. Are they herded into a class-room with eight other unrelated companies with varying payroll expertise, or are they person-ally trained on appropriate applications?

4. Ask your prospective service provider about its customer service model and culture. Many large payroll outsourcing companies use voice-response technology to route your call to the correct support group. Once you’re in the appropri-ate department, your account is supported in a call-center environment. Smaller provid-ers typically offer a dedicated customer service contact backed up by a team, and have its calls answered by a live person who will route you to the correct service group. This can provide clients faster, more accurate, consistent and personalized support when it’s needed most. If you require more functionality than auto-mated time and attendance tracking, does your potential service provider have what you need, and does it include it as part of its product offering? Is it supported by the same point of contact you’d have for your payroll service? If so, how inte-grated are the applications? Do you need to log in using mul-tiple user IDs and passwords?

5. Almost all payroll service providers offer a web interface, out of necessity. Unfortunately, many clients don’t realize until it’s too late that their web access is actually tied to a mainframe computer. Here’s

if yours is: Check whether or not the application is accessi-ble from any Internet Explorer browser, or if a workstation

-cate to access the application over the Internet. Or, if you’re accessing a preview of your processed payroll, check if the preview occurs instantaneous-ly, or if it takes 30-60 minutes, because the data needs to be “crunched” by a mainframe.

6. Lastly, if things go wrong who can you turn to? Ask your sales contact how long he’s worked for his current employer. It’s not unusual for sales persons to come and go frequently, mini-mizing your chance of having a friendly ally available, if needed. How far up the “chain” can you go if you have a problem that can’t (or won’t) get resolved? It’s very important to have executive sponsorship to insure that you’ll have a favorable out-sourcing experience. With many large companies, the buck usu-ally stops with a regional vice-president of customer service; while with a smaller company, a client can speak directly with the CEO if necessary.

In summary, outsourcing payroll is truly a viable alternative in today’s workplace. It simply doesn’t make sense to waste time, money and resources on a tedious task that is ancillary to your core business. If you determine that outsourcing is right for you, conducting due

payroll service.

NetChex, a TDA Perks partner, offers payroll, human resources, reporting and labor management services, and was recently named in Inc. magazine’s list of the 5,000 fastest-growing companies in the country. For more information regarding NetChex, please call: (877) 729-2661. For more informa-tion regarding TDA Perks Program, visit www.tdaperks.com, or call (512) 443-3675.


James L. Dunn,

Trustee

DDR Dental TrustServing Texas Dentists for more than 40 Years

800-930-8017

w w w . P o r t a b l e i v . c o m

Sign up for our newsletter or ask for more information.

Catharine Quartapella Goodson DDS. UT Houston 1985General Dentist providing In-office Dental I.V. Moderate

Sedation Services for your patient.

In-office DentalI.V. Sedation Services for

your patient.Sedation customized to

your patientspsychological &

physical requirements

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(office) 281.332.6964(cell) 713.417.9924

Website:www.portableiv.com


Ca

len

da

r o

f E

ven

tsa

2 – 5The Alliance of the American Dental Association will hold a conference in Richmond, VA. For more information, please contact Ms. Patricia Rubik-Rothstein, AADA, 211 E. Chicago Ave., Ste. 730, Chicago, IL 60611-2678. Phone: (312) 440-2865; FAX: (312) 440-2587; E-mail: [email protected]; Web: ada.org.

2 – 9The American Academy of Dental Practice Administration will hold its annual meeting at the JW Marriott Resort in San Antonio, TX. For more information, please contact Ms. Kathy S. Uebel, AADPA, 1063 Whippoorwill Ln., Palatine, IL 60067. Phone: (847) 934-4404; FAX: (847) 934-4410; E-mail: [email protected]; Web: aadpa.org.

2 – 5The Academy of Laser Dentistry will hold its 18th annual conference and exhibition at the Loews Coronado Bay Resort in San Diego, CA. For more information, please contact Ms. Gail Siminovsky, ALD, 3300 University Dr., Ste. 704, Coral Springs, FL 33075. Phone: (954) 346-3776; FAX: (954) 757-2598; E-mail: [email protected]; Web: lasterdentistry.org.

3 – 5The Academy of Osseointegration will hold its annual meeting, From Fundamentals to New Technologies for the next 25 Years, at the Washington DC Convention Center in Washington, DC. For more information, please contact Ms. Gina Seegers, 85 W. Algonquin Rd., Ste. 550, Arlington Heights, IL 60005-4422. Phone: (847) 439-1919; FAX: (847) 439-1569; E-mail: [email protected]; Web: osseo.org.

11 – 16The Omicron Kappa Upsilon will meet in San Diego, CA. For more information, please contact Dr. Jon B. Suzuki, OKU, Temple University Dentistry, 3223 North Broad St., Philadelphia, PA 19140. Phone: (215) 707-7667; FAX: (215) 707-7669; E-mail: [email protected]; Web: oku.org.

11 – 16The American Dental Education Association will hold its annual session and exhibition at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Michelle Allgauer, ADEA, 1400 K Street, NW, Ste. 1100, Washington, DC 20005. Phone: (202) 289-7201; FAX: (202) 289-7204; E-mail: [email protected]; Web: adea.org.

il 11 – 13The American Association of Public Health Dentistry will hold its National Oral Health Conference at the Hilton Pittsburgh in Pittsburgh, PA. For more information, please contact Ms. Pamela J. Tolson, CAE, 3085 Stevenson Dr.,

13 – 16The American Association of Endodontists will hold its annual session at the San Antonio Convention Center in San Antonio, TX. For more information, please contact Mr. James M. Drinan, AAE, 211 E. Chicago Ave., Ste. 1100, Chicago, IL 60611-2616. Phone: (312) 266-7255; FAX: (312) 266-9867; E-mail: [email protected]; Web: aae.org.

15 &16The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Dallas, TX. For more information, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

28 – 30The American Dental Society of Anesthesiology will hold its annual meeting at the Westin Keirland Resort & Spa in Scottsdale, AZ. For more information, please contact Ms. Barbra Josephson, ADSA, 211 E. Chicago Ave., Ste. 780, Chicago, IL 60611. Phone: (312) 664-8270; FAX: (312) 642-9713; E-mail: [email protected]; Web: adsahome.org.

a 5 – 8The Texas Dental Association will hold its 141st annual session, The TEXAS Meeting, at the Henry B. Gonzalez Convention Center in San Antonio, Texas. For more information, please contact TDA, 1946 S. IH 35, Ste. 400, Aus-tin, TX 78704. Phone: (512) 443-3675; FAX: (512) 443-3031; Web: texasmeeting.com.

6The TDA Smiles Foundation (TDASF) will hold its Healthy Smiles Golf Classic in San Antonio, TX. For more infor-mation, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 443-2441; Web: tdasf.org.


Ca

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ven

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

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

9 – 11The ADA will hold its Washington Leadership Conference in Washington, D.C. For more information, please contact Mr. Brian Sodergren, ADA, 1111 14th St., NW, Ste. 1100, Washington, DC 20005. Phone: (202) 789-5168; FAX: (202) 789-2258; E-mail: [email protected]; Web: ada.org.

17 – 21

in Boston, MA. For more information, please contact Ms. Kelly Radcliff, AACD, 5401 World Dairy Dr., Madison, WI 53718. Phone: (800)543-9220; FAX: (608)222-9540; E-mail: [email protected]; Web: aacd.com.

26 – 29The American Academy of Pediatric Dentistry will hold its 64th annual session at the Marriott Marquis New York in New York, NY. For more information, please contact Dr. John S. Rutkauskas, CAE, AAPD, 211 E. Chicago Ave., Ste. 1700, Chicago, IL 60611-2663. Phone: (312) 337-2169; FAX: (312) 337-6329; E-mail: [email protected]; Web: aapd.org.

11The TDA Smiles Foundation (TDASF) will hold a Smiles on Wheels mission in Mineral Wells, TX. For more informa-tion, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

15 – 18The ADA will hold its 25th New Dentist Conference in Chicago, IL. For more information, 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.

17 – 18

Disease and the Relationship to Systemic Health,” at the Marriott Plaza San Antonio Hotel in San Antonio, TX. For more information, please contact Dr. Ron Trowbridge, 2943 Thousand Oaks, Ste. 4, San Antonio, TX 78247. Phone (210) 653-7174; FAX (210) 653-8204.

23 – 25The ADA Council on Access, Prevention and Interprofessional Relations (CAPIR) will meet in Chicago, IL. For more information, please contact Ms. Carrie Campbell, ADA, 211 E. Chicago Ave., Chicago, IL 60611. Phone: (312) 440-2500; FAX: (312) 440-7494; E-mail: [email protected]; Web: ada.org.

15-17ADPAC, the American Dental Political Action Committee, will meet. For more information, please contact Ms. Cyn-thia Taylor, ADA, 1111 14th St., N.W., Ste. 1200, Washington, D.C. Phone: (202) 789-5172; FAX: (202) 898-2437; E-mail: [email protected].

28 – 31The Academy of General Dentistry will have its annual meeting and exhibition at the Ernest Morial Convention Cen-ter in New Orleans, LA. For more information, please contact Ms. Rebecca Murray, AGD, 211 E. Chicago Ave., Ste. 900, Chicago, IL 60611. Phone: (312) 440-3368; FAX: (312) 440-0559; E-mail: [email protected]; Web: agd.org.

28 – 30The International Association of Comprehensive Aesthetics will meet at the Manchester Grand Hyatt in San Diego, CA. For more information, please contact Ms. Mary Williams, IACA, 1401 Hillshire Dr., Ste. 200, Las Vegas, NV 89134. Phone: (888) NOW-IACA; FAX: (702) 341-8510; E-mail: [email protected]; Web: theiaca.com.

5 & 6The TDA Smiles Foundation (TDASF) will hold a Texas Mission of Mercy event in Texarkana, TX. For more informa-tion, please contact TDASF, 1946 S. IH 35, Ste. 300, Austin, TX 78704; Phone: (512) 448-2441; Web: tdasf.org.

18 & 19National Conference on Dentist Health and Wellness will be in Chicago, IL. For more information, please contact Ms. Mary Gilliam, ADA, 211 E. Chicago Ave., Chicago, IL 60611-2678. Phone: (312) 440-2500. FAX: (312) 440-7494; E-mail: [email protected]; Web: ada.org.


IMPORTANT: Ad briefs must be in the TDA of-

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

ads. Ads cannot be accepted by phone or fax. *

Advertising brief rates are as follows: 30 words or less — per insertion…$40. Addi-tional words 10¢ each.

The JOURNAL reserves the right to edit copy

-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.

PRACTICE OPPORTUNITIES

MCLERRAN AND ASSOCIATES:

AUSTIN: Associate to purchase. High gross-ing, family practice located in retail center with seven operatories was recently re-modeled. Near major freeway. High growth area. Practice boast solid, well-established patient base. ID #108.

-tory 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 #115.

CORPUS CHRISTI: Doctor retiring, six op

Good numbers, excellent patient base, good upside potential. Excellent practice for starting doctor. Priced to sell. ID #023.

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

RIO GRANDE VALLEY: Excellent four operatory, 20-year-old general practice.

with digital radiography. Fee-for-service patient base and very good new patient count. Great numbers. Super upside po-tential. ID #093.

SAN ANTONIO — Prosthodontic practice with almost new equipment and build out. Doctor wants to sell and continue to

SAN ANTONIO, NORTH CENTRAL — Two-op practice just off major freeway; perfect

-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

nice equipment and decor. Excellent op-portunity. ID #003.

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

SAN ANTONIO: Oral surgery specialty practice. Very good referral base. Almost new build out, great location, and excel-lent equipment. Good gross and net. Transition available. ID #113.

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 #112.

SAN ANTONIO, NORTH CENTRAL:-

ter with great visibility and access. New equipment and nice build out. Good solid numbers, very low overhead. ID #111.

SAN ANTONIO: Six operatory practice with three chair ortho bay located in 3,400

equipment. Free-standing building on busy thoroughfare. Practice has grossed in

-tion with super upside potential. ID #055.

SAN ANTONIO, NORTH CENTRAL: Five operatory, state-of-the-art facility with new equipment. Located in a medical pro-

income. ID #106.


SAN ANTONIO NORTH WEST: Excellent, four-chair general family practice in high

location. Solid gross income on 30 hours/week. Ideal opportunity for doctor wanting a quick start in low overhead operation. ID #086.

SAN ANTONIO, SOUTHEAST: Three opera-

retail center, good equipment, solid patient base, low overhead. Perfect location for a

ID #121.

NEW; SAN ANTONIO, SOUTHEAST: Three

visible retail center. Excellent location. Practice has tremendous upside potential. ID #121.

old practice with condo is priced very ag-gressively as doctor must sell. Call now to learn more about this great deal. ID #118.

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

WACO AREA: Modern and high-tech, three op general family practice grossing in mid-

#107.

Contact McLerran Practice Transitions, Inc.: statewide, Paul McLerran, DDS, (210) 737-0100 or (888) 656-0290; in Austin, David McLerran, (512) 750-6778; in Hous-ton, Tom Guglielmo and Patrick Johnston, (281) 362-1707. Practice sales, appraisals, buyer representation, and lease negotia-tions. See www.dental-sales.com for pictures and more complete information.

GARY CLINTON / PMA NORTHWEST OF DALLAS CARROLLTON 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 Clinton is a 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/

dual representation. Authorized closing -

based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general).

WATS: (800) 583-7765.

WE NEED SELLERS! GARY CLINTON / PMA: Serving the dental profession since 1973: I have buyers! Sell your practice and travel while you have your health. In many cases, you can stay on to work 1-2 days per week if you wish. I need practices to sell/transition as follows: Any practice in or near Austin, San Antonio, DFW and Houston areas, and other Texas locations. We have buyers for orthodontic, oral surgery, periodontic, pedodontic, and general dentistry practices. Values for practices have never been higher. Tax advantages high for present time. One hundred percent funding available, even those

y questions. We have the best sources for 100 percent buyer funding. Gary Clinton is a 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/

dual representation. Authorized clos-ing agent/escrow agent for numerous


based upon the comparables. More than 2,000 comparables to ensure accuracy of appraisal (specialty and general). Very

(800) 583-7765.

ORTHODONTIC PRACTICES FOR SALE / TRANSITION — GARY CLINTON / PMA TEXAS: O-1 Houston/Webster / Friendswood / South of Houston area — Few orthodontists in this area; tremen-dous opportunity area. Doctor retiring;

O-2 West Central Texas mid-sized to larger community — Ideal transition; professional 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

lovely building. He is ready to spend time with his grandchildren. Easy drive to San Antonio. We have the best sources for 100 percent buyer funding. Gary Clin-ton is a 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

interest/dual representation. Authorized closing agent/escrow agent for numerous


(800) 583-7765.

GARY CLINTON / PMA ARLINGTON PRACTICE FOR SALE: The place to be for young families. Texas Rangers base-ball. Cowboys football, and Six Flags for entertainment. Well-established practice. Excellent recare program. Near seven

operatories. We have the best sources for 100 percent buyer funding. Gary Clin-ton is a 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



(800) 583-7765.

GARY CLINTON / PMA FORT WORTH AREA GENERAL PRACTICES FOR SALE: Fl — Excellent patient base; well-established recall. Bread and but-ter practice. Very fast growing area near Texas Motor Speedway. Average gross

practice in southwest Fort Worth. Associ-ate buy-out or outright sale. Solid recall program. We have the best sources for 100 percent buyer funding. Gary Clin-ton is a 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



(800) 583-7765.

ORAL SURGERY PRACTICE FOR SALE HOUSTON AREA — GARY CLINTON / PMA: State-of-the-art practice. Fast growing location. Economy is strong in Texas. Many referring doctors for cos-metic and implant surgery. Outright sale.

relocating out of state; will transition on a limited basis. We have the best sources for 100 percent buyer funding. Gary Clin-ton is a 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

interest/dual representation. Authorized


closing agent/escrow agent for numerous


WATS: (800) 583-7765.

GARY CLINTON / PMA PLANO / FRIS-CO AREA: Future rapid growth area where people will want to live. Practice in the middle of the high growth area. Pro-

for 100 percent buyer funding. Gary Clin-ton is a 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



WATS: (800) 583-7765.

GARLAND / RICHARDSON AREA FULLY EQUIPPED OFFICE SPACE ONLY — GARY CLINTON / PMA TEXAS: No pa-

digital six-operatory space in strip shop-ping center. Call Gary Clinton, dental practice appraiser/broker, for more infor-mation, (214) 503-9696.

GARY CLINTON/PMA WEST OF FORT WORTH PRACTICE FOR SALE: A little more than an hour west of Fort Worth,

-

Excellent recall; six operatories. Fee-for-service; No DMO or low fee PPO. We have the best source for 100 percent buyer funding. Gary Clinton is a 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, associate transition/sale. No real estate commis-

(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

-enues, doctor to transition to comfort level of purchaser. Come build your retirement in low competition community. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTH HOUSTON GENERAL DENTAL PRACTICE — SALE: located on busy thoroughfare in rap-idly growing south Houston suburb. Six

additional plumbed operatories such that practice has capacity to grow well in ex-

Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

NORTH TEXAS GENERAL DENTAL PRAC-TICE — SALE: Small, well-established prac-tice in mid-sized community in north Texas. Three fully-equipped operatories. Experi-enced staff with excellent skills. Doctor will assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

CORPUS CHRISTI GENERAL DENTAL — SALE: Moderate revenues with a very

-cient facility layout. If you need to prac-tice to refund your retirement, but don’t

city, come see this practice. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

DFW METROPLEX ORAL SURGERY PRACTICE — SALE: Well-established practice enjoying 2009 revenues exceed-

Extensive referral base, experienced staff,

transition. Don’t miss this opportunity. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.


NORTHWEST HOUSTON GENERAL DEN-TAL PRACTICE — SALE: New practice in growing area located near well-traveled Highway 290 and Jones Road. Two fully equipped treatment rooms with three oth-ers plumbed for expansion. Digital X-rays. Moderate revenues on 3.5 days per week. If you want to be in the rapidly growing NW quadrant, this practice is for you. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTH OF HOUSTON GENERAL DENTAL PRACTICE — SALE: Established practice in mid-size town generating revenues ap-

Associate in place providing orthodontic treatment. Building is also for sale. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST HOUSTON GENERAL DENTAL PRACTICE — SALE: Wonderful opportunity in rapidly growing community west of Hous-ton. Excellent revenues, steady new patient

-tact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

LAS VEGAS ORAL SURGERY PRACTICE — SALE: Excellent practice with revenues

over 48 percent. Strong professional refer-

3D digital projection including CT scan-ner. Highly skilled, experienced staff. Doc-tor will assist in transition. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

DALLAS / FORT WORTH: Area clinics

industry average income with paid health and malpractice insurance while working in a great environment. Fax (312) 944-9499 or e-mail [email protected].

WACO PEDIATRIC DENTAL PRACTICE — SALE: Well-established practice with

on 4 days per week. Limited competition and a large facility. Ample room to grow in this community that is home to Bay-

lor University. All ortho cases are being completed, unless purchaser would like to expand new cases. No Medicaid being seen, but good opportunity with facility capacity. Experienced staff and steady

Building also available. Contact The Hind-ley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTH OF HOUSTON GENERAL DEN-TAL PRACTICE — SALE: Outstanding practice with very high growth potential

margin on 4 days per week. Extremely -

tion. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

BRYAN/COLLEGE STATION GENERAL DENTAL PRACTICE — SALE: Well-estab-lished practice in mid-size town. Four op-

must transition due to health reason. Con-tact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

EAST TEXAS GENERAL DENTAL PRAC-TICE — SALE: Well-established prac-tice in small town in hills in East Texas. Moderate revenues on 4 days per week; three operatories; excellent staff. Room to expand in adjacent space. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

FORT WORTH ORTHODONTIC PRAC-TICE — SALE: Excellent opportunity for

to add orthodontics to services offered; female dentist desiring part-time position while children in school; or older dentist wanting to utilize orthodontics as less physically taxing exit strategy. Doctor will mentor or assist with transition. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

WEST TEXAS GENERAL DENTAL PRAC-TICE — SALE:


fully-equipped operatories; two additional spaces plumbed for future use. Strong

Contact The Hindley Group. LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

ARLINGTON ORAL SURGERY PRAC-TICE — SALE: Highly successful practice with strong revenue history of more than

-tion in half due to back injury but will assist purchaser in rebuilding practice. Extensive referral pattern. Building also for sale. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

SOUTHEAST OF HOUSTON GENERAL DENTAL PRACTICE —SALE: Wonderful location on well-traveled street. Excellent

equipped operatories. Contact The Hind-ley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

DALLAS/FORT WORTH GENERAL DEN-TAL PRACTICE — SALE: Fully digitized

Four operatories with space for one addi-tional. Strong revenues, excellent staff, and wonderful mentor to assist in transition. Contact The Hindley Group at (800) 856-1955. Visit us at www.thehindleygroup.com.

ASSOCIATESHIPS: EAST TEXAS GEN-ERAL DENTAL PRACTICE — Small but busy practice generating mid-range revenues on 4 days per week. Located in quaint small town with excellent access to

boating. Excellent opportunity for den-tists looking ahead to separation from the military. Pre-determined buy-in terms. SOUTH CENTRAL TEXAS PERIODON-TAL —Wonderful practice completing periodontal treatment seeks long-term as-sociate who desires to be a partner within 1-2 years. Great location with strong new

and partnership terms. Wonderful mentor looking for an “equally-yoked” individual.

Excellent staff. SAN ANTONIO PERIODON-TAL AND ENDODONTIST ASSOCIATE-SHIPS — Periodontal associateship with pre-determined buy-in for very active,

-tist associate also needed in this practice. Outstanding mentor and cohesive staff. If you are “equally yoked” and the right person, this is an outstanding opportunity. WEST TEXAS GENERAL DENTAL PRAC-TICE — Associateship with pre-determined buy-in and partnership terms. Nine op-eratories. Strong mentor and experienced

Large Medicaid component. Contact The Hindley Group, LLC, at (800) 856-1955. Visit us at www.thehindleygroup.com.

HOUSTON AREA PRACTICE FOR SALE: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

(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 Watson, Brown & Associates at (469) 222-3200.

DALLAS / FORT WORTH: Dental One is -

urbs of Dallas and Fort Worth. Dental


as Riverchase Dental Care and Preston

top-of-the-line Pelton and Crane equip-ment, digital X-rays, and intra-oral cam-eras. We are 70 percent PPO, 30 percent full fee. We take no managed care or Med-icaid. We offer competitive salaries and

Dental One, please contact Rich Nicely at (972) 755-0836.

HOUSTON DENTAL ONE is opening new

Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We are 100 percent FFS with some PPO plans. We of-

-uity buy-in opportunities. To learn more about working for Dental One, please call Andy Davis at (713) 343-0888.

FULLY EQUIPPED MODERN DEN-TAL OFFICE SPACE AVAILABLE FOR LEASE. Have four ops. Current doctor is only using 2 days a week. Great opportu-nity to start up new practice (i.e., endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week. If you are wanting an associate, please inquire. Call (214) 315-4584 or e-mail [email protected].

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 schedule with community centrally located within 1 hour of three

leased or purchased separately and is spaciously designed with four operatories,

rental space. This is an excellent and prof-itable opportunity for a new dentist, a den-tist desiring to own a practice, or a satellite practice expansion. Contact C. Vandiver at (713) 205-2005 or [email protected].

SUGAR CREEK / SUGAR LAND: General dentist looking for periodontist, endo, ortho specialist to lease or sell. Suite is 1,500 sq. ft. with four fully-equipped

telephone system, computers, reception and playroom; 5 days per week. If seri-ously interested, please call (281) 342-6565.

AUSTIN: Unique opportunity. Associate-

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 opportu-nity 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 experi-enced dentist wanting to relocate and be-come part of an established practice with a reputation for providing comprehensive, quality dental care with a personable approach. Practice references available from local specialists. Contact Dr. Richard Krumholz, (409) 762-4522.

GENERAL DENTIST NEEDED to provide comprehensive dental services for com-munity health center dental practice. Services include examination, diagno-sis, and treatment of registered patients of the center. Scope of services include diagnostic, preventive, restorative, oral surgery, and endodontics. The center is a

Station. E-mail cover letter and resume to Dr. Alonge at [email protected].

HOUSTON: General dentist with pediat-ric experience needed. Full-time position available. Excellent compensation. Please send CV to [email protected].


ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established

-perience seeks a caring and motivated as-sociate for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their

-ful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledg-able staff will support and enhance your growth and earning potential while help-ing create a smooth transition. Interested candidates should call (903) 509-0505 and/or send an e-mail to [email protected].

ASSOCIATE NEEDED FOR NURS-ING 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

-tion presents unique technical medical, and behavioral challenges, seasoned den-tist 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 dynamic dentist to work full time in our pediatric practice. The perfect complement to our dedicated staff would be someone who is compassionate, goal oriented, and has a genuine love for working with children. If you are a motivated self-starter that is willing to give us a long-term commit-

resumes and cover letters to candice,[email protected].

GREAT OPPORTUNITY FOR A PEDIAT-RIC 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 tremendous, and we

any direction. We are looking for someone that is personable, caring, energetic, and loves a fast-paced working environment in a busy pediatric practice. We are willing to

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

develop experience in all facets of pediat-ric dentistry including behavior manage-ment using oral conscious sedation as well as IV sedation. For more information, please visit our websites at www.wyliechil-drensdentistry.com and www.parischil-drensdentistry.com. Please e-mail CV to [email protected].

SOUTHWEST FT. WORTH — GENERAL DENTAL PRACTICE WITH BUILDING FOR SALE OR LEASE: This very success-ful, well-established practice has an excel-lent patient base with referrals from near and far. The seller is retiring immediately or will negotiate a comfortable transi-tion. With a low overhead and excellent

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 visibility and stable economic commu-nity. With this practice comes an expe-rienced staff, computers in all treatment rooms, nice equipment, imaging software, and much more. Get out of that associ-ate 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].


GREAT PRACTICE IN BEAUTIFUL EAST TEXAS. This fee-for-service practice was established by a prominent community-involved dentist with an excellent reputa-

sq. ft. with four available treatment rooms

opportunity to become part of this stable economic town with an experienced staff and a growing patient base. Interested? Call (972) 562-1072 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 opportunity. 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 Kes-ner, [email protected].

SEEKING ASSOCIATE DENTISTS. Den-tal Republic is a well-established general dental practice with various successful lo-cations throughout the Dallas Metroplex. A brand new state-of-the-art facility in a bustling location 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 ex-

and by forming long-lasting friendships with our patients and staff members. Please contact Phong at (214) 960-3535 or e-mail CV to [email protected].

CARE FOR KIDS, A PEDIATRIC FO-CUSED PRACTICE, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive

-cluding medical, life, long- and short-term

401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texas’ kids. Please contact Anna Robinson at (913) 322-1447; e-mail: [email protected]; FAX: (913) 322-1459.

DDR PRACTICE SALES — DUNN/ISEN-HART: SERVING TEXAS DENTISTS FOR OVER 40 YEARS. National direct (and fax): (800) 930-8017.

CORPUS CHRISTI: Laid back lifestyle with

revenues on 4 days per week. Denture fo-cus could be expanded to a broader scope of restorative general treatment. In-house lab with experienced technician. Great location, great staff, and a great lifestyle.

will work as associate if desired. Call DDR Practice Sales at (800) 930-8017.

BRYAN/COLLEGE STATION AREA: Well-established practice serving rural commu-nity of 5,000 just 20 minutes from College

collections with substantial 40 percent net. High quality implant practice. Four

two full-time hygienists and a great staff. Ownership of free-standing 1,900 sq. ft. building is optional. Over 4,000 patient base with average age of 45. Call DDR Practice Sales at (800) 930-8017.

GALVESTON: Must sell for relocation. Thriving practice in Galveston providing the best of both worlds ... the great out-doors and a laid back lifestyle, yet quick access to metropolitan Houston. This 15-year practice has three fully equipped

-gienist, and a great staff. Half interest in free-standing building included in price.

-tions on only 3 days per week. Owner currently splits time with out-of-town practice. Call DDR. Practice Sales at (800) 930-8017.


AUSTIN: Five operatory, two hygien-ists, one associate dentist, gross of seven

wants to sell practice but is also willing to work contact for buying dentist; great location in beautiful Austin. Practice in the heart of most desired city in Texas. Substantial net income with four fully equipped operatories and two full-time hygienists. Current associate will remain at buyer’s discretion. Call DDR Practice Sales at (800) 930-8017.

DALLAS: -sional building, run very lean. Mid six-

your practice? Call DDR Practice Sales at (800) 930-8017.

CORPUS CHRISTI: General dentistry practice — location, location, location; 25-year-old practice grossed more than

-

DDR Practice Sales at (800) 930-8017.

HOUSTON: Motivated buyer seeking Galleria area practice. Willing to acquire

expand his practice. Call DDR Practice Sales at (800) 930-8017.

SAN ANTONIO: Beautiful fast-growing -

eratories. Ten-year-old practice, doctor

gross on 4-day week. Excellent opportuni-ty for younger dentist to make his or her mark. Call DDR Practice Sales at (800) 930-8017.

SAN ANGELO, ABILENE: Associates — outstanding earnings. Historically proven at over twice the national average for general dentists; future potential even greater. Thriving, established practice in great location. Bright and spacious facil-

of all worlds; big city, earnings, small-town easy lifestyle, outstanding outdoor recreation. Contact Dr. John Goodman at [email protected] or (325) 277-7774.

ASSOCIATE DENTIST NEEDED IN EU-LESS: Well-established general practice seeking full-time associate/future partner. Cosmetic and full family practice. Please send resume to [email protected].

TWO-YEAR DENTAL ASSOCIATESHIP — EL PASO: We are a quality children’s

and dental anesthesiologists. Pay per year for 2-year agreement equals generous

based commissions. Will train in oral seda-tion. Ownership opportunities available. Send resume to [email protected]. Call (915) 858-6868.

ESTABLISHED, SUCCESSFUL GENERAL PRACTICE AVAILABLE FOR OWNER-SHIP -ment. Niche market limited to removable prosthetics and related services. Guar-anteed minimum salary plus unlimited

package. Onsite lab. Monday through Fri--

cation, personal rewards. E-mail [email protected].

GREAT OPPORTUNITY FOR ORTHO-DONTISTS AND GENERAL DENTISTS to join our busy practices providing orth-odontic care in the Rio Grande Valley area. We are looking for orthodontists to oversee all aspects of patient care and general dentists to work in coordination with our orthdontists to be able to provide the highest quality care for our patients. Be a part of our exceptional team help-ing the children of Texas get great smiles. Please contact Dr. Hal D. Lerman at (214)

net.

KATY: Dr. Bui X. Dinh, D.D.S., M.S. is looking for a dentist right now with mini-mum 2 years experience. Please contact

or fax resume to (281) 579-6045.


Advertising

B r i e f s

FOR SALE — GREAT 41-YEAR SUC-CESSFUL PRACTICE IN SOUTH CEN-TRAL TEXAS. Owner retiring but will stay through transition period. Five operatories in beautiful building, Pan-O, digital X-ray. Experienced long-term dependable staff. Room for multiple dentists. Please mail letter of interest to Box 1, TDA, 1946 S. IH 35, Ste. 400, Austin, TX 78704.

SEEKING ASSOCIATE: Established

minutes away from South Padre Island) is seeking a caring, energetic associate. We

mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested

NEW, TYLER: Excellent opportunity, location, and lifestyle. Join an established doctor and share a 2-year-old, free-stand-ing, award-winning building on busy south Tyler Street. Five of 10 ops and

lab, and sterilization. Equity position in property available or lease. E-mail [email protected].

TEMPLE DENTAL CENTER IN TEMPLE, TEXAS, IS FOR SALE: Doctor changing professions. Firesale! Four operatories, tons of equipment and instruments, three

leave message. E-mail [email protected].

SAN ANTONIO NORTH WEST: Associate needed. Established general dental prac-tice seeking quality oriented associate. New graduate and experienced dentists welcome. GPR, AEGD preferred. Please

or [email protected].

EXPERIENCED DENTIST IS NEEDED FOR A PRIVATE GROUP PRACTICE LOCATED IN SPRING. General dentistry practice with a comfortable and friendly atmosphere without administrative responsibilities. Full-time position with competitive compensa-

opportunity for a quality oriented person.

e-mail [email protected].

TEXAS — PEDIATRIC DENTAL ASSO-CIATE NEEDED. Fast-growing pediatric dental practice is looking for a pediatric

from New Braunfels and 45 minutes from Austin. We offer a generous compensa-tion package including paid time off and holidays. Experience is a plus, but new graduates are welcome. Please respond via e-mail to Sherri at velezluke@yahoo.

OFFICE SPACE

SPACE AVAILABLE FOR SPECIALIST. New professional building located south-west of Fort Worth in Granbury between

of a state highway with high visibility and

SPECIALTY DENTIST NEEDED NEXT TO DENTIST IN HIGH GROWTH, HIGH TRAFFIC AREA IN ROUND ROCK, north of Austin in one of the fastest-growing

SHERMAN — 1,750 SQ. FT. DENTAL OFFICE. Building has established gen-

visibility with lots of parking. 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


ALLEN: Prior dental, high end practice that relocated. Five plumbed and ready

bath, some built-in cabinets, no equip-

street from large grocer. Offering 5-7 years lease plus extensions. Levin Realty, (323) 954-1934, [email protected].

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

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

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

INGLESIDE DENTAL BUILDING FOR SALE! 1,700 sq. ft., two chairs plumbed. Rental side, near Corpus Christ!. Busy main street location. Vacant, no equip-ment. Landscaping, parking, owner/den-

E-mail [email protected] or call (702) 480-2236.

ARLINGTON DENTAL OFFICE FOR LEASE: Current doctor is only using 1 day a week. Has four up-to-date opera-tories with HD TVs in each op, assistant computer, doctor computer, Casey edu-cational system, digital X-rays, digital panoramic machine, electric handpiece, sterilization room, laboratory, and Cerec CAD/CAM technology. Perfect for new practice start up. Visit our website to view

docdds.com, www.docdds.com.

WHITNEY: Free-standing vacant building for sale. Perfect location, 6 miles from the lake for any specialty start-up. Location near hospital complex, 2,600 sq. ft., no

built 1978. Pictures are available. For more information call (972) 562-1072 or e-mail [email protected]

COMPLETE DENTAL OFFICE CONTAIN-ING 3,362 SQ. FT. OF AREA located in busy shopping center anchored by 27,000 sq. ft. Dollar Tree store available Decem-ber 15, 2010. Location is at a busy in-tersection that includes Walgreen’s, HEB Grocery, McDonald’s, Whataburger, Big Lots, and Hallmark Cards. Some dental chairs and equipment may be purchased from existing dentist and shopping center

required. Current dentist has occupied this location for over 10 years and recently built his own building. Rent — $14 per sq. ft. plus NNN charges of $3.60 per sq. ft. Contact Cynthia Ellison at Grubb & Ellis Co. in San Antonio, (210) 804-4847.

FOR SALE

LARGE INVENTORY OF QUALITY REFURBISHED AIR DRIVEN DENTAL HANDPIECES. All have been repaired

have new ceramic bearing turbines and

SWL, $269; Kavo 640B, $279; Kavo 642B, $299; Kavo 647B, $299; Midwest Tradi-tion push button or lever, $239; new Kavo

Kavo coupler six-hole, $149; new Star

implant handpieces available, too. Qual-ity discounts are possible. I have been a TDA member for 25 years. If what you are looking for is not on this list, we stock a wide variety at wonderful prices, just inquire. Call (877) 863-4848 or visit our website, www.truespindental.com.

FOR SALE: Two mauve Dental-EZ dental chairs. Recovered 2007. Both are in good working order. Will sell single or as a pair. If sold single, $600 each. Pick-up only. If interested, please e-mail for pictures, [email protected].

INTERIM SERVICES

TEMPORARY PROFESSIONAL COVER-AGE (Locum Tenens): Let one of our distinguished docs keep your overhead


your staff busy, your patients treated

rate not a percent of production. Nation’s largest, most distinguished team. Short-notice coverage, personal, maternity, and disability leaves our specialty. Free, no

Trusted integrity since 1996. Some of our team seek regular part-time, permanent, 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].

INTERIM SERVICES

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

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

DENTAL OFFICE needed to lease 12 hours per week for Dental Assisting

downtime one weekend day and one

is $500 to $1,500 per month, depending on enrollment. Seeking locations in Dal-


las, San Antonio, and Houston. Please call the National School of Dental Assisting at (800) 509-2864.

THE NATIONAL SCHOOL OF DENTAL ASSISTING — NORTH DALLAS offers the Texas RDA course and exam. Call (800) 383-3408 for available dates.

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.

THE DENTAL HANDPIECE REPAIR GUY, LLC. I’m pleased to inform you that we are now operating a full-service hand-piece repair shop in Friendswood, Texas, where my father Dr. Ronald Groba has

been practicing for over 35 years. I have been doing his handpieces for over 20 years and decided to provide this service to other dentists. First and foremost, we provide expert service for your precision

nearly every make and model of high-speed, low-speed, and electric handpiec-es on the market. We use quality parts, take less time, and our costs are lower. We provide free pickup and delivery, warranties, and next-day service on most high-speed units and a 1-week turn-around for slow speeds, ultrasonic seal-ers, and electrics. The Dental Handpiece Repair Guy wants to be your handpiece servicing facility of choice. We would ap-preciate a chance to earn your business! Call (800) 569-5245 or visit our website, www.thedentalhandpiecerepairguy.com.


Ads Watson, Brown & Accociates .......................

Ace on Hold (TDA Perks) ......................................

AFTCO ....................................................................176

A.J. Riggins Co......................................................245

Anesthesia Education and Safety

Foundation..........................................................165

Crown Dental Studio .............................................

DDR Dental Trust ...................................................

Dental Practice Specialists...................................

Dental Systems......................................................

Doctors Per Diem ..................................................244

EVACVV .......................................................................

Fortress Insurance ................................................146

Gary Clinton, PMA.................................................175

Hanna, Mark — Attn. at Law .................................176

Henderson, Sherri L. & Associates......................151

Hindley Group........................................................146

Inspection Connection..........................................

JKJ Pathology........................................................

Kennedy, Thomas John, D.D.S., P.L.L.C..............245

LVI Global/Dr. ReeceLL ..............................................154

Ocean Dental..........................................................

Paragon, Inc. ..........................................................

Patterson Dental ..........................Inside Front Cover

Portable Anesthesia Services ..............................

Professional Recovery Network...........................246

Robertson, James M .............................................

Shepherd, Boyd Wilson ........................................

Southern Dental Associates.................................147

SPDDS ....................................................................

TDA ExpressA ..........................................................

TDA Financial Services Insurance A

Program..........................................

TDA Perks ProgramA ..................... Inside Back Cover

Texas Health StepsTT ................................................143

Texas Medical Insurance CompanyTT .....................166

TEXAS Meeting......................................................174

UTDB Houston.......................................................

UTHSCSA ...............................................................

UTHSCSA Oral & Maxillofacial LabA ......................

Waller, Joe..............................................................175

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