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CONTENTS PRESIDENT'S MESSAGE 4 OFFICIAL PUBLICATION OF THE UTAH DENTAL ASSOCIATION
CONTRIBUTING WRITERS ADA News Dental Abstracts Dr. Kay Christensen JADA Dr. Brent A. Larson Christopher A. Moore – ODA Today Laci Phillips – Today's FDA Jodi Schafer, SPHR SHRM-SCP Michigan Dental Association Dr. Mark D. Taylor Dr Scott Theurer Today's FDA Dr. John Vivano – JMDA
COVER PHOTO Bull Valley Gorge, Cannonville, Utah Amy Burns
PUBLISHER: Mills Publishing, Inc. PRESIDENT Dan Miller OFFICE ADMINISTRATOR Cynthia Bell Snow GRAPHIC DESIGNERS Ken Magleby Patrick Witmer
ART DIRECTOR Jackie Medina
ADVERTISING REPRESENTATIVES Paula Bell Paul Nicholas
The Utah Dental Association holds itself wholly free from responsibility for the opinions, theories or criticisms herein expressed, except as otherwise declared by formal resolution adopted by the association. The UDA reserves the right to decline, withdraw or edit copy at its discretion. UDA Action is published bi-monthly. Annual subscriptions rates are complimentary to all UDA members as a direct benefit of membership. Non-members $30. Utah Dental Association, 801-261-5315 1568 500 W Ste. 102, Woods Cross, Utah 84010 uda@uda.org. UDA Action is published by Mills Publishing, Inc. 801-467-9419; 772 East 3300 South, Suite 200, Salt Lake City, Utah 84106. Inquiries concerning advertising should be directed to Mills Publishing, Inc. Copyright 2022.
Be Somebody
ASSOCIATION 5
This Dentistry Thing is a Pretty Good Gig
9 Welcome Newly Elected Officer Dr. Rodney Thornell 2022-23 UDA Board of Directors 10
Dr Cesar R. Sabates – ADA President
CONVENTION 21
Thank You Dr Keddington and Dr Prince
HEALTH 21
Vitamin D Levels May Contribute Bruxism
PRACTICE 6
Relationships Are Worth It
7
Continuing Your Education
11
Embezzelment: Focus on What You Can Control
12
Rise in Oral Cancer Risk Factors Associated With the COVID-19 Pandemic Mandates a More Diligent Approach to Oral Cancer Screening and Treatment
15
Sleep Apnea: Is Dentistry Doing Enough?
18
Are You Meeting Just to Meet? The Key to Productive Meetings
18
No Suprises Act
20
How to Build an Effective Practice Marketing Strategy
22
Hygiene Profitability Dental Hygiene and Your Practice's Bottom Line
PRESIDENT'S MESSAGE BE SOMEBODY Wasn’t it great to be able to be back together again, in person, for the UDA Convention! We’re so grateful for all the time, effort, patience, and work that went into making this happen! Thanks to all the people, the vendors, the speakers and presenters, the hosts, the UDA staff, the Convention committee, and so many others who helped this come to fruition. And thanks to each and every dentist, hygienist, staff member, spouse, family member, student, and any other participant who came to be a part of the Convention. We hope you all were rewarded in some way for your attendance and participation! Because it had been a while since we had been able to convene like this in large gatherings, I wasn’t quite sure what to expect. But when I first stepped into the Salt Palace Convention Center and saw how many people were assembling for the convention, I was excited and, honestly, a bit surprised. I was unsure how many would be ready, willing, and comfortable to meet. It was reported that we had about 75% of the number of registrants as we’ve had in more typical years. Other states nationwide are reporting closer to 60-65% of previous attendance at their state meetings, so, good job, Utah! Holding the dental convention after a couple of years off felt kind of like starting over. Many of us have experienced things in recent months that have felt like starting things all over again. And for me, I see that as a good thing. When we start things over, we renew efforts with new energy and freshness, with a renewed and enhanced recollection of lessons of the past, and with a desire to make things better for the future. As an association of dental professionals, we can come together individually and collectively to help advance causes and needs of the profession and of oral health in our state and nation. The ADA recently listed its top advocacy issues for 2022 as dental insurance reform, student debt reform, improving Medicaid and health equity, and is supporting legislation associated with each of these priorities. These issues were also a part of Lobby Day this year. “Each year, the ADA’s advocacy has an impact on more than 25,000 dental students and more than 200,000 of our dentist colleagues,” said ADA President Cesar R. Sabates, D.D.S. “Perhaps most importantly, it also affects millions of patients. The message is clear: It is powerful when dentists unite.” Dentists and dental students can make their voices heard by signing up for the ADA’s Legislative Action Center. But what else can each one of us do to contribute to the growth and improvement of our profession? I’m reminded of an experience my wife and I had several years ago. We live a few miles outside of our small town, and one day as we were coming into town we noticed some garbage in a small pile on the side of the road. “Somebody should clean that 4
up”, I said, as we continued into town. As we drove into town the next day, the garbage was still there, and getting spread out a bit. “What a mess! Somebody should really clean up that mess!” The very next day we were again driving to town, the garbage still there, and starting to blow and spread all over. “Wow, that’s bad! Somebody really needs to clean that up!’’ Then, it was as if we heard a tiny voice say, “You are somebody!” So my wife and I drove again by where the garbage was, this time armed with trash bags and gloves, and we became “somebody”, and cleaned up that awful mess. I hope it becomes clear that we are all “somebody”. Each one of us can do something to be somebody. “Somebody should invite that new dentist to our meetings.” Be somebody. “I wish somebody would share that concern with the ADA.” Be somebody. “We need somebody to present some legislation about insurance reform.” Be somebody. “We need somebody to lead out and be a voice in our local leadership.” Be somebody. If you haven’t taken the opportunity to get more involved with organized dentistry and learn about the power that comes when dentists unite, I invite you to take that first step. Raise your hand and say, “I’ll do it!” Now is a great time to start over and be somebody! Dr Kay Christensen UDA President
Future UDA E
Future UDA Events 2022 September 6 – Box Elder & Cache CQI September 8 – Uintah Basin CQI September 13 – Weber CQI September 20 – South Davis & Central CQI September 22 – Cedar Breaks & Dixie CQI September 27 – North Davis CQI October 4 – Wasatch Back CQI October 6 – Provo CQI October 20 – Canyonlands CQI October 27 – Salt Lake North, Salt Lake South, Tooele CQI
September 6 – Box Elde September 8 – Uintah B September 13 – Weber September 20 – South D September 22 – Cedar B September 27 – North D October 4 – Wasatch Ba October 6 – Provo CQI October 20 – Canyonlan October 27 – Salt Lake N Salt Lake South,
May / June 2022
ASSOCIATION THIS DENTISTRY THING IS A PRETTY GOOD GIG We have all had them. If you have been at this game long, you have had days where nothing seems to go right. And, it all seems to happen on the same day. Crowns that do not fit well. Impressions requiring multiple re-makes. A class II composite with an open contact when you are already 20 minutes behind, and you thought this was the procedure where you might pick up a little time and get back on schedule. The whiny kid with the hovering parent. The inferior alveolar block that makes you feel like you are using expired anesthetic. This is all before lunch. I could go on. You know exactly what I am getting at. At the end of the day, you feel like a rag doll that has just been drug through a knot hole. When you arrive home, you just want to be alone and decompress. After kicking the family dog, he then emerges as the only one in the family that can stand being around you. At this point in time, you have nothing left to give to those who mean the most to you, your family. Fortunately for all of us, days like this are typically few and far between. Nevertheless, they do happen. In addition to being exhausting, they can also bring us to our knees, physically and spiritually, and even make us question if dentistry is right for us. You begin to wonder, “Did I make a mistake? Am I in the wrong line of work? Surely there must be something better...” It is usually at about this point in the day that you slowly begin to wake back up to reality. You re-discover, all over again, that yes, this dentistry thing really is a pretty good gig. You see, I have some perspective on this. Prior to dentistry I was a jack-hammer and bore-gun operator for the Tempest Company. The Tempest Company installs natural gas lines for the Questar Corporation. While a jack-hammer is likely familiar to most of you, a bore-gun may not be. A bore-gun is a beast of a machine used to drill under roads and other structures. It is notorious for either pinning its operator to the side of a ditch, or throwing him to the ground. Neither is very fun. The mere mention of it sends chills up my spine. The guy running the bore-gun and the jack-hammer is the lowest man on the totem pole. He does everything that everyone else up the line, the welders, the pipefitters and the backhoe operators, either would not, or could not do. As I recall, it was hot in the summer and cold in the winter. If it was not dusty, it was usually muddy. The hours were long and the pay was poor. But, it was a job, and at the time, I felt lucky to have it. As time has passed during my career as a dentist, the full value of that miserable ditch digging job began to sink in. Its real value was the perspective it gave me on my current occupation. It always served to quickly bring me back to the realization of just what a great profession we have in dentistry. I have also learned that bad days can happen in any line of work. Why
Photo: Image licensed by Ingram Image
should dentistry be immune? Additionally, I have learned to expect a few “bad days” now and again. Moreover, I have discovered that bad days do not have to last all day. The whole day does not need to take on the label of “bad.” From time to time, it is good to remind ourselves just what an awesome opportunity it is to be a dentist. We do work hard, but most of us would not have it any other way. Think about it, the list on the positive side is long. This is my top ten: 1. Flexible hours – If I want a vacation, I take a vacation. 2. Flexible modes of practice – We do the procedures we most enjoy doing. Dentistry gives us such variety. 3. Security – We will not be replaced by a robot, nor can our work be done remotely, at least not anytime soon. 4. Money enough for a comfortable lifestyle, a reasonable retirement, and even a few toys. 5. Comfortable, climate-controlled, indoor environment, unlike my other job digging ditches. 6. The opportunity to make a profound difference in the quality of life for many people – Wow, this is a biggie! 7. The development of lasting friendships with staff, patients, and colleagues. 8. The intellectually stimulating marriage of art and science that is so much a part of our work. 9. The ability to have a life outside the office in order to pursue other interests. 10. Autonomy1 – We do not have someone looking over our shoulder checking our work. So, there you have it. We really do have a pretty good gig. I love being a dentist, and hope you feel the same way! Dr Mark R. Taylor UDA President Elect 1 This autonomy, of necessity, stipulates that we practice ethically and with the utmost integrity. In the next issue I would like to review the ADA’s Code of Ethics and focus on our ethical responsibility to ourselves, our staff, our patients and our profession.
UDA Action
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PRACTICE RELATIONSHIPS ARE WORTH IT In 2021, my son was living in Augusta, Georgia, for a year as he finished his medical training. He is active in his religion, so when arriving in Augusta, he contacted his local church unit. After attending the first church meeting, the Bishop called him into his office and asked if he would serve as his executive secretary. My son agreed to accept this position and hoped it would help him get better acquainted with other church members. He enjoyed his time there serving members of the congregation, but his position had challenges because it was at the height of Covid restrictions. Almost all church meetings, large and small, were held virtually on Zoom. As an executive secretary, he was asked to attend council meetings with other church leaders, as well as all regular Sunday meetings. All were held virtually, with little face-to- face interaction. Upon completing his final year of training, it was time for him to find a permanent job, requiring him to move to a new location. Before moving away, the Bishop asked if he would speak in church to give a farewell address to the congregation. After completing his talk, a member of the congregation, who served as President of the Elders Quorum, approached him. The President introduced himself, saying, “I don’t think we have ever met.” This same individual had been in the very same meetings that my son had participated in for a solid year. They had been involved in many conversations about many things. These meetings and conversations were conducted on Zoom--not in person. Zoom has been a benefit and blessing during this Pandemic, but virtual meetings are not the same as face-to-face interactions. There is something tangible about seeing someone in person, talking, conversing, and interactions cannot be replaced with virtual reality. My son and the Quorum President, although involved in the same meetings for a year, had not formed any kind of relationship. They were like minded, willing to serve and anxious to help others in need. But they had missed the opportunity to develop what could have been a rewarding relationship. The Pandemic has done that to many of us. In this Spring of 2022, we are just getting back to normal life and socialization after two years of restricted interactions. Many of us have missed the face-to-face communication we had enjoyed in previous years. Meeting in person, having the opportunity to talk with someone, is something we all took for granted--until we could no longer do it. Virtual meetings and interactions have been necessary for a Pandemic, but they are 6
no panacea. As dentists, we have been lucky because we have been able to see our patients face-to-face on a regular basis. It has been our interactions with colleagues that has suffered. As I look back on my career of over 40 years practicing dentistry, I realize that the personal relationships I developed with my patients and colleagues have been the most rewarding part of my career. I don’t look forward to how soon I can retire. I worry about losing many of those relationships when I do retire. My patients have been my day-to-day interactions and being their dentist has been a privilege and honor. Relationships with my colleagues have resulted in long term friendships and have made me a better dentist. I know that these friendships will continue beyond my days of private practice. I have met colleagues through involvement in continuing education, a wonderful study club, through service and philanthropic opportunities, but mostly through my involvement in organized dentistry. Being actively involved in the AGD, the DOPL Board of Dental Examiners, and the UDA, I have met and worked with amazing individuals. These are people whom I have come to admire and trust and people who have made my practice of dentistry more fulfilling and rewarding. My activity in a study club and UDA have been my most rewarding source of wonderful relationships. Being a leader is challenging and rewarding--in any organization-but the most important thing in getting to know people and becoming friends is to just show up. It has been said that 80% of great leadership is the ability to show up. I would add that a willingness to join professional organizations, and to do your part are also critical. Working with other like-minded individuals, face to face, arm in arm, is the way to keep our profession vital. By our association, we can develop and foster relationships with colleagues professionally and make lasting friendships. Don’t let the Covid social distancing stop you from developing good relationships with your colleagues. Take advantage of your professional organizations. The solution is composed of the following things: Join Show up Do your share Treat other colleagues as you would like to be treated. Life is too short to live any other way. Lifelong friends are worth the effort. Brent A. Larson DDS ADA Delegate May / June 2022
ASSOCIATION CONTINUING YOUR EDUCATION Required Continuing Education30 Hours Every 2 Years Licensed dental professionals by Utah Code “shall show compliance with continuing education renewal requirements” [58-69-303 (2)]. “During each two-year licensure cycle or other cycle defined by rule, a licensee under this chapter shall complete qualified continuing professional education requirements established by division (DOPL) rule made in collaboration with the board.” [58-69-304] Utah Department of Professional Licensing (DOPL) rules include: “All licensed dentists and dental hygienists shall complete 30 hours of qualified continuing professional education during each two-year period of licensure, relevant to the licensee’s professional practice, prepared and presented by individuals who are qualified by education, training and
experience to provide dental and dental hygiene continuing education, and have a method of verification of attendance and completion.” [DOPL R156-69-304a] Other noted requirements for CE credit recognition include a minimum of 50-minute blocks of time and being sponsored by DOPL or a professional association such as the ADA, UDA, ADHA, or a peer study club. Maximums of 15 hours can be via Internet or home study, or 3 hours of practice or office management during a two-year licensing period. Certifications such as CPR, BCLS, ACLS, and PALS courses are excluded, however an hour of CE is recognized for every 4 hours providing volunteer service. Licensees are responsible for maintaining competent records of completed qualified CE for 4 years beyond each 2-year licensing period - continuously maintaining a rolling 6-year CE record. Required clinical and academic CE not only satisfies statutory requirements, but also has the potential to increase clinical
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UDA Action
7
success and improved patient care. That being said, if one limits their continuous education to only required CE needed for licensure, they will miss out on a huge volume of practical knowledge.
Optional Continuing Education The extra time during the early months of the pandemic gave me time to increase awareness of dentistry focused webinars, podcasts, electronic newsletters, and social media groups. Daily my inbox seems to have messages about dental topics or learning opportunities. Most aren’t recognized as “qualified” CE, but they may help your dental team succeed or your worklife balance. My experience is that some of these are “sponsored” by manufacturers, trade associations, software vendors, and groups with a narrow focus or particular marketing agenda. Most are free or have a reasonable subscription cost. I’ve found that even if the presenter only discusses the materials, software, instruments, supplies or treatment protocols of their sponsor – the general principles taught can be utilized with the brands or systems I already own or use. Here’s a list of some I feel have added to the success of our practice. Some are more clinical and some more directed to practice management including spouses active in a dental practice. These are my personal recommendations and should not be considered to be endorsed by the UDA or any other professional organization.
Podcasts Dental Digest podcast w/ Dr Melissa Seibert - Evidence-based exploration of clinical topics (digitaldigestinstitute.com) Dentistry Uncensored w/ Howard Farran - Interviews with leaders in dentistry.
Dental Management Excellence Community by AADOM A private networking group for members of the American Association of Dental Office Management (AADOM). Nate Lawson – Instagram page, Director of the Division of Biomaterials at the University of Alabama Birmingham School of Dentistry.
Newsletters and Online Dental Groups Clinician’s Report - Non-profit, educational research institute to identify the products, techniques, and equipment for delivery of oral care through laboratory and clinical research. (Cliniciansreport.org). DentalTown.com - Free forum to discuss cases, practice management tips with over 250,000 registered members, and participate in online continuing education. DrBicuspid.com - A comprehensive community for dental professionals covering dentistry news, research, and clinical procedures. ADA Morning Huddle - A digest of important news affecting dentist and dentistry selected from thousands of sources. Sign up at ada_morninghuddle@smartbrief.com. These are just a few of the internet resources available. Consider sharing your favorite by posting it to the Utah Dental Association Facebook or Instagram page. Make sure you get at least the 30 hours of qualified continuing education and keep a permanent record in the event of a DOPL CE audit……… And continue your education by exploring quality online sources of learning. Dr Scott Theurer ADA Delegate
Dentalpreneur podcast w/ Mark Costes - Maximizing access to advanced clinical and practice management education. The FFS Dentist podcast w/ Drew Byrnes - Dentists and dental professionals share best ideas to grow high quality practices.
Facebook and Instagram Groups Dental Clinical Pearls - Focused on quality dentistry, where dentists and residents can discuss and share their cases. Dental Nachos - Its mission is to increase the success and happiness of dentists across every stage of their careers. LDS Dental Wives – Invitation only FB group includes spouses of dental students, residents, dentists, and retired dentists. AADOM Dental Spouse Business Network – Invitation only FB group of business and life partners who share, advise and support their partner’s practice success. 8
Registration Opens June 1, 2022 May / June 2022
2022-2023 UDA BOARD OF DIRECTORS
ASSOCIATION THE UDA WOULD LIKE TO WELCOME OUR NEWLY ELECTED OFFICER TO THE UDA BOARD
Kay B Christensen DDS
Mark R Taylor DDS
Len R Aste DDS
Rodney J Thornell DMD
UDA President
UDA President Elect
Dr Rodney Thornell is the newly elected Secretary of the UDA Board. Dr Thornell has served the last four years as an ADA Delegate on the UDA Board.
UDA Treasurer
Greg W Gatrell DDS UDA Past President
UDA Secretary
Brent A Larson DDS
ADA Delegate 2019-2023
The Utah Dental Association board being sworn in during the House of Delegates held at the UDA Convention on April 1, 2022 by Dr Brett Kessler, ADA District 14 Trustee. Ken J Baldwin DDS
ADA Delegate 2020-2024
Scott L Theurer DMD
ADA Delegate 2021-2025
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UDA Action
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ASSOCIATION DR CESAR R. SABATES ADA PRESIDENT What do you see as the greatest challenge for you as president of the American Dental Association (ADA)? Although there may be complex issues to handle, I wouldn’t call them challenges – I’d call them opportunities. These are areas where I’d like to see the ADA get stronger in service to our members and their patients. I would say the three biggest opportunities ahead for the ADA are dealing with the continued realities of the COVID-19 pandemic; third party payer issues, which often rank among members’ top concerns; and optimizing the ADA’s business model to adapt to the evolving needs of the 21st century dentists and patients. What gives you the most joy in this role? I consider it a blessing to be able to give back to a profession and a community that has given me so much. The work is very important, and I also derive a sense of joy from getting to know dental colleagues all around the country. There’s something about meeting a fellow dentist and feeling the immediate connection because it’s likely that we have the same passion for patients. ADA members span four generations. How does the ADA meet the needs of such diverse members? The generational diversity within the ADA is one of the many topics we’re facing right now. And meeting the needs of a diverse membership requires us to understand our members’ value and identify where there is common ground. We certainly want to be a more inclusive organization, where our leadership reflects the makeup and varied perspectives of our overall membership. Arriving at this point means embracing different backgrounds and points of view. In my opinion, there are some things that matter to everyone, no matter their age or career stage – everyone wants to thrive, everyone wants to equitable opportunities to contribute and everyone wants to feel supported in their professional endeavors by their association. Everything we do is in service to our mission of helping all dentists succeed. What is one piece of advice you would give to a new dentist? A midcareer dentist? One nearing retirement? Find ways to give back. I believe that before anything else, dentists are agents of helping and healing. We should be everything we can to promote the health of our communities and to bolster dentistry’s role in the big picture of health care. Giving back can take a number of forms. Maybe you volunteer with your dental association at the state, local or national level. Maybe volunteer with projects like Give Kids A Smile or Donated Dental Services. Or offer a helping hand to a colleague who may need support. After a cancer diagnosis in 2015, I would have needed to close my 10
practice to undergo treatment out of state. But my friends stepped in and offered to help me. It meant the world to me, and it also meant everything to the team I work with and the patients we cared for, many of whom I’d known for decades. Generosity – whether it is with your time or talent – doesn’t have just a singular impact. It creates a ripple effect that goes beyond one act of kindness and reaches so many others. Your service on a committee or council could result in good changes for our overall profession. Volunteering to provide dental services to underserved children can alleviate a burden on their entire families. I even say that my colleagues saved my life; because of them I could focus on healing. My family, my team and my patients felt the love. Many dentists are experiencing challenges in finding hygienists, assistants, and other team members. Is the ADA addressing that? The pandemic has certainly compounded the staffing shortages facing many dental practices around the country. Yes, the ADA is working to address the issue and we’re looking to support state societies in strengthening the dental workforce. It’s certainly on our radar and there’s more to come. In your opinion, what is the No. 1 reason to belong to organized dentistry? The sense of community. I consider the dental community a professional family. The relationship that I’ve cultivated have been priceless, and I believe that everyone who is a member of the ADA should experience that sense of warmth and belonging. I’ve talked about the ADA being a “third place” for dentistry. The third place is a sociological concept that posits the importance of providing communities a chance to gather aside from home or work. We often take for granted the connections we make in places like our book clubs, coffee houses, social clubs, or sports teams that we or our children are involved in. But these third places are where we convene on ideas and engage with others who share our passions, and they’re vital for keeping a community strong. I want the ADA to be a third place for all dentists – it’s where they can connect on their passion for patients and for moving our profession forward. In addition to the interpersonal benefits of being an ADA member, there’s also the recognition of strength in our numbers. The greatest example of this has been during the COVID-19 pandemic – we were able to do more together as an association than any one dentist could have accomplished on his or her own. The ADA amplified dentists’ voices before federal agencies, and we were able to secure small business relief for practice owners and have dentist prioritized for personal protective equipment. We were able to provide the dental perspective to the White House, the U.S. May / June 2022
Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and groups like the National Academies of Sciences, Engineering, and Medicine. These agencies have been instrumental in leading our nation’s pandemic recovery effort – from infection control protocols to vaccine distribute – and the ADA has their ear. That’s the value of being part of the ADA: Dentists’ voice are heard. Their perspectives are shared and taken into account, which means everything in times of crisis and otherwise. Why is it important to have a tripartite structure – one that requires membership at the local, state and national level? At the ADA, when we talk about the tripartite, we often refer to the phrase “The Power of Three.” And, at its essence, the tripartite
structure is about strength and value provided to members at all three levels and leveraging it for overall good. It’s about creating relevant member experiences at the national, state, and local levels where members receive valuable benefits and resources from the level best suited to provide it and in ways that complement each other. It’s supporting location-specific advocacy that benefits all members wherever they live. Dentist’s concerns and challenges may vary city by city, state by state. The district and constituent societies work to address these issues where they are. The ADA supports the states and local districts on their effects, along with driving federal advocacy and big picture issues that have broad impact. Today’s FDA November/December 2021
PRACTICE EMBEZZELMENT: FOCUS ON WHAT YOU CAN CONTROL This article continues a discussion on embezzlement and it’s impact on the dental community. Last month’s column revealed how endemic this crime is and identified typical behaviors that thieves exhibit – behaviors that you may be mistaking for those of a trusted, dedicated employee. This month I’ll provide some advice about what to do if you suspect fraud or embezzlement in your practice, plus tips on how to minimize the impact. There are some basic things you can do to try and to prevent potential employee risks from entering your practice in the first place. Checking an applicant’s references and criminal background prior to hire should be standard procedure. However, in most cases, the potential embezzler is already on staff and has been working for you for eight or more years. And, he or she probably had a clean employment history when hired. Remember, theft starts small. What may have begun as a onetime incident of “borrowing” becomes much more intentional over time due to the employee’s own greed or desperation. Because embezzlement is an intentional act rather than a crime of opportunity. It is carefully executed, with full awareness of the control you have in place. While managing passwords, monitoring audit trail reports, reviewing day sheets and deposits daily and limited access to your accounting system are all good practices to employ, they will only help you detect embezzlement earlier, not prevent it from happening altogether. Unfortunately, there are many ways for someone to steal from your practice, and those who are intent on doing so will modify their approach to fit their situation. However, the behavioral traits of embezzlers are remarkably consistent. If you do suspect fraud in your practice, do not investigate on your own. Tipping off a guilty employee is the worst thing you can do. If she thinks you are on to her, she may begin to destroy evidence. In one extreme case, an employee burned down the office in an effort to cover her tracks! Your best bet is to contact someone who is skilled in this area.
If the investigation can’t be conducted covertly, then I recommend suspending the suspected employee while the investigation proceeds. You need to cut off any access he or she may have to files, data, email, carrier websites, bank accounts, software systems, etc., so that an expect can gather all the facts without evidence being tampered with or destroyed in the process. If your suspicions are confirmed after a thorough investigation, you should terminate the employee and then determine whether or not you want to prosecute. Surprisingly, only about 20% of dentists choose to pursue legal recourse. Most are afraid of the negative publicity that prosecuting could have on their practice. Some even feeling bad for the employee! In my experience, many dentists simply terminate the employee, fight the unemployment claim, and (if possible) work out a repayment plan. This may be the path of least resistance, but it is not without consequences. From a financial perspective, failure to prosecute can reduce the likelihood of monetary recovery. While most practices have insurance policies that cover theft, these policies typically cap the payout and require a police report to be submitted with all claims. From an HR perspective, failure to report also makes it more likely that a new employer will unknowingly hire your thief, since her actions will not be made a matter of public record. Regardless of your choice, the pain, anger and embarrassment of a situation like this takes its toll. Remembers, you are not alone. Embezzlement is the result of greed and/or desperation and has nothing to with the way you run your practice. Despite your best efforts, you can’t prevent it. What you can do is increase your awareness of this issue and monitor behavior in your practice so that you detect risks early. Jodi Schafer, SPHR Michigan Dental Association
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PRACTICE RISE IN ORAL CANCER RISK FACTORS ASSOCIATED WITH THE COVID-19 PANDEMIC MANDATES A MORE DILIGENT APPROACH TO ORAL CANCER SCREENING AND TREATMENT The COVID-19 pandemic has brought about a public health crisis of substantial scale. As of January 2022, there had been over 281 million confirmed cases of COVID-19 worldwide and over 5.4 million deaths reported to the World Health Organization. In response to the pandemic, global lockdowns, social distancing, and quarantine procedures were imposed. Because of the high risk of transmission of COVID-19 due to aerosols and other occupational exposures, many countries suspended elective oral health care during the pandemic. According to the American Cancer Society, oral cancer is a cancer within the oral cavity including the buccal mucosa, the teeth, the gums, the front two-thirds of the tongue, the floor of the mouth below the tongue, the bony roof of the mouth and the retromolar trigone. Oral cancer is a major health concern in both high- and low-income countries. The American Cancer Society’s estimates for oral cancer in the United States in 2021 included about 54,010 new cases of oral cavity or oropharyngeal cancer, with an overall 5-year survival rate of approximately 60%. Regular dental visits are integral to maintaining oral health and minimizing risks associated with a delayed and more severe diagnosis. The pandemic, in addition to interrupting continuity of care and preventative health care visits, has led to a dramatic increase in certain risk factors for oral carcinogenesis, including increased use of tobacco and alcohol, poor diet, and increased rates of obesity and poor oral hygiene. It is critical to understand the impact of the practice restrictions on oral health care and oral cancer diagnosis and progression. The post lockdown continuation of these trends raises substantial concern for health care providers. Health care providers need to be vigilant in identifying changes in patient lifestyle behaviors.
Background
Oral cancer remains the sixth most common cancer in the world. In most ethnic groups, the prevalence of oral cancer is 3 times higher in men than in women. According to the World Health Organization, there are an estimated 657,000 new cases of cancers of the oral cavity and pharynx each year and more than 330,000 deaths. From 2014 through 2018, oral cavity and pharynx cancer showed an increase in mortality for men and a decrease in mortality for women. Patients undergoing kidney, bone marrow, heart, or liver transplant and patients with HIV infection are all at increased risk of developing oral malignancies, which may be related to the underlying immunosuppressed state or immunosuppressive treatment regimens for patients with these conditions. In 12
addition, oral cancer is associated with a depression of the cellmediated immune response. The Centers for Disease Control and Prevention considers immunosuppressed patients to be at high risk of developing serious illness from COVID-19. This is particularly concerning for patients with long-standing use of systemic corticosteroids or other immunosuppressive agents related to cancer treatment, including patients with oral cancer. Lee and colleagues reported in 2021 that compared with participants without cancer, those living with cancer had a 60% increased risk of a positive COVID-19 test. Chemotherapeutic treatment also was associated with a 2.2-fold increased risk of testing positive for COVID-19, with the association between cancer and COVID-19 infection most pronounced among participants who were 65 years and older and male. Although it is unsurprising that the most severe outcomes of a respiratory illness like COVID-19 have been associated with patients diagnosed with lung cancer the association of the immunosuppressed state with carcinogenesis and chemotherapy puts patients managing a cancer diagnosis at an increased risk.
Risk Factors for Oral Cancer: Changing Trends During the COVID-19 Pandemic
The development of oral cancer has been linked to tobacco and alcohol use, poor diet and nutrition, excess body weight, human papillomavirus (HPV) infection, poor oral hygiene, and male sex. Emerging research indicates that tobacco use, alcohol consumption, and obesity rates have risen significantly during the COVID-19 pandemic. These risk factors, in addition, are implicated in an increased risk of experiencing COVID-19 related mortality. If post pandemic trends in tobacco use, alcohol use, diet, and obesity continue, we postulate increases in global oral cancer rates and a necessity for more aggressive screening practices.
Tobacco
The relationship between tobacco use and oral cancer pathogenesis has been established firmly. Research suggests that the risk of developing oral cancer is 3 times higher in smokers than in nonsmokers. However, pandemic-related anxiety, boredom, and irregular routines have driven substantial increases in tobacco use during the COVID-19 pandemic. Even more concerning, smoking cessation rates also have declined during the pandemic. Calls to cessation support programs in 2020 were at the lowest since 2007, further demonstrating the substantial negative impact the COVID-19 pandemic had on smoking rates compared with rates during the previous period of over a decade. Studies have found no sex differences May / June 2022
rates declined approximately 20%. We posit that these changing trends in oral hygiene and vaccination rates will lead to higher incidence of oral cancer in the future.
with increased smoking rates or reduced smoking cessation, suggesting that these trends are holding true for all smokers. A 2020 study found a global increase in electronic cigarette consumption as well as nicotine products used to cope with pandemic-related stress and anxiety.
Alcohol
The COVID-19 pandemic has interrupted routine preventative dental services severely, owing to dental office closures amid lockdowns. Poor oral hygiene and oral health care and chronic ulceration due to improper dentures have all been implicated in an increase in oral cancer rates, especially in combination with other risk factors. With the use of masks, toothbrushing frequency also has been shown to have decreased significantly, as people have been less concerned about oral hygiene and reported halitosis.
Many patients who receive a diagnosis of oral cancer are heavy drinkers, and alcohol use remains high in countries with increasing oral cancer rates. In a cross-sectional study of US adults during the pandemic, approximately two-thirds of participants reported increased alcohol consumption compared with before the pandemic. Study participants reported consuming an average of 26.8 alcohol drinks on 12.2 of the past 30 days. A total of 34.1% of participants reported engaging in binge drinking, and 7% reported engaging in extreme binge drinking during this time. Across Europe and Asia, alcohol sales and consumption have increased similarly.
In addition, poor oral hygiene also can be secondary to selfneglect in people with depression, which has been exacerbated because of the pandemic. In addition, poor oral hygiene has been shown to be an independent risk factor for HPV infection. HPV disrupts the cell cycle, destroying tumor suppressor proteins and leading to dysplasia in the mouth and throat. Moreover, early in the pandemic, HPV vaccination rates among adolescents fell 75% owing to a decrease in wellness visits, and throughout the pandemic, child and teen HPV vaccination
The top reported reasons for increased alcohol use were higher levels of stress, greater alcohol availability, and general boredom. People with pandemic-related depression were 64% more likely to increase their alcohol intake, and those with pandemic-related anxiety were 41% more likely to do so. A study found that the relationship between emotional distress and increased alcohol consumption was more significant for men than women, with 12.7% of men indicating that they began drinking more during the pandemic compared with 11.6% of
Personal hygiene and HPV
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women. These studies indicate that extreme stress during the pandemic was correlated with more significant increases in alcohol consumption.
Diet, nutrition, and obesity
Poor diet and nutrition and obesity have been linked to oral carcinogenesis. Obesity has been found to be associated with a 5-fold increase in risk of experiencing death from earlystage squamous cell carcinoma of the tongue. In addition, obesity has been linked with worse outcomes once a patient has been diagnosed with oral cancer, possibly putting the patient in an even more immunocompromised state. Hyper adiposity, dysregulated energy metabolism, increased levels of proinflammatory mediators, and altered adipolin levels all have been postulated as carcinogenic mechanisms.
As of January 2022, nearly 507 million COVID-19 vaccine doses had been administered in the United States,49 and more than 8.6 billion COVID-19 vaccine doses had been administered worldwide. However, both domestically and globally, many more doses must be administered for a return to normalcy in daily living and clinical care. With unreliable sources of information on the internet and social media, it is a dentist’s responsibility to serve as a knowledgeable guide to navigating the intricacies of living through a pandemic. Providers must investigate how informed a patient is about avoiding risk factors, discuss vaccination and the importance it holds as a prevention tool, and provide a nonjudgmental space for learning.
Throughout the COVID-19 pandemic, prolonged lockdowns, work from home policies, and gym closures all have contributed to worse dietary habits and increased body weight. Studies examining adolescent food intake during the COVID-19 pandemic recorded increased consumption of fried and sweet food and red meat and increasing caloric intake of foods with lesser nutritional value. According to the American Psychological Association, weight gain has been particularly challenging for parents of children 18 years and younger, with 55% of fathers reporting unintentional weight changes. Rises in weight gain during the pandemic also can be attributed to a general loss of routine and structure involving sleep dysregulation, reduced physical activity, disrupted family time, increased access to unhealthy snacks, and less consistent access to appropriately proportional meals.
Oral health care providers also must educate their patients about the oral systemic risks associated with increased alcohol and tobacco consumption, poor diet and nutrition, and worsening oral hygiene. Dental care practitioners must be vigilant about rises in oral cancer risk factors and must increase screening measures for all demographics, with particular attention to weight and nutritional changes in adolescents and fathers and increases in alcohol use among men. We recommend that oral health care providers increase collaboration with their medical counterparts to increase HPV vaccination rates and encourage medical wellness visits throughout the pandemic. Given pandemic related trends, dentists must continue to examine for oral manifestations of HPV and improve in-office screening metrics.
A cross-sectional study among US adults after mandatory quarantines were lifted still found increased consumption of sweet and salty snacks that was adopted during the pandemic. If habits adopted during the COVID-19 pandemic continue, practitioners must take additional considerations to assess risk stratification for patients with oral cancer who are at high risk and continue to ask patients about lifestyle changes at regular intervals.
Although the true effect of the COVID-19 pandemic on oral cancer risk factors remains unclear, dental care practitioners must remain vigilant. Increasing COVID-19 rates may increase patient high-risk behaviors and reduce the frequency of patient visits to their dental homes, further necessitating more comprehensive screening practices. Educating patients about how to conduct their own at-home oral cancer screenings also can be beneficial to mitigating oral cancer spread.
Discussion
Conclusions
The COVID-19 pandemic has brought about many lifestyle and behavioral changes that can greatly affect oral cancer incidence, detection, and treatment. Worsening rates of tobacco and alcohol use, poor diet, weight gain, and oral hygiene, all of which are postulated to contribute to the acceleration of oral cancer development, have been documented globally in the past year. These statistics provide reason to believe that the incidence of oral cancer can rise as more patients return to dental care providers, especially as lockdown trends continue. Increasingly severe presentations of oral cancer at the time of diagnosis because of treatment delays intended to minimize COVID-19 transmission are also of concern. Given that over 6 million adults have lost their dental insurance owing to the pandemic and more than 1 in 10 people in the United States have delayed oral health care owing to cost, lack of insurance, and fear of exposure to severe acute respiratory syndrome coronavirus 14
2,48 health care providers must screen vigilantly for these risk factors and lifestyle changes in the context of oral cancer.
Medical and dental health care providers must be conscious of the lasting impact the COVID-19 pandemic may have on oral cancer outcomes for decades, owing to altered lifestyle habits that have formed since March 2020. The recent uprise in cases and widespread dissemination of the Delta variant indicate that our struggle with severe acute respiratory syndrome coronavirus is far from over. Thus, to minimize the degree of spread, it is important that providers maintain proper public health measures. JADA March 5, 2022
May / June 2022
PRACTICE SLEEP APNEA: IS DENTISTRY DOING ENOUGH?
Photo: Image licensed by Ingram Image
Sleep apnea affects almost one-billion people worldwide, leaving those afflicted feeling tired, accident prone, moody, depressed, and susceptible to a host of significant medical concerns, often culminating in a shortened lifespan. Particularly noteworthy during the COVID-19 pandemic is that unmanaged sleep apnea is associated with increased hospitalization from influenza infection. The alarming fact that more than 85% of those afflicted with sleep apnea remain undiagnosed begs the questions: Is dentistry doing enough?
What is sleep apnea and how is it managed?
Sleep apnea involves disturbed breathing during sleep and is part of a spectrum of breathing issues, the most benign being simple snoring caused by soft tissue vibration, followed by the narrowing of the airway leading to strained breathing, and finally to intermittent full collapse of the airway, preventing breathing altogether. The gold standard of therapy for sleep apnea is continuous positive airway pressure (CPAP) where a mask interface is used to splint the upper airway open through the use of pressurized air. Another conservative option is oral appliance therapy (OAT), which involves the use of an oral appliance to reposition the jaw and prevent it from dropping back during sleep, resulting in a more patent airway. It is not as effective as a CPAP in eliminating all of the breathing events, but is much better tolerated by patients, and demonstrates a higher adherence rate than CPAP.
How well is sleep apnea being managed?
The American Academy of Sleep Medicine (AASM) documents sleep apnea as a disease with remarkable medical, social, and economic impacts. A 22-country market research study conducted by SomnoMed, a leading oral-appliance manufacturer, documented approximately 2.5 million sleep studies performed during the 2020 fiscal year (estimated to be down by 0.5 million due to COVID-19). These studies
resulted in approximately 1.9 million patients proceeding with therapy: 1.35 million with CPAP, 350,000 with OAT, and 200,000 with lifestyle changes, various surgery, etc. Of those trying CPAP, approximately 700,000 or 52% dropped off. Of those trying OAT, approximately 28,000 or 8% dropped off. It is very notable that of the 700,000 patients who dropped off CPAP, most remained unmanaged. A Frost and Sullivan report commissioned by the AASM in 2016 corroborates the SomnoMed report documenting that approximately 40% of patients diagnosed with sleep apnea drop out of therapy and remain unmanaged. In fact, poor CPAP adherence is wellestablished in the literature, with a recent comprehensive, systematic review involving 82 papers finding that, “CPAP adherence remains persistently low over 20 years’ worth of reported data.” Notwithstanding these statistics, there is a very prevalent bias regarding the use of CPAP to manage sleep apnea – it is prescribed approximately 85% of the time. In general, physicians are accustomed to patients not complying with prescriptions; the National Association of Chain Drug Stores documents that only 25% to 30% of patients actually fill and take medications as prescribed. So it may be that from a physician’s perspective, medicine is doing a good job by providing a service that demonstrates approximately 60% adherence. In this regard, even when one considers that only about half of patients are wearing their CPAP all night long, leaving the other half sub-optimally treated, CPAP adherence is still fairly similar to other prescribed medical treatments. So how one answers the question “How well is sleep apnea being managed?” depends on one’s point of view. From a physician’s perspective, about two-thirds of patients are being fully managed or at least partially managed. However, from
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a dental perspective, it can be said that about two-thirds of patients are being sub-optimally managed or unmanaged.
CPAP versus OAT: An evidence-based comparison
Without question, CPAP is not only very effective in eliminating sleep apnea, but it is also superior to OAT regarding consistent elimination of the issue. However, only about a third of patients comfortably adapt to wearing their CPAP all night long; the next third wear their CPAP only part of the night; and the final third are not able to wear CPAP at all. The literature documents that CPAP adherence, which when using a commonly cited benchmark of four hours use/night, five nights/week, is approximately 50% at six months and 17% at five years. OAT fully normalized sleep apnea approximately a third of the time; another third will experience a clinically important reduction of greater than 50% with persistence residual apnea, and the final third will not achieve this reduction. However, when considering adherence, in contrast to CPAP, approximately 90% of patients use their oral appliance long term with nightly adherence of up to 7.5 hours. Notwithstanding the difference in ability to eliminate sleep apnea, numerous studies comparing health outcomes for both CPAP and OAT have demonstrated very similar results; this similar impact on health outcomes is thought to be higher adherence associated with OAT. In fact, when one compares CPAP and OAT from a mean disease alleviation (MDA) perspective, which takes into consideration both the level of event reduction along with the level of therapy usage, both approaches result in an MDA of approximately 50%. Literature clearly documents that objective health outcomes such as sleepiness, psychomotor speed, driving simulator outcomes, and mortality are similar. In addition, function outcomes such as snoring, sleepiness, neurocognitive function, quality of life, and mood are also similar. CPAP is considered first line therapy for the management of sleep apnea. However, it is also important to note that OAT is considered a standard of care for all severities of sleep apnea if the patient cannot tolerate CPAP, or if the patient simply prefer OAT to CPAP. Having patients who have difficulty with CPAP remain unmanaged is simply unacceptable. It truly doesn’t matter how well CPAP works if the patient cannot tolerate wearing it. After 25 years of managing sleep apnea patients with OAT, I propose that whichever therapy is provided, the most important factor that will determine if the patient will be adequately managed is the answer to this question: Will the patient use it?
What happens when OAT falls sort?
When residual apnea persists with OAT, all is not lost. Adjunctive therapies such as modifying sleep position, losing weight, improving fitness, and other strategies are used to help manage the sleep apnea problem further. In addition, concern for possible ineffectiveness is not a reason to discount OAT. For those patients seeking assurance that OAT will in fact adequately manage their sleep apnea, there is a literaturevalidated test that can be used to establish efficacy before an 16
oral appliance is even fabricated. (MATRx Plus Zephyr Sleep Technologies, Calgary). In fact, in my clinic I have managed all levels of sleep apnea including hourly events well over 100 per hour.
The connection between sleep apnea and dentistry.
Unmanaged sleep apnea also impacts on the dentistry we provide our patients. Sleep bruxism is associated with unmanaged sleep apnea and has been demonstrated to reduce in severity when the sleep apnea is successfully managed. A recent study involving 67 implant patients found that 13 of the 16 patients experiencing complications such as porcelain fracture, fracture of the screw or implant, loosening of the screw, and decementation had sleep apnea, with 81% of the patients with sleep apnea experiencing complications with their prostheses. Recent students demonstrate that unmanaged sleep apnea can increase in severity by a factor of 50% for 50% of patients when a brux appliance is worn, suggesting that simply providing postrestorative night guards may not be the appropriate approach. These findings suggest that all patients should be screened for sleep apnea before undergoing any treatment.
Societal change begins with awareness
Awareness campaigns and changes in legislation regarding driving under the influence of alcohol and exposure to secondhand smoke have result in a better quality of life for society as a whole. Analogous issues can be found regarding sleep apnea. Drowsy driving is just as incapacitating as driving under the influence of alcohol. Patients with unmanaged sleep apnea are often drowsy during the day. And studies demonstrate seven-times odds of being involved in an automobile accident among those with sleep apnea over controls. Furthermore, similar to the impact of second-hand smoke on innocent bystanders, studies demonstrate that bed partners of unmanaged sleep apnea patients are meaningfully impacted by second-hand sleep apnea, experiencing increased arousals and decreased sleep efficiency, with effects similar to a reduction of one hour of sleep each night. I predict that increasing awareness of the impact of sleep apnea on both individuals and society will result in changes in legislation and societal norms, to everyone’s benefit.
COVID-19 and OAT
The COVID-19 pandemic has raised concerns around the spread of the infection throughout the household due to CPAP mask leaks in those with the infection. The AASM website guidance currently recommends that if a CPAP user becomes positive for COVID-19 they should speak to their physician about assessing risks and benefits of continuing to use the CPAP device. According to the AADSM, OAT could be considered an effective alternative to CPAP for these patients. OAT does not share any of the aerosol concerns associated with CPAP use and is also much easier to disinfect daily in comparison to a CPAP machine, hose and mask. In fact, the AADSM currently recommends that OAT should be prescribed as a first line therapy for sleep apnea during the COVID-19 pandemic. Of course, any changes in therapy should be considered only under the supervision of a physician. May / June 2022
Do your bit to ensure dentistry is doing enough?
Dentistry is ideally positioned to help eradicate this medical problem. According to the Canadian Dental Association website, roughly 80% of Canadians have a dentist, and approximately 86% of Canadians visit the dentist within a twoyear period. Considering these statistics, if dentistry committed to actively screening each patient of record for sleep apnea, we would all get busy helping these patients get well, whether through the use CPAP, OAT, surgery, or by recommending lifestyle changes. The sleep apnea OAT market is projected to grow exponentially as patient awareness increases and more dentists seek training on its clinical utility. General dentists who are currently overwhelmed in a competitive marketplace can differentiate themselves by becoming knowledgeable. Recently, our dental regulator has struck a working group for the development of guidance on the dental management of obstructive sleep apnea and snoring. As well, the American Dental Association has published a document describing the role of dentistry in the management of sleep apnea. Dentistry currently finds itself in a unique state of opportunity; patient need, robust literature data, evidence-based guidelines, and the support of our evidencebased organizations and licensing bodies position dentistry to
make a meaningful and positive impact on the prevalence of sleep apnea. There has never been a better time for dentistry to become more involved, and this is especially impactful for those patients who have demonstrated intolerance to CPAP. Learn about what OAT has to offer these CPAP-intolerant patients. If you are a dentist: Choose to get involved, become the local expert, learn the evidence supporting OAT, and help to ensure that dentists are in fact, doing their bit to eradicate sleep apnea. If you are a physician: Be open to working collaboratively alongside qualified dentists. When one considers that more than 85% of sleep apnea remains undiagnosed, approximately 50% of diagnosed patients still need therapy, and sleep apnea holds negative implications on the dental treatment we so proudly provide our patients, it’s clear that more work needs to be done. When you consider that OAT has been demonstrated to have a 90% long-term adherence rate, numerous studies comparing CPAP and OAT health outcomes demonstrate similar results, and how grossly underutilized the OAT alternative is, the following question begs to be asked: Is dentistry doing enough? Dr John Vivano JMDA
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PRACTICE ARE YOU MEETING JUST TO MEET? THE KEY TO PRODUCTIVE TEAM MEETINGS Communication is a key element in a happy team environment. Many times, we receive feedback from the team regarding poor interoffice collaboration, lack of team meetings and overall need for more interaction among colleagues. At Practice Dynamics, we are firm believers of effective communication and know this is not something that comes easily to everyone. One of the ways to ensure great communication is through productive team meetings, and I’ve outlined our yearly key team meetings below.
The Big Once a Year: Strategic Planning Session
This is the perfect meeting to start your year off on the right foot. We recommend having this all-team meeting in the third quarter of the year to plan your strategies for the next 12 months. Plan for two to four hours of activities and exercises to generate ideas for goals and growth.
Quarterly: Touch base with the Big Goal
This meeting is all about touching base with the team on the progress of your Big Yearly Goal. Plan to meeting with the team for two hours to review the goals you set in your strategic session. You can update your tracking board and perhaps set a few new goals to get your closer to the Big Yearly Goal.
Monthly: Lunch and Learns
We love our lunch and learns and schedule six external throughout the year. Your six internal meetings consist of each department in your office; doctors, administrative, business, clinical, hygiene, and marketing to give a one-hour session focusing on key items the entire time should be aware of and participating in.
Weekly: Lead Check In
Checking in with your leads will ensure you are always aware of all components of the practice. This is a 15 minute check in at the end of the week. • How was last week, were there any issues with patients or team members I should be aware of? • How does the next week look? • Any team members out on PTO? • What do you need from me? • Here is what I need from you.
Daily: Huddle
This is your morning or afternoon huddle and shouldn’t be longer than 15 minutes. It’s designed to start the day with communication for the entire team. Your agendas should be short, sweet and to the point. • How was yesterday – what worked, what didn’t? • How does today look? Anything we need to change or adjust? • Where can we put emergencies this morning and this afternoon? • Daily opportunities for growth. • Wrap up with a leadership statement. There is much communication that could – and should – happen in the office to manage a happy team. If your team may need more or better communication, start with this list of productive meetings. Laci Phillips Todays FDA
PRACTICE NO SURPRISES ACT Reports from the American Dental Association (ADA) and the Center for Medicare and Medicaid Services (CMS) indicate a new federal law that took effect at the beginning of 2022 will very likely have an impact on most dental offices and across the nation. The No Surprises Act is intended to provide consumers with new billing protections when receiving emergency care, nonemergency care from out-of-network facilities and air ambulance services from out-of-network providers. The law also addresses transparency of health care costs for all uninsured or self-pay patients (i.e. insured patients who pay their care on their own without using their insurance) who visit any private dental office.
Balance Billing
The new law’s balance billing requirements “generally apply to items and services provided to consumers enrolled in group health insurance coverage, as well as federal employees’ health benefit 18
plans.” Dental benefit plans, however, are excluded under the law. Similarly, “hospital, ambulatory surgical centers, rural health centers and federally qualified health centers (FQHCs) are all examples of health care facilities that are included in the No Surprises Act,” while private dental practices are not. These exclusions, effectively mean that the new law’s balance billing provisions “largely do not affect private edental offices.” It is possible that a relatively small number of dentists who provide care to a patient whose dental benefits are embedded in their medical plan could be effected. But they would still need to provide the care in question, “in an out-of-network hospital or ambulatory center under a plan with no out-of-network reimbursement.” These are rare situations, and it is expected May / June 2022
that they will be addressed on a case-by-case basis by the involved plans.
Good Faith Estimates
Dentists and other health care providers must provide their uninsured or self-pay patients with an estimate of expected charges (i.e. a good faith estimate) before providing an item or service. This estimate must be provided if the patient requests one or as the patient is being scheduled for an item or service. It should include the expected charges for the primary item or service the dentist is providing “and any other items or services that are provided as part of the same scheduled experience.” For example, if a new patient is being scheduled for an examination and possibly other services, the dental office would need to inform the patient of their fees for a limited and/or comprehensive exam, possibly radiographs and other services that the patient might reasonably need during their initial visit. The good faith estimate needs to be provided over the phone or in-person if requested and then followed up with a written (paper or electronic) estimate.
If the dentist’s bill for the services turns out to be $400 or more expensive that the good faith estimate, then the patient may have grounds to file a complaint under the patient-provider dispute resolution of the No Surprise Services Act. “For most dentists, complying with the No Surprises Act will be a matter of utilizing good patient financial expectations between the patient and the dentist,” said Dr. Manny Chopra, chairman of Council on Dental Programs and Dental Practice. “It’s really just good common sense and business practice to ensure patients understand their financial obligations prior to treatment, irrespective of this new law.” The No Surprises Act does not apply to individuals covered by programs such as Medicare, Medicaid, the Indian Health Service, Veterans Affairs Health Care and TRICARE, which already have in place their own systems to protect against surprise bills. Christopher A. Moore, MA ODA Today
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PRACTICE How To Build An Effective Practice
MARKETING STRATEGY
Investing in a strong dental marketing program has become more important than ever to achieve your goals and establish a strong future for your practice. “The top priority for a majority of our clients is to attest, acquire and retain new patients,” says Sean White, CEO of Whiteboard Marketing. “However, strategic marketing efforts also are important for improving and building your brand, connecting and developing relationships with patients, and establishing yourself as an expert in the industry. A practice marketing strategy creates a roadmap and action items that help you accomplish what is most important to you and your practice. Setting goals and determining the top priorities for your practice will help you develop an actionable plan as you start to shape your marketing strategy. “When we take a client through strategic marketing planning, we always ask three key questions,” says Kristi Simone, CMO of Whiteboard Marketing. “Where do you want to go? Where are you now? And how will you get there? These three questions help uncover rich and fulfilling insights as you consider a marketing approach for your practice.” When developing your practice marketing strategy, the most essential elements to consider are your goals, your budget, the marketing tactics that best fit your practice and how you will track success.
Step 1: Establish Your Goals
First, where do you want to go? Consider what your ultimate goal is for your practice’s marketing plan. “What are the goals you’d like to achieve in terms of patient acquisition and retention, and the services you’d like to promote and generate revenue from in the future? Knowing crucial demographics about your current patients will help you be more strategic where you allocate your time and energy for marketing efforts,” says Simone. Next, where are you now? Take time to audit your marketing practice efforts and consider what is and isn’t working. “There are special auditing resources and tools that exist to help critically evaluate your marketing tactics and point in the right directions,” says White.
Step 2: Determine Your Budget
“How much you spend is truly up to your practice,” says White. “It’s rare to not see some form of a return on investments in a well-thought, intentional data-driven marketing plan. The industry standard for dental marketing expenditures is generally 3%-6% percent of your revenue. Expenses across the board generally include search engine optimization (SEO), dynamic call and form tracking, social media management, Facebook boosting, online review, and reputation management, local SEO and business listings management and email marketing. Larger 20
spends come with the introduction of pay-per-click (PPC) advertisement, website chat and blog writing.” It’s important to consider what this spend looks like for your practice. If you’re a new practice or are still determining what you want to accomplish with your strategy, starting on the lower end of the budget spectrum may be best.
Step 3: Select the Marketing Tactics That Best Fit Your Practice
Once you have established your goals and budget, determine how you will get there. “Depending on the budget you’ll willing to set for marketing, we always recommend that our clients use multiple methods to ensure they are creating targeted campaigns to receive the highest return on investment possible,” says White. “SEO, social media and Google PPC advertising, social media content strategy, online patient reviews and reputation management, Google My Business and business listing management, website design and update, and dynamic call and form tracking are all marketing tactics used to create a comprehensive marketing strategy that drives results.” “In today’s world of immediacy, you’ll also want to include immediate conversion opportunities for patients,” says Simone. “Website chat, online scheduling, patient forms on your website and online bill pay are all excellent ways to help website visitors convert into new patients without having to wait.”
Step 4: Track Your Success
“Each marketing tactic that you incorporate into your marketing program has a specialized platform to measure performance and effectiveness,” says White. “For example, our SEO team uses Google Analytics to track how many people have visited your site each month, where they are looking on your site, what pages have the highest traffic and more. Our digital marketing specialists use social media insights to understand what content people are liking, sharing and commenting on across your social channels.” Tracking your marketing and your spending is fundamental to the ultimate success of your efforts. Keep an eye on what tactics work for you, and what doesn’t. If one is working better than another, you may want to consider allocating part of your budget toward that instead. It’s important to set goals, determine your budget, select the marketing tactics that best fit your practice, and track your success in order to create a comprehensive marketing program that yields results. Ultimately, building an effective practice marketing strategy will help you attract new patients, keep current patients coming back and continue to reach your practice goals. Today’s FDS November/December 2021 May / June 2022
CONVENTION THANK YOU DR KEDDINGTON AND DR PRINCE The Utah Dental Association would like to thank Dr James Keddington and Dr David Prince.
HEALTH VITAMIN D LEVELS MAY CONTRIBUTE BRUXISM The severity of tooth clenching and grinding that patients experience may be associated with their vitamin D levels, according to a study by researchers at the Department of Oral Medicine, Faculty of Dentistry, University of Damascus in Syria. The study was published in Clinical and Experimental Dental Research. Blood tests revealed that individuals with low levels of 25-hydroxyvitamin D (25[OH]), the metabolized form of vitamin D that is used to assess deficiency, reported having moderate and severe bruxism, the authors wrote.
Dr Keddington was the Scientific chair for the UDA Fall Back Live Event held in September.
To study the correlation between bruxism and vitamin D levels, researchers tested the blood of 100 participants. Of those participants, 76 reported experiencing bruxism and 24 did not. For vitamin D levels, concentrations of less than 20 ng/ml were considered deficient, levels between 21 ng/ml and 29 ng/ml were considered insufficient and concentrations between 30 ng/ml and 150 ng/ml were considered as sufficient. Of the participants, 43% had vitamin D deficiencies. After analyzing the data, the authors found an association between deficient levels of vitamin D and the severity of bruxism. More individuals reporting moderate and severe bruxism were deficient in vitamin D concentrations than those experiencing no symptoms or other levels of tooth clenching or grinding. The study had limitations, including that the diagnosis was based on clinical exams and selfreports from participants. A definitive diagnosis of bruxism should be supported by instrumental approaches, clinical features and exams and selfreports. However, instrumental approaches were not available. Learn more about this study in Clinical and Experimental Dental Research; doi. org/10.1002/cre2.530. CDA April 2022
Dr Prince was the Scientific chair for the UDA 2022 Convention. UDA Action
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PRACTICE HYGIENE PROFITABILITY
Dental Hygiene and Your Practice’s Bottom Line Background:
Prophylactic care provided by dental hygienists is the most frequent reason for dental visits. Although dental hygiene care is essential to maintaining good oral health, it has not historically been regarded as contributing to the profitability of dental practice. This article discusses new approaches to organizing dental hygiene departments and workflows to provide excellent patient care while making a profit.
Economics of Dental Hygiene:
The traditional focus on dental cleaning does not take full advantage of the potential contributions of dental hygiene care. Regular maintenance visits provide a great opportunity to provide patient education and motivation, while making the patient a believer and advocate for the practice. Dental hygiene can be transformed into a profit center while still providing excellent oral health care, and without overtreatment. Its importance to practice economics was demonstrated after the economic crash of 2008, when patients who were not spending money on extra services were still making routine preventive visits covered by insurance. Expanding the role of dental hygiene does not mean selling extra services, but rather treating patients as family, focusing on the presence of or risks for dental disease. Many characteristics of the practice contribute to the profit margin of dental hygiene, although an industry standard of 33% has been described: one third each to the hygienist, to overhead and back to the practice. Practice overhead has a significant impact on the profitability to dental hygiene. Profitability is more likely to be achieved in fee-for-service practice, although it can be done in preferred provider organization settings. In terms of hygienist compensation, the most productive approach may be a base salary plus commissions, providing incentives to be productive. Some practices offer bonuses related to daily productivity and recommended treatments based on “proper, thorough and ethical diagnosis.” This approach to profitability may be more difficult to achieve in pediatric dentistry practice.
Dental Hygiene Services and Policies:
Where dental hygiene is a profit center, hygienists are expected to provide more services, depending on their level of expertise and the needs of the practice and patients. One expert states that hygienist should perform the maximum services that they are legally licensed to provide. This may include taking radiographs, performing anesthesia, or doing quadrants of scaling and root planning. Hygiene visits should be viewed as wellness visits. Hygienists appreciate the opportunity to support patients’ health by assessing vital signs, screening for possible oral-systemic disease and medication conditions or educating patients about nutrition or tobacco cessation as well 22
as oral hygiene. Hygienists should be viewed as frontline caregivers in promoting lifelong health, in partnership with the dentist and patient. As a rule, hygienists should not be dealing with issues like scheduling, no-shows, or cancellations. Making appointment should be the responsibility of business employees, who have responsibility for keeping hygienists productive. A team approach to patient care can provide wellness services beyond teeth cleaning, providing extra motivation for patients to make return visits. Keeping the practice schedule full can also benefit others who have the potential to earn bonuses based on productivity. Is has been estimated that the national average rate for no-shows exceeds 20%. One consultant suggests that the schedule should have no more than one-half hour of an opening per day, although it is advantageous to keep a few hygiene spots available for new patients.
Time Management:
In modeling for dental hygiene profitability, the focus would be not on adding more people but on better allocating the available time. For example, seeing patients every 30 minutes allow for minimal patient education on interceptive periodontal treatment – which should account for about one-third of hygiene production. Much of the information hygienist need to perform risk assessments can be collected on a health history, without chair time. Burnout is more likely to occur in settings with haphazard scheduling; operating at peak efficiency is less stressful for everyone. The practice should have a plan for keeping hygienists busy when cancellations or no-shows occur, such as contacting potential patient who are waiting for appointments. Burnout and musculoskeletal disorders are real risks for busy dental hygienists.
Benefits of Modeling for Profitability:
Beyond the bottom line, the profitability approach has benefits for the entire practice. This includes the ability to upgrade equipment or make other investments that help to keep hygienists productive. Since patients spend so much time with hygienists, expanding the hygiene program can help to build relationships and improve patient retention. Taking on an expanded role where they spend more time with patients also provides hygienist with the opportunity to do a better job as clinicians, promoting job satisfaction. If done “wisely and equitably,” the profitability model has economic and other longterm benefits for dentists, hygienists, and the practice – while also achieving the overall goal of improving patient health. Dental Abstracts Volume 66, Issue 1
May / June 2022
Utah Dental Association 2023 Convention Salt Palace Convention Center
March 30 & 31, 2023