1. Oral Health with a Focus on Disabilities June Sadowsky, DDS, MPH Associate Professor, Dentist Geriatrician The University of Texas Health Science Center at Houston School of Dentistry General Practice and Dental Public Health 1

2. Dr. June Sadowsky Dr. June Sadowsky was a member of the HRSA funded Houston Geriatric Education Center when this presentation was developed. Dr. Sadowsky has presented this work to interprofessional audiences. Please credit her for the work she provided in the development and updating of this presentation. 2

3. Funded By This project was funded by a grant from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The grant was initially funded in 2007 with renewed funding for five years beginning in 2010. (Grant #UB4HP19058). The grant was successfully completed in June, 2015.

4. Learning Objectives Successful completion will allow the student to: – Gain knowledge of the risk factors associated with oral health and disabilities – Perceive the oral manifestations of systemic disease – Be aware of the diseases and oral management – Understand some interventions to assist older adults 4

5. 5 School of Dentistry 7500 Cambridge, Houston, Texas 77054

6. Major Risk Factors Periodontal disease Caries Socio-behavioral factors Environmental factors Health status 6 UT Health 2002

7. A Risk Factor for Cardiovascular Disease 7 Scannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic Diseases. JPeriodontal. 1998 Jul;69(7)841-50. and Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. ChenYW etal,J Clin Periodontol, 2009 Oct;36(10):830-5.

8. Other Risk Factors 8 Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000 Volume 62, Issue 1, pages 59–94, June 2013Volume 62, Issue 1, Medications which reduce saliva flow Smoking Diabetes Cancer Microsoft

9. Link Between Heart Disease and Gum Disease Inflammation is a major risk factor for heart disease, and periodontal disease may increase the inflammation level throughout the body. Since several studies have shown that patients with periodontal disease have an increased risk for cardiovascular disease, cardiologists and periodontists developed clinical recommendations and will now see joining forces to help patients. British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81 showed that there was an unexpected correlation between dental disease and systemic disease (stroke, heart disease, diabetes). 9 A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The Online Versions Of Two Leading Publications, The American Journal Of Cardiology (AJC), A Publication Circulated To 30,000 Cardiologists, And The Journal Of Periodontology (JOP), The Official Publication Of The American Academy Or Periodontology (AAP). J Periodontol July 2009. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum, Impact of Periodontal Therapy on General Health American Journal of Preventive Medicine Volume 47, Issue 2, Pages 166–174, August 2014American Journal Of CardiologyJournal Of PeriodontologyVolume 47, Issue 2

10. Caries Risk 85% had coronal and/or root caries > 75% were taking medications with hyposalivary side effects Lack of fluoride in oral environment Saliva very acidic 10 Caries Activity And Associated Risk Factors In Elderly Hospitalized Population – 15-months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58 Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463.

11. Environmental Factors Societal healthcare Cultural values Education Health promotion Lifestyle choices Stress Work–related environment Fluoridated water Sugar consumption Alcohol use 11

12. 12 Environmental Quality Built Environment Environmental Factors University of Wisconsin Population Health Institute Model 2012 Physical Environment 10% Social and economic factors -40% Health Behaviors – 30% Clinical Care - 20% Mortality (length of life) 50% Morbidity (quality of life) 50% Tobacco use Diet and exercise Alcohol use Sexual Activity Access to Care Quality of Care Community Safety Education Employment Family and Social Support Income Health Outcomes Health Factors Policies and Programs

13. Socio-Behavioral Risk Factors Human biology Vulnerability Health care organization Public policy changes Lifestyle Develop personal skills to deal with life Recreation Use fluoride products Environment Create more support for elderly Income inequality 13 1974, Marc Lalonde Google.com/images

14. 14 The common risk factor approach (adapted from Petersen, 2003) Petersen PE, Sociobehavioural risk factors in dental caries – international perspectives, Community Dentistry and Oral Epidemiology Volume 33, Issue 4, pages 274–279, August 2005Volume 33, Issue 4,

15. Health Status Tobacco Alcohol Diet – well balanced – Decrease sugar intake – Increase fruit and vegetable – Vitamin D deficiency Fluoride use and plaque removal twice per day Regular dental checkups 15 Microsoft.com

16. Caries Management By Risk Assessment Caries Risk Assessment Treatment Plan Caries Free Education 16 http://ncpresby.pbworks.com/f/dental%2016.jpg

17. Chronic Diseases Heart disease Stroke Cancer Chronic respiratory diseases Diabetes REPRESENT 60% OF DEATHS 17 chronicdiseases@who.int Microsoft.com

18. Manifestations of Systemic Disease 18

19. GI Disease Oral manifestations Crohn’s disease – Noncaseating granulomas – Lip, mucosal swelling – Cobblestone-like gingiva – Mucosal tags – Angular chelitis – Decreased saliva production and malabsorption may lead to dental caries Ulcerative colitis – Areas of hemorrhage and ulceration – Aphthous ulcers and chelitis GERD – Mouth pH – 5.5 – Erosion – Sensitivity Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohn’s Disease N Engl J Med. June 1 200; 342(22):1644 Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 26, No.8 (August 1981) Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J Gastroenterol.Apr 2007;21(4):241-4 19

20. Chronic Liver Disease Liver Dysfunction – Coagulation/Vitamin K deficiency – Gingival bleeding (in the absence of inflammation) – Petechiae – Jaundice (bilirubin in submucosa of soft palate) Hepatitis - lichen planus, xerostomia, sialadenitis, erosive lesions ALD or Cirrhosis 20 Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.Dental considerations in patients with liver disease. J Clin Exp Dent.2011;3(2):e127-34. Microsoft.com CD Johnson

21. Chronic Kidney Disease Presence of kidney damage or decreased kidney function Chronic NSAID use Oral symptoms – Ammonia like taste and smell (urea in saliva) and frost on skin – Stomatitis – Gingivitis – Parotitis – Xerostomia – Decreased salivary flow – Atrophic glossitis – Thirst 21 Little JW. Dental management of the medically compromised patient. 2013 Elsevier/Mosby, St. Lous Mo. Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.Dental considerations in patients with liver disease. J Clin Exp Dent.2011;3(2):e127-34. Google.com/images

22. Anemia Occult Blood Loss Iron deficiency Anemia – Chronic inflammation B-12 Deficiency (Pernicious Anemia) – Gastrectomy Folate Deficiency Oral Manifestations – Pale gums – Glossitis (folate and Vitamin B-12 deficiency) – Angular stomatitis (candida infection) – Pica (desire to consume unusual substances, such as ice or dirt) 22 Spivak JL. Anemia In The Elderly: Time For New Blood In Old Vessels?. Arch Intern Med. Oct 24 2005;165(19):2187-9.

23. Connective Tissue Disorders 23 Porter S, Scully C. Connective tissue disorders and the mouth. Dent Update 2008 Jun;35(5):294-6, 298-300, 302. Klasser GD, Balasubramaniam R Epsein J,Topical review-connective tissue diseases: orofacial manifestations including pain. J Orofac Pain.2007 Summer;21(3):171-84. Sjogren’s Syndrome – 90% females over 50 – Sicca syndrome – dry eyes and mouth – Xerostomia – Atrophy of papillae of tongue produces a cobblestone effect – Increased incidence of candida infection – Dental caries

24. Pulmonary Conditions COPD – 90% caused by smoking – Air pollution – Irreversible damage to the airways – Restricts movement – Cough and breathlessness – Soft palate irritation from inhaler use – Dry mucous membranes Wegener’s granulomatosis – Necrotizing vasculitis – Ulceration and hyperplastic gingival enlargement 24 Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care Med. Apr 1 2009;179(7):533-41 Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review. J Am Dent Assoc. 2007 Mar;138(3):338-48; quiz 396, 398 J Am Dent Assoc.

25. Diabetes Affects approximately one in four Americans age 60 and older The number of adults age 75+ with – 1 million in 2000 to more than 4 million in 2050 23.1% of patients 60+ OR one of every 4.2 patients you see over the age of 60! 5.7 million are undiagnosed 82% of diabetic patients with severe periodontal disease have experienced one or more – Major cardiovascular – Cerebrovascular – Peripheral vascular events Compared to only 21% of diabetics without periodontal disease Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and worldwide. MMWR 2003;52(06):101-106 Measley BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J Periodontol 2006 Aug;77(8):1289-130 25 http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages

26. Diabetes Uncontrolled diabetics exhibit higher levels of collagenase that can degrade periodontal tissues (Ryan 2003, Salvi 1997) Periodontal disease results in higher pro- inflammatory cytikine TNF- ﻪ that causes insulin resistance (Grossi 1998) Diabetic patients who have full-mouth disinfections every three months showed significant reductions in their HbA1c serum levels (blood glucose) (Lang 2008) 26

27. Arthritis Leading cause of disability Affects 8 million Severely limits ability to perform Activities of Daily Living (ADL’s) Loss of Range of Motion Stiffness Joint Deformity Overweight, Fatigue Unexplained fever May affect TMJ (temporomandibular joint) Rutger Persson G. Rheumatoid arthritis and periodontitis: inflammatory and infectious connections: review of the literature. J Oral Microbiol 2012; 4:10. 27

28. Arthritis Joint Pain, tenderness and inflammation CRP=C-Reactive Protein in blood serum produced in the liver during acute inflammation or infection Osteoarthritis – common Rheumatoid - + RF in blood Gout – Uric acid Beer, sardines, organ meats Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:10–25 Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental Res 2012; 91:914–920. 28

29. Arthritis and Periodontal Disease Patients referred for periodontal treatment – prevalence of self-reported rheumatoid arthritis was 3.95% – Significantly higher than that seen in patients not referred for periodontal treatment (0.66%) – that reported in the general population (1%). 29 Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth loss and incident rheumatoid arthritis: results from the First National Health and Nutrition Examination Survey and its epidemiological follow-up study. J Clin Periodontol 2011; 38:998–1006

30. Arthritis and Periodontal Disease Of those referred patients with rheumatoid arthritis, 62.5% – advanced forms of periodontal disease – self-reported prevalence of cardiovascular disease and diabetes mellitus 30 Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol 2010; 37:1800–1804

31. Arthritis and Periodontal Disease Conclusions: there is good evidence to suggest that individuals with moderate to severe periodontal disease are at higher risk of suffering from rheumatoid arthritis and vice versa. 31 Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000 Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol 2010; 37:1800–1804

32. Osteoporosis People with osteoporosis are much more likely to lose their teeth due to bone loss in the jaw. Good homecare is even more important to help prevent tooth loss. Osteoporosis Treatment Bone-replacing cells in bone are suppressed and if an extraction, bone may not heal. Mattson JS Mattson JS 1, Cerutis DR, Parrish LC.Osteoporosis: a review and its dental implications. Compend Contin Educ Dent. 2002 Nov;23(11):1001-4Cerutis DRParrish LC Compend Contin Educ Dent. Dervis EDervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Sep;100(3):349-56.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 32

33. Oral Manifestation of Viral Diseases Herpes Zoster (Shingles) 33Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007

34. Oral Manifestation of Viral Diseases Human papillomavirus Squamous cell papilloma and ver­ruca vulgaris Human immunodeficiency virus Plantar warts on hands 34 Schubert MM. Oral manifestations of viral infections in immunocompromised patients. Curr Opin Dent 1991;1:384-97. Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007

35. Head and Neck Cancer Incidence oral and pharyngeal cancer in 2012 in the US 40,250 new cases (28,540 in men and 11,710 in women) Estimated Deaths in 2012 – 7,850 people (5,440 men and 2,410 women) Careful monitoring of the oral cavity with strict application of preventive measures Lower radiation doses or intensity-modulated radiotherapy (IMRT) Use of shielding Reduction in the use of toxic drugs Improved oral instructions and expectations Completion of dental treatment before beginning cancer care benefits the patient greatly 35 http://www.cancer.org/acs/groups/cid/documents/webcontent/003128-pdf.pdf

36. Drug Induced Oral Manifestations Apthous stomatitis – Canker sores Lichen Planus – ACE inhibitors – Beta-blockers – NSAID’s – Diuretics – hydroxychloroquin e Gingival Enlargement (hyperplasia) – Phenytoin – Ca+ Channel Blockers – Cyclosporine Dry Mouth/Xerostomia (hyposalivation) – Single most adverse effect – Anticholinergic effect – Alters taste – Difficulty eating, swallowing – Treatment Increased hydration Artificial saliva Procholinergic agents Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C Virus And Lichen Planus: A Case Control Study Of 340 Patients. J Am Acad Dermatol, Nov 1999;4195):787-9 Abdollahi M, Radfar M; A review of drug induced manifestations, J Contemp Dent Prac, 2003(2)1:10-31 36

37. Dry Mouth 37 CD Johnson

38. Drug Induced Oral Manifestations Stevens-Johnson Syndrome – 3 weeks after meds – Rash to purpuric macules – 50 % oral Sulfonamides Penicillin Phenytoin Phylbutazone Drug -induced Neutropenia – Ulcers on gingiva Fungal Infections – Radiation – Chemotherapeutics – Immunosuppressives Bologna JL, Jorizzo, JL, Papini, RP, Dermatology. Spain: Mosby 200338

39. Candidiasis 39

40. Diseases and Oral Management 40

41. Disease and Oral Management Alzheimer’s/dementia Dental Management Of Patients With Alzheimer's Disease And Other Dementias ( Ronald L Ettinger July 2000volume 17, Issue 1pages X–xi, 1–64) Alzheimer's Disease And Dental Management (Hümeyra Kocaelli Etal Oral Surg, Oral Med, Oral Path, Oral Rad and Endo Vol 93 5, May 2002, Pages 521-524) Stroke Movement disorders Parkinson’s Oral Health and Peripheral Arterial Disease. Hung HC, Circulation. 2003; 107: 1152-1157 Oral care for patients with cardiovascular disease and stroke ( Louis F. Rose LF, Etal. J Am Dent Assoc, Vol 133, No suppl1, 37S-44S. 2002) Can’t do ADL’s 41

42. Disease and Oral Management Continued growth of population over 65 Globally oral health is poor in elderly – Prevention is not emphasized – Those in dependent situations have few oral caregivers More people are keeping their teeth longer means more teeth at risk 42 World Wide Public Health Of Elderly - Improving The Oral Health Of Older People: The Approach Of The WHO Global Oral Health Programme Poul Erik Petersen, Tatsuo Community Dentistry And Oral Epidemiology Volume 33, Issue 2, Pages 81–92, April 2005Volume 33, Issue 2,

43. Disease and Oral Management Long –term care – Patient consent issues – Seventy percent of patients in long-term care facilities had unacceptable levels of oral hygiene (Kiyak et al. 1987, McIntyre et al. 1986) – lack of knowledge about oral care Homebound Hospice Oral Cancer patients – Majority elders 43 Kiyak HA. An explanatory model of older persons’ use of dental services: implications for health policy. Med Care 1987;25:936–52. MacEntee MI, Weiss R, Waxler-Morrison NE, Morrison BJ. Factors influencing oral health in long term care facilities. Community Dent Oral Epidemiol 1987;15: 314–6.

44. Other Barriers to Dental Care Access – Transportation Housing – Live in abandoned car Legal – VA Benefit – Alien status 44

45. Interventions to Assist Older Adults 45

46. Management Options Education – Entities caring for seniors – Students and faculty to retain patients Linkage to Community Resources – Transportation – Mental Health – Living – Caregiving Outreach to Seniors concerning dental needs 46

47. Management Options Education – Caregiver training video designed for nursing homes, assisted living facilities, and individuals. – Make a donation of one to a facility near you. http://son.uth.tmc.edu/coa/community.htmhttp://son.uth.tmc.edu/coa/community.htmhttp://son.uth.tmc.edu/coa/community.htm 47

48. Dental Management Make all offices elder friendly Literacy alert – Bigger print – Language easy to understand Educate caregivers Alter toothbrushes Forms for daily documentation of oral care Mobile/portable dental teams 48

49. References Scannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic Diseases J. Periodontal. 1998 Jul;69(7)841-50 ChenYW etal. Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. J Clin Periodontol, 2009 Oct;36(10):830-5. Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000 Volume 62, Issue 1, pages 59–94, June 2013 Volume 62, Issue 1, A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The Online Versions Of Two Leading Publications, The American Journal Of Cardiology (AJC), A Publication Circulated To 30,000 Cardiologists, And The Journal Of Periodontology (JOP), The Official Publication Of The American Academy Or Periodontology (AAP). J Periodontol July 2009 American Journal Of CardiologyJournal Of Periodontology Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum, Impact of Periodontal Therapy on General Health American Journal of Preventive Medicine Volume 47, Issue 2, Pages 166–174, August 2014Volume 47, Issue 2 British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81 Caries Activity And Associated Risk Factors In Elderly Hospitalized Population – 15- months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58 Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463. 49

50. References University of Wisconsin Population Health Institute Model 2012 1974, Marc Lalonde chronicdiseases@who.int Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohn’s Disease N Engl J Med. June 1 200; 342(22):1644 Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 26, No.8 (August 1981) Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J Gastroenterol.Apr 2007;21(4):241-4 Bagan JV, Aguirre JM etal; Oral lichen planus and chronic liver disease: A clinical and morphometric study of the oral lesions in relation to transaminase elevation; Oral Surgery, Oral Medicine, Oral Pathology Volume 78, Issue 3, September 1994, Pages 337–342Oral Surgery, Oral Medicine, Oral PathologyVolume 78, Issue 3 Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.Dental considerations in patients with liver disease. J Clin Exp Dent.2011;3(2):e127-34. Little JW. Dental management of the medically compromised patient. 2013 Elsevier/Mosby, St. Lous Mo. Porter S, Scully C. Connective tissue disorders and the mouth. Dent Update 2008 Jun;35(5):294-6, 298-300, 302. Klasser GD, Balasubramaniam R Epsein J, Topical review-connective tissue diseases: orofacial manifestations including pain. J Orofac Pain. 2007 Summer;21(3):171-84. 50

51. References Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care Med. Apr 1 2009;179(7):533-41 Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review. J Am Dent Assoc. 2007 Mar;138(3):338-48; quiz 396, 398 J Am Dent Assoc. Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and worldwide. MMWR 2003;52(06):101-106 Measley BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J Periodontol 2006 Aug;77(8):1289-130 http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages The influence of diabetes on periodontal disease, Ryan ME, Carnu O, Kamer A. JADA, Vol. 34, (10): 34S-40S. Salvi G, Yalda B, Collins J, et al. Inflammatory mediator response as a potential risk marker for periodontal diseases in insulin dependent diabetes mellitus patients. J Periodontol 1997;68(2):127:35. Grossi SG, Genco RJ: Periodontal disease and diabetes mellitus: a two-way relationship. Ann Periodontol 3:51–61, 1998 Lang NP, Tan WC, Krahenmann MA, Zwahlen M. A systematic review of the effects of full-mouth debridement with and without antiseptics in patients with chronic periodontitis. J Clin Periodontol. 2008 Sep;35(8 Suppl):8-21.J Clin Periodontol. 51

52. References Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:10–25 Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental Res 2012; 91:914–920. Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth loss and incident rheumatoid arthritis: results from the First National Health and Nutrition Examination Survey and its epidemiological follow-up study. J Clin Periodontol 2011; 38:998–1006 Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000 Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol 2010; 37:1800–1804 Mattson JS, Cerutis DR, Parrish LC. Osteoporosis: a review and its dental implications. Compend Contin Educ Dent. 2002 Nov;23(11):1001-4Compend Contin Educ Dent. Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Sep;100(3):349-56.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Zachariasen RD, Oral manifestations of menopause. Compendium, 1993, 14(12):1584, 1586-91 52

53. Questions June M. Sadowsky, DDS, MPH – 713-500-4064 – June.Sadowsky@uth.tmc.edu June.Sadowsky@uth.tmc.edu Images – HoustonGEC would like to thank: Microsoft images Google.com images UTHEALTH School of Dentistry New Patient Information – UTHealth School of Dentistry – 713-486-4000 53