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CONTENTS

OFFICIAL PUBLICATION OF THE UTAH DENTAL ASSOCIATION

CONTRIBUTING WRITERS Chelsea Anderson, RDH Dr. Len Aste CDA Dr. Gregory Gatrell Dr. Daniel Klemmedson Dr. Brent A. Larson Dr. Casey Lynn Maria Roberts Dr. Sharine V. Thenard Dr. Scott Theurer Dr. Bryan Trump Tim Twig

COVER PHOTO Ski Powder Mountain Jeremiah Watt for Utah Office of Tourism

PUBLISHER: Mills Publishing, Inc. PRESIDENT Dan Miller OFFICE ADMINISTRATOR Cynthia Bell Snow GRAPHIC DESIGNERS Ken Magleby Patrick Witmer

PRESIDENT'S MESSAGE 4 What Does the UDA/ADA Do For Me? ASSOCIATION 6 The UDA and the ADA House of Delegates 8 Dentistry is Essential … So What Does That Mean? 10

UDA Legislative Successes

The Alternative P.P.P. Plan

RACTICE P 5 Dental Workforce Crisis 7

Oral Pathology Puzzler: Do You See What I See?

Updated Data Shows Increase in Utah HPV Vaccination Completion Rates

Have You Checked Your Finances Lately?

Saliva Analysis is a New Patient Engagement Tool

Recruiting and Hiring: The Short Game

Tongue and Lip Ties

Tooth Loss Associated With Dementia

Pediatric Patients, Parenting and the Pandemic: Caring For Children in Modern Times

RESEARCH 15 Third Molar Extraction May Improve Long-Term Taste Function

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 2021.

Moderate Alcohol Use Linked With Higher Cancer Risk

Study Reveals New Aspects of Body's Response to Plaque

PRESIDENT'S MESSAGE WHAT DOES THE UDA/ADA DO FOR ME? The year has gone by too fast. From my perspective every year goes a little bit quicker, and every year there seems to be a little more to do. Others say the same too.

bothered to check. They must have assumed that someone would do it for them. Fortunately for those who caught their error early it was easily remedied by a simple call to DOPL, but uncorrected the ramifications of this mistake would be profound.

This year, as always, the Utah Dental Association has attempted to visit all the dentists in the state during our Continuous Quality Improvement seminar. It seems over the years attendance has diminished, especially along the Wasatch Front.

Many ask what does the UDA/ADA do for me? We work hard to do the things individual dentists can’t do or are unlikely to do themselves. We work on issues like staying on top of current and proposed legislation and we work to provide affordable continuing education that helps dentists meet the requirements of licensure. We will never be able to compete with the many custom CE programs available to dentists around the country but many of the topics we provide are requirements for licensure and are not something that many dentists want to pay top dollar for. But many are unwilling to take the time to attend the courses.

The goal of our CQI meetings is to bring timely and important information to dentists that will greatly affect the practice of dentistry in the state. In Utah we have the third highest rate of solo practice in the country. That means that the individual practitioner is responsible for understanding and executing all the changes that occur each year. I was amazed as we visited dentists last year that hundreds of dentists had the wrong license. Having the correct license and the correct malpractice insurance should be one of the most important aspects of your practice, but many dentists never

What’s your practice worth?

The most common complaint I hear regarding the UDA is that we have not changed the rates that insurance companies pay to their PPO’s and that there are too many dentists participating in PPO plans. Fortunately for all dentists in the state the UDA won’t come into your office and change the way you practice dentistry. This in a decision for individual practitioners and offices to make. If you don’t like the rate you are reimbursed by a company, then don’t accept the plan. Its that simple. Many insurance companies still reimburse for dental work done by non-PPO providers. Some even pay more. Many of us want to make these changes in our own practices but we haven’t taken the time to do it yet. We are too busy, and we keep hoping someone will do it for us. I too feel like I have been too busy this year. Some of it is for play, some for “work” and some for family responsibilities. I still have not found the time to find a place to hang all our raft frames in our new garage and it has been sitting in my wife’s parking spot since the end of summer. She has asked a few times if I plan on working on it this weekend, but it seems like something more important keeps coming up… Dr. Gregory Gatrell UDA President

Since 1968

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PRACTICE DENTAL WORKFORCE CRISIS Nationally, dentistry is facing a workforce crisis. The shortage of dental hygienists, dental assistants and dental office administrative staff that existed prior to COVID-19 appears to have been exacerbated by the pandemic, as some staff members did not return to the profession after COVID-related dental office shutdowns. With regulations easing and vaccinations becoming more prevalent, many practices are again seeing an increase in patient appointments. Our neighboring states of Wyoming, Nevada and Colorado are experiencing significant hygienist shortages leading to substantial increases in salaries. Unlike Utah where many hygienists continue to seek additional employment in an oversupplied marketplace. The four Utah public Higher Ed institutions which educate dental hygienists; Weber State, UVU, SLCC and Dixie State, continue to have high numbers of applicants. Similarly, the four Tech Colleges with dental assisting programs; Bridgerland, Ogden-Weber, Davis, and Mountainland, have wait lists for entry into their dental assisting certificate programs. Some dental offices have invested heavily or ramped up their use of patient communication platforms to compensate for a shortage of business office team members. According to a May 17, 2021 study by the ADA Health Policy Institute, 35.8% of owner dentists were recruiting assistants; 28.8% were seeking hygienists and 26.5% were seeking administrative support staff. The same study reported hiring struggles: 86% of dentists reported hygiene recruitment efforts as “extremely” or “very” challenging; and 83% reported assistant recruitment efforts as “extremely” or “very” challenging. While COVID is partially to blame, the American Dental Education Association’s (ADEA) Snapshot of Dental Education of 2019-20 data indicates that the problem has been developing for many years.

problem is not just a need for larger classrooms, but a need for a larger applicant pool. Dentistry needs to be more aggressive in attracting young people to dentistry, hygiene and assisting careers. To fulfill the ADA Mission of “helping dentists succeed and support the advancement of the health of the public”, it is imperative that dentists be supported by an adequate, welltrained dental team. This is a critical element in access to care and the financial viability and sustainability of dental practices. Perhaps best achieved by recruiting and training an adequate workforce, while also taking steps to increase employee tenure, by helping establish a safe and encouraging workplace environment. ADA agencies have been tasked to undertake a national public relations campaign through existing print and social media communications materials to promote and encourage high school students to consider careers in dentistry, dental hygiene and dental assisting. There is also an urgent need to understand variables that lead to burnout and high employee turnover, as well as the variables that encourage long term employment. The profession needs to increase the tenure of dental team members. Bottom line……….. let’s take care of our important team members by creating a safe, nurturing workplace environment and opportunities for an increased skill set, additional responsibility and compensation. And……. help fill the pipeline of future dental team members by encouraging our teen age patients, especially those of under-represented populations, to consider a post high school education, focused on a dental career. Scott Theurer, DMD ADA Delegate

According to ADEA, from 2007 through 2017, the average number of dentists graduating from CODA accredited educational programs increased each year from 4,714 to 6,238 (32.3%). During the same 10-year period, the average number of hygienist graduates from CODA-accredited programs increased modestly from 6,652 to 7,294 (9.7%), and the average number of assistants from CODA accredited programs actually decreased from 6,097 to 4,852 (-20.4%), partially the result of the increase in unaccredited assisting programs.

NEW E-PRESCRIBING LAW The Division of Occupational and Professional Licensing (DOPL) is expected to finish the rule filing for this new law in November. It will allow an extension till January 1, 2024 for dental offices. More information will be coming as it is available.

Clearly the number of credential completing dental team members is not keeping pace with the number of graduating dentists. There is no single solution to this growing workforce shortage. A kneejerk reaction may be to increase class sizes, but some schools report declining applications and enrollment. The UDA Action

ASSOCIATION THE UDA AND THE ADA HOUSE OF DELEGATES We have just completed a week at the American Dental Association meetings in Las Vegas. We discussed a variety of issues facing Dentistry - what an eye-opening experience. We discussed issues that will impact our daily practice, professional future and lifestyles. Many issues that we discussed cannot be significantly influenced by individuals but can be influenced by combined voices. Using the combined voice of an association, the “dentists” perspective will be heard. The ADA has been very effective in representing us. Some of the areas of concern that were discussed and acted upon during this last meeting include the following: DENTAL MEDICARE - as proposed, it will be a problem. At this point dental services are to be for everyone on Medicare and included in Part B. That part of Medicare is designed for medical care. Because of differences in procedure coding, diagnostics, and software for claim submissions, dentistry is not a fit. The paperwork to participate and submit claims will be extensive and complicated. Opting out of Medicare will be difficult and result in the loss of many older patients to a practice. As it stands dental Medicare will be severely underfunded. That will lower reimbursements not only for Medicare patients, but for insurance fee schedules in general. Dental offices will be once more part of a broken system.

The ADA is now influencing the way dental Medicare should be structured. The ADA is pushing for a “stand alone” program that fits our dental software. Also encouraging dental to be a part of Medicare only for those whose income puts them at 300% of poverty level or below. This would allow better reimbursements and provide care to those truly in need. If dental Medicare becomes a reality, we hope it will be much more favorable to patients and to providers. DENTAL EDUCATION needs constant attention. We, as practicing dentists, must keep up with new advancements. Our dental schools must continue to provide excellent dental education. The value of the Doctorate degree must be maintained. The ADA is continually looking for ways to keep dental education a priority for all. We must influence THIRD PARTY INTRUSION where we can. Services to help dentists interact with frustrating 3rd party carriers will be available. They can be invaluable once you know where to access those services. The repeal of the McCarran Ferguson Act pertaining to Medical and Dental insurance has been a long-awaited success and policies that encourage insurance plans to protect patient rights and freedom of choice have been effective. Insurance issues are complicated. As long as dentist agree to and sign up for insurance plans that significantly reduce reimbursements or services there is little that can be done. The ADA is addressing issues that can be influenced and trying to make help available to its members. The ADA is making efforts to PROTECT EMPLOYEE

Your patients rely on your expertise to evaluate and make recommendations to keep them healthy. Your local independent insurance agent can do the same for you when it comes to suggesting the right combination of coverage to protect the practice you’ve worked hard to build.

SPEND YOUR TIME EXAMINING YOUR CLIENT’S TEETH, NOT YOUR COVERAGE.

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November / December 2021

PRACTICE DENTISTS. Legal action has been initiated to assure inappropriate records won’t be attributed to employee dentists and ensuring proper billing and business practices will be followed.

ORAL PATHOLOGY PUZZLER: DO YOU SEE WHAT I SEE?

POLICIES have been developed that pertain to anesthesia and teledentistry. These will help state legislatures formulate statutes that will be appropriate for their states and their dental practice acts. OTHER AREAS where direction was given to the ADA by the House of Delegates are: • Continuing advancements in our profession through research and science. • Increasing the value of membership with additional member services. • Promoting Inclusion and diversity efforts by opening doors for those who go into dentistry and help direct the profession by participating in the ADA. • Advocating and advising on a variety of other legal and political issues. • Helping to improve access to oral care and outcomes. The ADA has a budget of over $140,000,000. How those resources will be used and allocated is decided by the House of Delegates. By writing, discussing, and voting on resolutions the House directs exactly what issues we will influence and the direction the ADA will take. Through active representation we impact ADA programs and positions that will benefit our local state and region. We can direct the services that are most utilized and how they can be improved. If there are unmet needs, we can direct resources to meet those needs. Unfortunately, our representation is in jeopardy. Because of the high number of Utah dentists that did not renew membership last year, Utah will be losing a Delegate. That will not only impact our State but also our region. As a smaller state, we are already fighting an uphill battle to address issues specific to our region. We cannot afford to have even less input. Our national district has provided high level, national leaders, but that can only continue if we have votes and representation. Every Utah dentist who joins the ADA/ UDA allows us to have more say in issues that affects us every day and help determine what the future holds for our profession. Thank you for stepping up and supporting your profession through membership in the ADA/UDA. If you know someone who hasn’t joined, encourage them to join, help get them going. It is only by everyone participating that we create a united voice. That is how we can make a difference. Brent A Larson DDS ADA Delegate and proud member of the ADA/UDA

UDA Action

Case History: A 39 year old male reported lesions developing a few days after an office visit. During that visit, 3 different attempts were made for a crown impression (yes, it was an appointment with a dental student but we’ve all been in the same situlation at some point). No previous occurrence noted by the patient. Some pain and tendereness noted. Which of the following represents the best diagnosis for the clinic findings: a) Aphthous ulcers b) Traumatic ulcers c) Erythema migrans d) Pseudomembranous candidiasis e) Intraoral herpes simplex (continued on page 13)

Text to: 1. 2.

801 -261 -5315

I nc l ud e y o ur Fi rs t a nd La s t N a m e Yo ur i nt e re s t s t o ge t i nv o l v e d : a) b) c) d) e)

House of Delegates - Governance UDA Action Committee- Publications UDPAC Committee – Legislation I know my legislators – Name them & connection I’d be willing to be a Collaborative Dentist

ASSOCIATION DENTISTRY IS ESSENTIAL … SO WHAT DOES THAT MEAN? On October 19, 2020, the American Dental Association’s (ADA’s) House of Delegates passed Resolution 84H-2020, which states that oral health is an integral component of systemic health. The resolution also explains that dentistry is essential health care because of its role in evaluating, diagnosing, preventing, or treating the oral diseases that can affect systemic health. The House ratified an interim policy that was created by the ADA Board of Trustees earlier in the year as part of our efforts to advocate for dentistry and oral health during the COVID-19 pandemic. 84H-2020 Resolved, that the profession of dentistry is essential and defined as the evaluation, diagnosis, prevention and/ or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, craniomaxillary area and/or the adjacent and associated structures and their impact on the human body, provided by dentists, within the scope of their education, training and experience, in accordance with the ethics of the profession and applicable law, and be it further Resolved, that dentistry is essential and should remain an independent health care profession that safeguards, promotes and provides care for the health of the public, which may be in collaboration with other health care professionals. The policy statement is sound and, coupled with the ADA’s advocacy efforts, has been helpful in prioritizing dentistry to receive much-needed personal protective equipment (PPE) and securing financial help for dentists’ returning to practice. The early weeks of the pandemic—when dentistry paused, and patients were unable to access all except urgent and emergency dental care—underscored the importance of preventive and routine oral health care. The fragility of our general and oral health care infrastructure became clear to our members, our patients, the dental industry, and policy makers on the state level and in our nation’s capital. The ADA has successfully traversed the COVID-19 pandemic. Now that our most crucial frustrations associated with the pandemic have passed and dentistry is for the most part nearing prepandemic volumes, • Are we still essential, and what does that mean? • Is oral health care essential? 8

Photo: Image licensed by ingram image

• Is oral health care essential to overall health? • Is oral health care essential to everyone? • Is oral health care essential to dentists and the business of dentistry? Of course … all are true. I see oral health care as integral to and an essential component of overall health. Conversely, I consider overall health and the many exogenous factors that contribute to it to be essential to achieving oral health. I have heard from many upset member dentists and volunteer leaders who, despite their assertion that dentistry is “essential,” want the ADA to “swim only in our lane.” Their opinion is that if it does not happen in the mouth or in a clinical dental facility, our association should not engage in it. Let us talk about “essential.” Dictionaries define it as “absolutely necessary” and “extremely important.” Not much room for debate there. If we apply that definition to the policy passed by the House, the essential nature of dentistry extends well beyond the mouth and into the environments, both physical and social, that exist outside our offices. If we believe what we say, we should be engaged wherever opportunities exist to improve the oral and general health care of the public. The policy’s first resolving clause describes the broad scope of our profession and its relationship to the human body. Not mouth—body. The second resolving clause reiterates November / December 2021

the essential nature of our profession in safeguarding and promoting the health, not only the oral health, of the public.

and shaping solutions. Dentistry’s response to the pandemic benefitted overall public health—not only oral public health.

The Constitution of the ADA states that “[t]he object of this Association shall be to encourage the health of the public, and promote the science and art of dentistry.”

How do we use “essential” for the good of our profession and the patients we serve? Essential health care should be accessible for those who need it and desire it. Can we advocate to improve patient benefit options, both private and public? The need for a significant portion of “essential” oral health care can be avoided. We have every opportunity to double down on prevention. Does anyone think childhood caries is not “essential” to conquer? It should be our priority to address this through all means possible. Dentistry is as essential as medicine. Is it not an advantage for our patients, our members, and our profession to improve and normalize collaboration and integration with our medical colleagues where clear benefit exists?

Our mission is to “help dentists succeed and support the advancement of the health of the public.” Our vision is “empowering the dental profession to achieve optimal health for all.” These statements do not describe a swim lane. They talk about the entire pool. It is to our profession’s advantage to be in that pool. Our patients do not exist only in “dentistry’s lane.” There are numerous determinants that can influence a patient’s health status. Fulfilling our mission, vision, and constitutional obligations requires us to account for these factors. The profession of dentistry—as defined by our constitution, mission, and vision—and its essential nature as codified in ADA policy is obligated to be in the pool. The opportunities are boundless. Although pitfalls are certainly present, COVID-19 has also shown us that we are skilled in defining problems

“Essential” is an opportunity. There is an implied responsibility that accompanies “essential.” We have defined ourselves and our purpose. We now have to walk the walk. Dr Daniel Klemmedson ADA President 2020-2021 JADA September 2021

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UDA Action

ASSOCIATION UDA LEGISLATIVE SUCCESSES

(UTAH LAWS DISCUSSED AT RECENT UDA CQI MEETINGS)

Non-Covered Services (2017) SB 44 - Senator Allen Christensen; Rep Ray Ward see Utah statute 31A-22-646. 40+ states have passed similar legislation

Prior Authorizations: (2019) SB 264 Senator Evan Vickers and Representative Suzanne Harrison. See statute UCA 31A-22-650 .

• A dental insurer is prohibited from setting fees for dental services that are not covered services under the dental insurance. • A contract between a dental plan and a dentist to provide covered services may not prohibit a dentist from offering or providing noncovered dental services to a covered individual at a fee determined by the dentist and the individual who will receive the noncovered services. • The state laws only apply to state regulated insurance plans. Many dental plans are federally regulated.

In discussing Prior Authorizations, we should explain the difference between Prior Authorization and Pre-Treatment estimates

Retroactive Denials: UCA 31A-26-301.6(14)

Network Leasing: (2021) HB 359 Representative Jim Dunnigan and Senator Karen Mayne See UCA 31A-22-646.1

Nothing in this section may be construed as limiting the ability of an insurer to: (a) recover any amount improperly paid to a provider or an insured: (i) in accordance with Section 31A-31-103 or any other provision of state or federal law; (ii) within 24 months of the amount improperly paid for a coordination of benefits error; (iii) within 12 months of the amount improperly paid for any other reason not identified in Subsection (14) (a)(i) or (ii); (iv) within 36 months of the amount improperly paid when the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance Program, or any other state or federal health care program;

Virtual Credit Cards: (2020) HB37 - Representative Jim Dunnigan and Senator Curtis Bramble See UCA 31A-26-301.6 This gives dental offices an option to accept or opt out of Virtual Credit card payments methods. Thus, saving the office from the credit card fees associated with credit card payments. This bill gives dental offices an option to accept or opt out of Virtual Credit Card payment methods. 10

A Prior Authorization means the third-party payer has agreed to make payment for the services being sought prior to treatment (Usually Written) This Legislative bill spelled out that a Prior Authorization, if done correctly, would be more like a commitment or contract by the third-party payer for payment

When a dentist signs up with a third-party payer to be a provider, the third-party payer leases that contract to other third-party payers. Now the dental office is contracted with more plans than they are often aware. Network Leasing Plan Requirements 86 if the contracting entity is an insurer, a provision indicating: 87 that the contract grants a third party access to the provider network; and 88 for a contract with a dental carrier, the dentist has the right to choose not to 89 participate in third-party access 95 require a third party to identify the source of the discount on all remittance advices 96 or explanations of payment under which a discount is taken unless the transaction is an 97 electronic transaction mandated by the Health Insurance Portability and Accountability Act; 98 notify a third party of the termination of a provider network contract no later than 99 30 days after the day on which the contract terminates with the contracting entity; 100 at least 30 days before the day on which a third party begins leasing a network

November / December 2021

Network Leasing (continued) 101 provider, notify each network provider subject to the lease; 102 make available to a participating provider, within 30 days after the day on which the 103 provider makes a request, a copy of the provider

network contract at issue in the adjudication 104 of a claim; and 105 maintain a list of the contracting entity's affiliates on the contracting entity's 106 website.

Also as part of 2021’s HB 359, See UCA 31A-26-301.7. An insurer may not maintain a dental plan that: • Based on the provider’s contracted fee for covered services, uses downcoding in a manner that prevents a dental provider from collecting the fee for the actual service performed from either the plan or the patient; or • Uses bundling in a manner where a procedure code is labeled as nonbillable to the patient unless, under generally accepted practice standards, the procedure code is for a procedure that may be provided in conjunction with another procedure. Downcoding, Bundling, EOB Verbiage 153 An insurer may not maintain a dental plan that: 154 based on the provider’s contracted fee for covered services, uses downcoding in a 155 manner that prevents a dental provider from collecting the fee for the actual service performed 156 from either the plan or the patient; or 157 uses bundling in a manner where a procedure code is labeled as non-billable to the 158 patient unless, under generally accepted practice standards* the procedure code is for 159 a procedure that may be provided in conjunction with another procedure. 160 An insurer shall ensure that an explanation of benefits for a dental plan includes the 161 reason for any downcoding or bundling result. What Does This Mean? • Insurance Companies can still downcode & bundle, but: • They cannot force you to write off a separate service • If they don’t pay, THE PATIENT PAYS! • Examples: • Third Party Payors EOB’s stating to write off a build-up • Gingivectomy with crown prep • Crown lengthening with crown prep • Non-coded technology with treatment • Any pulp caps with fillings • Four quads of SRP at same appointment • Any diagnostic or treatment codes with limited exams • Bitewings and Pano to FMX • Many others…

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UDA Action

PRACTICE UPDATED DATA SHOWS INCREASE IN UTAH HPV VACCINATION COMPLETION RATES Vaccines are the greatest public health success in history and have helped save millions of lives. The HPV vaccine prevents a viral infection that can cause six types of cancer including cervical and throat cancers and represents a new era of cancer prevention. According to the American Cancer Society (2021), each year in the U.S., more than 35,000 men and women are diagnosed with an HPV-related cancer. Most of these cancers could be prevented with vaccination. In addition to these cancers, there are hundreds of thousands of women who undergo treatment for new cases of cervical pre-cancers each year, most which could have been prevented with vaccination. Current research has proven the COVID-19 pandemic having a negative effect on vaccination rates. Parents have avoided pediatrician visits to avoid transmission of the virus. The CDC estimates that HPV vaccinations are down by more than 20% or 1 million doses compared to 2019 (American Cancer Society, 2021). To monitor current state immunization coverage, the Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (CDC, NCIRD) sponsor a yearly survey called the National Immunization Survey (NIS) (Centers for Disease Control and Prevention, 2021). The data collected comes from randomized telephone surveys to parents of adolescents ages 13-17 years old and paper surveys to primary care physicians on immunization practices for ageappropriate vaccines approved by the Advisory Committee on Immunization Practices (ACIP) (CDC, 2021). Just a few weeks ago the 2020 NIS data was released to the public. Remarkably, Utah saw a slight increase in their HPV vaccination completion rates. Nationally, 58.6% of adolescents both male and female are fully vaccinated with the HPV vaccination (CDC, 2021). Comparatively, Utah’s HPV completion rate is 45% which is up 0.4% from 2019 numbers (CDC, 2021). Utah is ranked 59th out of the 62 population-based, state, selected local areas and territories that were monitored in the NIS data (CDC, 2021). Utah continues to experience gender and geographical disparities amongst their HPV vaccination rates. The uptake in the HPV vaccine remains higher in females at 49.8% compared to only 40.2% of adolescent males (CDC, 2021). Additionally, urban areas throughout the state have a 44.4% HPV completion rate compared to 38.3% HPV completion rates in rural and frontier communities (CDC, 2021).

In 2018, the American Cancer Society (ACS) launched Mission: HPV Cancer Free, a public health campaign to drastically reduce vaccine-preventable HPV cancers through vaccination with a goal of reaching 80% HPV completion rates by 2026, which marks the 20th anniversary of the release of the HPV vaccination. In 2020, ACS received a grant from Merck to partner with Huntsman Cancer Institute at the University of Utah to increase HPV vaccine rates by building a regional consortium, launching focused education, and implementing quality improvement interventions with clinical partners. During the 2020 consortium meetings, dental providers were identified as a partner to engage on helping to educate parents and adolescents on the importance of the HPV vaccine. In 2022, the American Cancer Society will be partnering with the Nevada Dental Hygienist’s Association to launch a 4-part virtual continuing education webinar series dedicated to providing HPV related content to dental providers throughout our 5-state project including Utah. The series will launch January 26th, 2022 and continue every two weeks concluding on March 9, 2022. Topics will include: HPV 101 and the Effects of the Pandemic on Vaccinations, Barriers to Dental Care in Rural and Frontier Communities, Oral Screenings and Malignancies, and an in depth look on the Treatment and Side Effects of HPV-Related Oropharyngeal cancer. To learn more and to register for this series, please visit: https://nvdha.com/.

References: American Cancer Society. (2021). Cancer Facts & Figures 2021. American Cancer Society. https://www.cancer.org/content/ dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf American Cancer Society. (2021, May 3). The American Cancer Society Encourages Parents to Reschedule Missed Vaccine Visits for Kids. American Cancer Society. http://pressroom.cancer. org/2021-05-03-The-American-Cancer-Society-Encourages-Parents-to-Reschedule-Missed-Vaccine-Visits-for-Kids Centers for Disease Control and Prevention. (2021, May 14). Vaccination Coverage among Adolescents (13 – 17 Years). Centers for Disease Control and Prevention. https://www.cdc. gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/ index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fvaccines%2Fimz-managers%2Fcoverage%2Fteenvaxview%2Fdata-reports%2Fhpv%2Findex.html November / December 2021

PRACTICE ORAL PATHOLOGY PUZZLER: DO YOU SEE WHAT I SEE? (continued from page 7) Correct answer: (e) Aphthous ulcers are usually limited to moveable mucosa and wouldn’t typically occur on the attached mucosa of the palate or gingiva. While traumatic ulcers could be noted in this location, they wouldn’t be as numerous as in this clinical presentation. Most traumatic ulcers present as a single ulceration. While an office visit with three attempts for an acceptable crown impression can be traumatic, just not in the physical sense unless the patient has a hypersensitivity reaction to the PVS material. Erythema migrans is basically geographic tongue (benign migratory glossitis) of the soft tissues. Labial mucosa and buccal mucosa are the most common locations. Pseudomembranous candidiasis would wipe off and would clinically present as a more generalized process, rather than localized to a specific area. Herpes simplex virus is spread primarily through saliva or active perioral lesions. Ultraviolet light exposure has been the only condition to unequivocally induce lesions experimentally (herpes labialis and not intraoral lesions). A symptomatic primary infection (acute herpetic gingivostomatitis) typically occurs before 5 years of age. Affected mucosa develops numerous pinhead vesicles. Both movable and attached oral mucosa can be affected. Eighty-percent of primary infections are asymptomatic. After initial exposure, virus is taken up by the sensory nerves and transported to associated sensory ganglia and enters a latency period. The most common site of

latency is the trigeminal ganglion. When the virus reactivates, the result is a secondary, recurrent, or recrudescent infection. The most common site of recurrence for herpes simplex virus is the vermilion border and adjacent skin of the lips (herpes labialis, “cold sore,” ”fever blister”). A prodrome (pain, burning, itching, tingling sensation) can occur 6-24 hours before lesions develop. Intraoral lesions are almost always on keratinized, bound mucosa (palate, attached gingiva). Lesions exhibit subtle changes. They begin as as 1-3 mm vesicles that rapidly collapse to form a cluster of erythematous macules that coalesce and slightly enlarged. The damaged epithelium is lost and the result is a central, yellowish area of ulceration that usually heals in 7-10 days. Dr Bryan Trump University of Utah School of Dentistry Works Cited Neville, Damm, Allen, Chi (2016). Oral and Maxillofacial Pathology, 4th Ed. St. Louis: Elsevier.

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UDA Action

PRACTICE HAVE YOU CHECKED YOUR FINANCES LATELY? When people hear the word “embezzlement,” they typically visualize a large company and millions of dollars absconded with such as the case of Sujata “Sue” Sachdeva, who was the trusted 15-year veteran vice president of finance, secretary and principal accounting officer of Koss Corporation. During the span of more than five years, she stole nearly half the company is pretax earnings. The scheme was uncovered when America Express noticed her credit card balances were being paid through large wire transfers originating from a company bank account. Koss is a Milwaukee-based, mostly privately held small company that’s a prominent global designer and marketer of stereophonic headphones. In an article “How an embezzler stole millions from a small company,” by Curtis C Verschoor, Koss CEO Michael Koss asked the judge to sentence Sacheva to the maximum sentence of 15 to 20 years, writing that she “stole from the hardworking employees of the company and their families, and ultimately the stockholders of the company.” In a pre-sentencing letter, he stated, “The full extent of the damage to the reputation of the company and its employees caused by Ms. Sachdeva’s criminal acts cannot be expressed in words.” Unfortunately, embezzlement in dental practices is not uncommon. In his book “Dental Embezzlement: The Art of Theft and the Science of Control,” David Harris, CEO of Prosperident, states that based on Prosperident’s case files, the average amount that a thief successfully steals from a dental practice before they get caught is $109,000, making this problem more than an unremarkable nuisance. Harris goes on to state that regardless of size and type of

entity, “embezzlement touches every corner of dentistry” and because it is “a highly personal act. . . many dentists who are victims struggle emotionally for years after the crime.” Harris reference the 2018 Report to the Nations by the Association of Certified Fraud Examiners which found that the median loss when an employee had worked for an entity for less than a year was $40,000, whereas the median loss when a thief had been with an organization for six to 10 years was $173,000. Whether you read Harris’s book, the ADA’s “Protecting Your Dental Office from Fraud and Embezzlement” or any other publication on the topic of embezzlement, you will find that internal controls and supervision by an engaged owner are the cornerstones of the mitigation efforts. If you do suspect you have a problem there are specific steps you should take to ensure a proper investigation is conducted. The ADA has a “Dos and Don’ts if you Suspect Fraud” checklist which can help you focus on the next steps. You will want to get in touch with your insurance agent regarding coverage afforded under your business owner’s policy and claim reporting requirements. Coverage for embezzlement is typically found under “Employee Dishonesty;” most policies have a minimal amount of coverage included with the option to purchase to cover loss plus fraud investigation and legal fees. Be engaged and be vigilant when it comes to the practice you have worked so hard to build. Maria Roberts WDAJ August 2021

PRACTICE SALIVA ANALYSIS IS A NEW PATIENT ENGAGEMENT TOOL Empowering patients to engage in their oral health care can be a constant challenge for dental professionals. Some patients are fearful of procedures, some want you to make all the decisions, and some just want to get in and out and not come back. Or, if insurance doesn’t cover it, they’re not interested to learn how it may help them. Salvia analysis screening technology can provide information you didn’t previously have and can amp up your conversation to deliver oral health and hygiene education backed by objective measurements. It may just keep your patients coming back for more. 14

What Does Chairside Saliva Screening Look Like Today? A few available tests can identify specific pathogens that cause disease, are considered diagnostic and are more expensive to administer as you must send the sample out to a lab for analysis. Salvia screening tools differ in that they are quick and easy to use and typically cost much less to implement. One saliva analysis system uses dual wavelength reflectance spectrometry to measure key saliva biomarkers through a chemical reaction on the test pad, which eliminates culturing of bacteria for days to get numbers or sending samples off to a lab. Other saliva tests measure the pH of saliva to determine if the oral cavity is acidic or salivary flow to determine hyposalivation. Saliva screening test results are tools that can November / December 2021

be used to complement a clinical assessment of your patient to provide more information to support suggesting new oral hygiene habits, products or treatments. The most comprehensive chairside saliva screening measures the presence of biomarkers in three key areas of tooth health, gum health, and oral cleanliness, providing results for levels of cariogenic, acidity, buffer capacity, blood, leukocyte, protein and ammonia. These results can indicate a higher or lower risk for developing caries and gum disease, which can support the discussion with your patients on what their oral health looks like today and where you are encouraging them to take it. Can A Saliva Screening be Beneficial for My Practice? Dr Brian Novy, noted saliva lecturer, CAMBRA president and chief dental officer for the state of Massachusetts, added chairside salvia screening to his practice a few years ago and finds it beneficial for both the team and patient. Team Benefits • Quick, easy procedure doesn’t interrupt current hygienist’s routine and supports clinical case presentation. • Customizable report fields to create a unique, patientcentered report card that clearly explains the issue and staff recommendations. • SillHa Results Advisor provides insight to potential causes and recommendations that support the conversation with patients. • Tracks progress over time so that everyone can see what is working and how health is improving.

Patient Benefits • Objective, visual evidence to help understand what the clinician is telling them about disease risk. • A report card just for them that clearly explains the issue and the recommendations • Develops trust in their provider that what they are recommending has some basis • Tracking patient result over time motivates them to continue behavioral changes to see improved outcomes. Another office is using salvia analysis for a different audience and finds similar benefits. Dr Boyd Simkins, a pediatric dentist in Utah, states that saliva analysis has changed the conversation with parents of his pediatric patients. He feels he is no longer saying the same things over and over to glazed-eyed parents about brushing and flossing, and no more sugar. Now, he discusses outcome and progress as the numbers are changing. Discussions are more meaningful with a salvia screening analysis to show how their child is responding to treatment. Dr Simkins believes it is a valuable addition to his practice. A salvia screening tool can change and add impact to your preventive care routines. Empowering your staff with this simple method to have a deeper and more meaningful conversations to engage patients can be the boost a practice needs to make a great comeback after a year of uncertainties and smarter patients. Chelsea Anderson, RDH Today’s FDA August 2021

RESEARCH THIRD MOLAR EXTRACTION MAY IMPROVE LONG-TERM TASTE FUNCTION Patients who had their third molars extracted had improved tasting abilities decades after having the surgery, according to a new Penn Medicine study published in the journal Chemical Senses. The findings challenge the notion that removal of the third molars only has the potential for negative effects on taste and represent one of the first studies to analyze the long term effects of extraction on taste. “This new study shows us that taste function can actually slightly improve between the time patients have surgery and up to 20 years later,” said senior author Richard L. Doty, PhD, director of the Smell and Taste Center at the University of Pennsylvania Dr. Doty and co-author Dane Kim, a third-year student at the University of Pennsylvania School of Dental Medicine, evaluated data from 1,255 patients who had undergone a chemosensory evaluation at Penn’s Smell and Taste Center over the course of 20 years. Among that group, 891 patients had received third molar extractions and 364 had not. The “whole-mouth identification” test incorporated five different concentrations of sucrose, sodium chloride, citric acid and caffeine. Each solution was sipped, swished in the mouth and then spit out. Subjects then indicated whether the

solution tasted sweet, salty, sour or bitter. The extraction group outperformed the control group for each of the four tastes, and in all cases, women outperformed men. The study suggests, for the first time, that people who have received extractions in the distant past experience, on average, an enhancement (typically a 3% to 10% improvement) in their ability to taste. Two possibilities could explain the enhancement, according to the authors. First, extraction damage to the nerves that innervate the taste buds on the front of the mouth can release inhibition on nerves that supply the taste buds at the rear of the mouth, increasing whole-mouth sensitivity. Second, hypersensitivity after peripheral nerve injury from a surgery like an extraction has been well documented in other contexts. Learn more about this study in Chemical Senses (2021); dx.doi. org/ 10.1093/chemse/bjab032. CDA September 2021

UDA Action

PRACTICE RECRUITING AND HIRING: THE SHORT GAME Prior to the pandemic, we were experiencing a tight labor market. This as a result of an expanding economy and fewer available workers for a number of job openings. Now, because of the pandemic, the labor market is even tighter – especially in dentistry – but for various reasons. Some of these include: 1. Many have chosen to retire. 2. Many have chosen new or different career paths, given potential risk factors of working in a dental office environment. 3. Many are needed at home for childcare, home schooling and/or caregiving. 4. Many have chosen to delay returning the workforce due to underlying health conditions, or stimulus checks or extended unemployment benefits. 5. Many dental assisting and hygiene school closed and have yet to reopen, thus graduating fewer students. 6. Many of the testing options for licensing and certification were postponed or suspended, meaning smaller numbers of qualified candidates. Given these factors, it is no wonder that the pool of available candidates is quite small and causing a lot of frustration for many dentists. When it comes to recruiting and hiring there is a “short game” and a “long game.” The short game is doing whatever you can now to fill the openings. The long game is: 1) focusing on developing quality employees and 2) putting conscious effort into employee engagement and creating the type of organizational culture that supports long-term retention, thus reducing the need to recruit. Here we will focus on the short game. Most employers want some “silver bullet,” or guaranteed, foolproof set of tactics for recruiting and hiring. Unfortunately, such a thing does not exist. There are some basic principles that can help your recruiting and hiring success. One rule of thumb: Hire first for the things you cannot teach or train. You cannot teach attitude and personality. Attitude and personality are things that all of us, including your patient, experience when we interact with other. You can’t teach it. You can’t train it. So, you look for these things first. Experience can be gained by working with you and skills can mostly be taught and/or trained, so they are next in line for consideration. 16

Photo: Image licensed by ingram image

To set the stage for more effective recruiting and hiring, make sure you clearly define the job. Have an accurate, up-to-date and concise job description. This should truly delineate the duties, responsibilities, requirements and expectations of the job. A comprehensive job description acts as a form of communication that supports performance and accountability – it is the recipe for success in that position. It can provide a road map for training and onboarding. It should be focused and clear – don’t make assumptions about people’s knowledge of the job. Use all the common sources for finding candidates, such as: Indeed, Dental Post, Zip Recruiter, employment agency, Craigslist etc. Don’t forget to contact and network with school and professional organizations in your area, especially internally with your existing (good) employees and patients who might know of someone looking for a job or a career change. Once you have a candidate pool (large or small), engage in applicant screening. The primary purpose of screening is to quickly assess who stays in the running. Eliminate those who, for whatever reason, are not going to be moved forward in the process. It’s far easier to eliminate at this stage and saves you time in the long run. Screening is done via a phone call (with or without Zoom) and lasts only a few minutes. Ask each person the same relevant two to three questions and evaluate whether you like them (attitude and personality), can communicate well with them November / December 2021

and you want to learn more about them. Anyone who passes the screening “test” is then asked to complete and sign an application (if that hasn’t been done yet) and moves on to an actual interview. When interviewing: • Prepare by reviewing the application and developing questions (i.e. don’t shoot from the hip!) • Avoid yes/no questions • Ensure that 60% of the questions you ask are behavioralbased questions • Focus on “fit” over experience • Interview multiple times with multiple people (ideally) • Avoid snap judgments, biases and stereotyping • Allow the candidate to do most of the talking For the top one to two candidates create opportunities to

“unmask” them to get a deeper idea of what they’re like. This could be something like taking them to lunch, which affords an opportunity to see and experience this person and how he or she interact with servers (respectfully or not) and other people. This might prove to be the best $25 you ever spent. Incorporating the following round out the recruiting and hiring process: skills assessments, job match personality assessment, and reference and background checking – all of which are valuable components to increase success and minimize risks. Hopefully, this information and these suggestions will lead to a great success moving forward as we being to put COVID-19 in the rearview mirror. Tim Twig Today’s FDA August 2021

PRACTICE TONGUE AND LIP TIES You hear it from parents all the time. “My kid is the pickiest eater,” “We tried to breastfeed, but gave up after a month of issues,” “He’s been in speech therapy for four years.” Many of these complaints fall on deaf ears. The basis for many of these growth and development woes we hear about stem from a functional issue in the mouth, mostly due to restrictions of the tongue and/or lips. If the tongue cannot rest in the palate which is the normal resting position, you’ll see constricted upper arches and airways as well. As experts of oral health, dentists should be on the forefront of addressing these issues. Unfortunately, tethered oral tissue (TOTs) training is absent in most dental school curriculums. The subject isn’t taught even in pediatric residencies and if it is, proper diagnosis and treatment is not. Many of the above issues stem from TOTs namely tongue and/ or lip ties. Parents often turn to their pediatricians for advice on these issues and are told there are no “tongue ties” present or the child will grow out of it. Pediatricians unfortunately also lack the formal education needed to properly identify functional issues in the mouth. Many are only concerned if the patient can’t stick their tongue “out,” but posterior lift/function is a huge part of normal tongue function. This can be disheartening because as one “issue” passes, another can occur. Even adults with TOTs are affected as they typically have sleep, breathing, head and neck tension issues. The good news is, with the right questions and some simple exam techniques, we all can start to identify issues early on and help many patients thrive! It’s estimated that up to 30% of the population has some sort of functional restriction in the mouth. New, higher-level research is being done to turn the “fad” of tongue ties into

a legitimate issue that all dental and medical providers can learn about. Great educational resources are becoming more available to people all over. Dr Richard Baxter, a pediatric dentist who runs the Alabama Tongue Tie Center and Dr Soroush Zaghi, an ENT who runs the Breathe Institute, are leading the way in both research and education. As more is done to investigate TOTs, more providers can understand what to look for and how to properly treat those issues. Releasing these tissues can be easily done with numerous instruments, although soft tissue lasers allow for quicker, cleaner and better healing than many other options. It’s important to understand that these procedures release the tissues, but without proper function, many patients will still struggle. The procedure needs to be done with a team to help with this. For infants and moms struggling with breastfeeding, working with lactation consultants and body workers is crucial. For adolescents with speech and/or feeding issues, speech language pathologists help support the healing process and teach the patient proper function. Even adults with issues need support around their surgery, which is typically done with the help of a myofunctional therapist and body worker. When a proper assessment is done with a clean surgery and the correct support is provided, fixing TOTs issues can be lifechanging! Helping a patient speak more clearly, eat without struggles and sleep more peacefully is extremely rewarding – and with a little more training, all dentists can start asking the right questions and helping more patients daily. Dr Casey Lynn Today’s FDA August 2021

UDA Action

ASSOCIATION THE ALTERNATIVE P.P.P. PLAN In the many years that I have been a dentist, I’ve heard too little counsel given to the happy, well-adjusted, high-producing dentists. Those lonely inhabitants of what must be the most neurotic group in dentistry. No ADA Journal articles probe their ability to cope with the pressures of dentistry. No research studies examine their sturdy mental health. At dental meetings they sit contently while the emotionally unstable reveal their problems. They simply do not belong. Yet there is hope for this stable, well-adjusted group. With effort, problems can be created, guilt induced, sorrow generated, and self esteem destroyed. The following “Principles of Problem Production (P.P.P.)” earnestly applied, can make these out-of-step dentists as miserable as the rest of us. Snowballing. If you face problems when they first appear, they tend to vanish away. Don’t let them. Let them get a firm foothold on you. Let them snowball you. The best “snowballers” practice a simple rule, which is, “when it is past time to do something about a problem, wait a little longer.” With staff, for example, refuse to express feelings of irritation or disappointment for days, even weeks. This will allow enough pressure to build up to blow any work relationship apart. The Reverse Allen. Dentists who refuse to internalize their problems and assume problems that belong to other people, are hopeless failures at problem production. However, by reversing their attitude we formulate one of the most clever problem producing techniques. Suppose a patient refuses your treatment plan. Immediately assume that it is your fault. Internalize it. Blame yourself. Before long you will have worried yourself sick. The I-told-Me-So Syndrome. The idea here is that we expect bad things to happen, making them more likely to occur. If you are going to a dental meeting, for example, predict that you will have a terrible time. Make yourselves believe it. When you get there, sit alone away from the action. Avoid meeting new dentists. Then, later gripe and moan about the fact that no one would have anything to do with you.

You can generate anything from anxiety to depression with the skillful use of negative thinking. Barrier Building. If you discover that friendship and unity has occurred in your relationship with your staff or patients, don’t panic. Several general principles, constantly applied, will soon restore those cold, uncomfortable barriers. First, never give compliments. Indeed, avoid any encouraging remarks. Next, set up criticism. Nag, complain, fuss, judge and blame others. Avoid being reasonable. Demand everything be your way. Tell your staff, “as long as you work for me, you’ll do what I want.” In no time at all, you will build up a satisfying wall of resentment. The Martyrdom. All that is needed to become a John or Joan of Arc is a reasonable opportunity. Dentists can overburden themselves with work, family and other responsibilities, then say to themselves, “No one cares about me. As far as my staff and patients are concerned, I’m just another slave. I work my fingers to the bone and beat my brains out for everybody and no one gives a darn. Everyone uses me.” Burning yourselves at the stake not only generates bad feelings in yourselves, it also disgusts and irritates the people around you. This enables you to feel even worse. These Principles of Problem Production clearly illustrate the control we have over our lives. They suggest that we not only can, but do, create for ourselves problems and unhappiness. If you recognize yourself in any of these principles, I hope you have been able to say,” Hey, that’s what I do, but I’m going to try and stop doing it now.” We will not always have the privilege to do everything we want in dentistry, but we do have the power to enjoy most of what we do. Joy and success, or sadness and failure, are equally the offspring of our thoughts and actions. The choice is ours. Len Aste, DDS UDA Secretary

Negative Focus. Don’t let men like Dale Carnegie and Norman Vincent Peale blind you with their positive principles. Real power lies in negative thinking. Remember the times when you were treated unfairly or when someone spoke unkindly to you. Say to yourself “I am always misunderstood and mistreated by my staff and patients.” Beware of the intrusion of happy thoughts. If you should think of something good about yourself, quickly remember a corresponding weakness. Focus on it. Internalize it. 18

November / December 2021

RESEARCH

PRACTICE

MODERATE ALCOHOL USE LINKED WITH HIGHER CANCER RISK

TOOTH LOSS ASSOCIATED WITH DEMENTIA

A new study from the World Health Organization’s (WHO) International Agency for Research on Cancer (IARC) has found an association between alcohol and a substantially higher risk of several forms of cancer, including breast, colon and oral cancers.

Tooth loss is a risk factor for cognitive impairment and dementia — and with each tooth lost, the risk of cognitive decline grows, according to a new analysis led by researchers at the NYU Rory Meyers College of Nursing and published in JAMDA: The Journal of Post-Acute and Long-Term Care Medicine. However, this risk was not significant among older adults with dentures, suggesting that timely treatment with dentures may protect against cognitive decline.

Increased risk was evident even among light to moderate drinkers (up to two drinks a day) who represented 1 in 7 of all new cancers in 2020 and more than 100,000 cases worldwide, according to the study published in the journal Lancet Oncology. In Canada, alcohol use was linked to 7,000 new cases of cancer in 2020, including 24% of breast cancer cases, 20% of colon cancers, 15% of rectal cancers and 13% of oral and liver cancers. “All drinking involves risk,” said study co-author Jürgen Rehm, PhD, senior scientist at the Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute at the Centre for Addiction and Mental Health (CAMH). “And with alcohol-related cancers, all levels of consumption are associated with some risk. For example, each standard-sized glass of wine per day is associated with a six times higher risk for developing female breast cancer.” The impact on cancers is often unknown or overlooked, highlighting the need for implementation of effective policy and interventions to increase public awareness of the link between alcohol use and cancer risk and decrease overall alcohol consumption to prevent the burden of alcohol-attributable cancers, researchers said. The modeling study was based on data on alcohol exposure from almost all countries of the world, both surveys and sales figures, which were combined with the latest relative risk estimates for cancer based on level of consumption. The main mechanism of how alcohol causes cancer is through impairing DNA repair, according to the study. Additional pathways include chronic alcohol consumption resulting in liver cirrhosis and alcohol leading to a dysregulation of sex hormones, leading to breast cancer. Alcohol also increases the risk of head and neck cancer for smokers, as it increases the absorption of carcinogens from tobacco. Research into the link between light to moderate drinking and cancer is relatively new and public policy does not yet reflect the degree of cancer risk, according to the study.

About 1 in 6 adults aged 65 or older have lost all of their teeth, according to the Centers for Disease Control and Prevention. Prior studies show a connection between tooth loss and diminished cognitive function, with researchers offering a range of possible explanations for this link. For one, missing teeth can lead to difficulty chewing, which may contribute to nutritional deficiencies or promote changes in the brain. A growing body of research also points to a connection between gingivitis and cognitive decline. In addition, tooth loss may reflect lifelong socioeconomic disadvantages that are also risk factors for cognitive decline. For the study, researchers conducted a metaanalysis using longitudinal studies of tooth loss and cognitive impairment. The 14 studies included in their analysis involved a total of 34,074 adults and 4,689 cases of people with diminished cognitive function. The team found that adults with more tooth loss had a 1.48 times higher risk of developing cognitive impairment and 1.28 times higher risk of being diagnosed with dementia, even after controlling for other factors.

“As an epidemiologist, I would recommend higher taxes to fully reflect the burden of disease from alcohol,” Dr. Rehm said. “Along with limiting the physical availability and marketing of alcohol, price controls are recognized as high-impact, cost-effective measures to reduce alcohol-related harm.”

However, adults missing teeth were more likely to have cognitive impairment if they did not have dentures (23.8%) compared to those with dentures (16.9%); a further analysis revealed that the association between tooth loss and cognitive impairment was not significant when participants had dentures.

Read more of this study in Lancet Oncology (2021); doi: 10.1016/S1470-2045(21)00279-5

Learn more about this study in JAMDA (2021); doi.org/10.1016/ j.jamda.2021.05.009.

CDA October 2021

CDA September 2021

UDA Action

PRACTICE PEDIATRIC PATIENTS, PARENTING AND THE PANDEMIC: CARING FOR CHILDREN IN MODERN TIMES When I entered my residency in the early 2000s, there was already talk among pediatric specialists about how prevalent parenting styles were changing from previous generations. More than 15 years later, the consensus is it is still happening. Being a pediatric dentist is challenging. Children are unique. They are not “little adults,” and their teeth are not just smaller versions of permanent teeth. I would say, however, that the greatest challenge in treating children is not the clinical aspect, but the behavioral and psychological aspects. Children are attached to adults, and the accompanying adult also has plenty of emotional needs that the dentist must assess and decide how to address. Parental guilt, defensiveness or denial are all emotions that any dental professional needs to deal with, along with sometimes unrealistic expectations or very prescriptive guidelines from parents. I remember one mother telling me before an operative appointment with an anxious boy: “Don’t tell him about his cavities, don’t tell him why he’s here today, don’t let him see any dental tools, don’t use nitrous … and don’t let him cry!” In addition to being a pediatric dentist, I am also a parent of three children. If there is one thing that makes a decent human being feel insecure, frustrated and at times helpless, it is being a parent. Parenting is incredibly complex, challenging and emotionally charged. I often find myself getting very frustrated with my children, while being patient with other people’s children in the office is a given. I can confidently say that many of us who are currently raising children have decided which elements of parenting we would like to replicate from our own upbringing and which we adamantly refuse to use on our own children. Many parents today take guidance from books or other parents and do their best. Parenting is happening in the context of today’s society, not in isolation and not in the society of days past. In addition to the psychological dynamic between parent or caregiver and the child, the changing nature of family structure 20

and family dynamics also impacts parent behavior and child behavior. Dr. Clarice Law and colleague’s article sheds light on understanding the parent-child dynamic to deliver person-centered dental care to children. While the nature of parenting is changing, the understanding of child development continues to deepen. I think you will find the update on childhood brain development, along with emotional and cognitive development, fascinating. In addition, the article reviews generational differences, impact on child development and new approaches to managing child behavior. Just as understanding the parent-child dynamic is vital in the delivery of person-centered dental care to the child, so too is the understanding of Photo: Image licensed by ingram image that family’s environment and beliefs. Because parents are the gatekeepers to their children’s food, activities and hygiene, they also control their health. In their article, Dr. Paul Casamassimo and colleagues give an overview of person-centered care, also known as patientcentered care (PCC), and tailoring prevention and treatment to the child and family. They explain how PCC has been used in pediatric dentistry and how it can expand the general dentist’s awareness of the greater influences of societal and environmental factors of oral health. PCC acknowledges the individual and interacting contributions of the patient, family, community and environment in disease and health maintenance. While being a dentist who provides care for children in the best of times has its share of difficulties, being a dentist who cares for kids in COVID-19 times is even more stressful. Like you, I have had to navigate how to safely deliver care during the pandemic. How do we care for patients in ways that keep everyone safe, without worsening our patients’ dental conditions, and within the confines of what is behaviorally and emotionally acceptable for children and their caregivers? Dr. Ray Stewart and co-authors describe how pediatric dentistry has experienced an increase in telehealth technology to serve children’s dental needs. Because of the pandemic, the UCSF Department of Pediatric November / December 2021

Dentistry and many other dental practices in California now use teledentistry in their care models. Professionals who care for kids must be aware that the underlying circumstances and stressors that manifest as behaviors for both patient and parent often carry over into the interactions parents have with their child’s health care provider. Not surprisingly, the COVID-19 pandemic has further complicated this. I have had families come into the office over the past year and tell me that this was the first outing for their children in months. I know many parents whose children have shown behavioral changes, children who were perfectly well adjusted before who now suffer from anxiety or depression and are in therapy. The pandemic and the resulting isolation have negatively harmed many children in ways that are being noticed now and likely in ways that will leave a lasting impact on this generation. In their article, Dr. Jessica Lee and colleagues describe the effects on child development, psychological consequences of the pandemic and the impact on dentistry for children.

Whether you are currently treating children in the dental office or trying to raise your own while keeping your mental health intact, I hope you will appreciate this issue of the Journal. It highlights how extraordinary childhood is with the complexities of cognitive, emotional and social development, all layered with parental and environmental influences and topped with an unexpected pandemic. I thank the authors who have shared their time and knowledge on these relevant topics. It is truly a privilege to treat children. It’s difficult and at times delicate, but also delightful and so much fun. Children see the world through fresh eyes, speak the truth and find wonder in the everyday. Whether treating them in the dental chair or raising them at home, we should remember that children are indeed a gift. They deserve our attention and kindness and for us to keep trying our very best. Dr Sharine V. Thenard CDA October 2021

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RESEARCH STUDY REVEALS NEW ASPECTS OF BODY’S RESPONSE TO PLAQUE the study’s authors, wrote that understanding the variations in gum inflammation could help better identify people at elevated risk of periodontitis. It is also possible that this variation in the inflammatory response among the human population may be related to susceptibility to other chronic bacterial-associated inflammatory conditions such as inflammatory bowel disease. In addition, the researchers found a novel protective response by the body, triggered by plaque accumulation, that can save tissue and bone during inflammation. This mechanism, which was apparent among all three phenotypes, utilizes white blood cells known as neutrophils. In the mouth, they act something like cops on the beat, patrolling and regulating the bacterial population to maintain a stable condition known as healthy homeostasis. Photo: Image licensed by ingram image

A team led by University of Washington researchers has, for the first time, identified and classified how different people respond to the accumulation of dental plaque. The study, recently published in the journal Proceedings of the National Academy of Sciences (PNAS), sheds important new light on why some people may be more prone to serious conditions like gingivitis that lead to tooth loss and other problems. The researchers also found a previously unidentified range of inflammatory responses to bacterial accumulation in the mouth. Bacteria buildup on tooth surfaces generates inflammation, a tool the body uses to tamp down the buildup. Previously, there were two known major oral inflammation phenotypes: a high or strong clinical response and a low clinical response. The team identified a third phenotype, which they called “slow:” a delayed strong inflammatory response in the wake of the bacterial buildup. The study revealed for the first time that subjects with low clinical response also demonstrated a low inflammatory response for a wide variety of inflammation signals. Richard Darveau, MS, PhD, of the UW School of Dentistry, one of

In this instance, plaque is not a villain. To the contrary, the researchers said that the proper amount and makeup of plaque supports normal tissue function. Studies in mice have also shown that plaque also provides a pathway for neutrophils to migrate from the bloodstream through the gum tissue and into crevices between the teeth and gums. When healthy homeostasis exists and everything is working right, the neutrophils promote colonization resistance, a lowlevel protective inflammatory response that helps the mouth fend off an excess of unhealthy bacteria and resist infection. At the same time, the neutrophils help ensure the proper microbial composition for normal periodontal bone and tissue function. The researchers’ findings underscore why dentists preach the virtues of regular brushing and flossing. Read more of this study in PNAS (2021); doi.org/10.1073/ pnas.2012578118. CDA September 2021

When sending in your UDA/ADA 2022 dues, be sure to send $70 for your spouse’s membership in the Utah Dental Alliance. The state and national Alliances are involved in legislative advocacy, the well/being of the dental family, and dental health education.

November / December 2021

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2022 UDA Spring Seminar Friday, February 11, 2022 Courtyard Marriott St. George, Utah

2022 UDA Convention March 31 – April 1, 2022 Salt Palace Convention Center Salt Lake City, Utah

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