EGP Aug 18

Bythe Book

As DSOs continue to attract attention of industry regulators, staying current and knowledgeable of the rules is an imperative

JULY/AUGUST . 2018

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July/August . 2018

Editor’s Note

A changing narrative............................................................................ 4

ADSO Summit

By the Book

As DSOs continue to attract attention of industry regulators, staying current and knowledgeable of the rules is an imperative.......16

Implantology

The ADSO Summit draws C-level executives and team members from DSOs as well as Industry Partner representatives from more than 150 companies. These Industry Partners specialize in providing the products and services required to help DSOs grow strategically.......... 6

Advances in technology and digital workflow have led to easier implant procedures – both for doctors and patients................24

DSO Crystal Ball................................................................... 8

Experts weigh in: Which bur is right for your dental practice?.........32

How to Ignite Emotional Engagement................11 A Clean Finish

A high quality prophy paste leaves patients with a clean, polished feeling...............................................12

Efficiency In Group Practice is published six times a year by Share Moving Media • 1735 N. Brown Rd. Ste. 140 Lawrenceville, GA 30043-8153 Phone: 770-263-5257 • Fax: 770-236-8023 www.dentalgrouppractice.com

EDITORIAL BOARD

Jack Allen, national purchasing director, Great Expressions Dental Centers.

DeAnn McClain, vice president of operations, Heartland Dental.

Lorie Streeter, FAADOM, CTC, chief operating officer, American Association of Dental Office Managers.

Burs

Reprocessing Dental Handpieces

Compliance with CDC guidelines for reprocessing is vital to the safety of the dental staff and patients...........................37

Health News & Notes...................................................42 Industry News......................................................................44

EDITOR Laura Thill • lthill@sharemovingmedia.com

ADVERTISING SALES Diana Craig dcraig@sharemovingmedia.com

MANAGING EDITOR Graham Garrison • ggarrison@sharemovingmedia.com ASSOCIATE EDITOR Alan Cherry • acherry@sharemovingmedia.com

ADVERTISING SALES Jamie Falasz, RDH jfalasz@sharemovingmedia.com

CIRCULATION Laura Gantert • lgantert@sharemovingmedia.com ART DIRECTOR Brent Cashman • bcashman@sharemovingmedia.com

Efficiency In Group Practice is published six times a year by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2018 by Share Moving Media All rights reserved. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address.

POSTMASTER: Send address changes to Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publishers. Publishers cannot accept responsibility for the correctness of an opinion expressed by contributing authors.

ISSUE 4 • 2018 : DentalGroupPractice.com

3

Editor’s Note

A changing narrative DSOs may be a relatively new concept, but one that continues to grow in popularity among dental professionals looking to reduce the administrative and financial demands associated with running a multi-site practice. So, it’s easy to forget that they still make up only a small percentage of dental practices in the United States, and sometimes fall victim to misinformation.

DSO leaders have worked hard to educate the public – from dentists, patients and policymakers to industry stakeholders – about their benefits. And, indeed, the narrative is steadily changing.

In this issue, industry experts Mark Hahn, vice president and general counsel, Mortenson Dental Partners, and Lisa Steelman, vice president of government affairs, the Association of Dental Support Organizations (ADSO) share their expertise regarding the impact of regulatory issues on DSOs. “Although certain states have taken regulatory measures, most of those measures have been aimed at clarifying existing laws rather than increasing scrutiny,” says Hahn. “However, any additional scrutiny stems from the fact that DSOs are a new way to think about dentistry, and anything new often receives heightened scrutiny.”

At the end of the day, the more DSOs can do to ensure their dental members stay current with regulations, the better dental professionals can attend to their clinical responsibilities. “As we all know, the thousands of dentists who choose to practice in a DSO model maintain the same requirements and professional standards as dentists who perform administrative and business tasks themselves or with the assistance of multiple service vendors and consultants,” Steelman points out.

“DSOs help enable dentists to be more attentive to patient care and allow knowledgeable business professionals to assist with the non-clinical administration of the practice.”

Hahn concurs: “The clinician’s responsibility is to provide outstanding patient care, while we pick up all of the administrative details,” he says. “That way, our affiliated clinicians can focus on what they do best: Practice dentistry.”

We invite readers to explore this and other topics featured in this issue, as we strive to support you in doing just that: Provide the best possible care to patients, efficiently and effectively.

Laura Thill

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Efficiency In Group Practice : ISSUE 4 • 2018

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ADSO Summit

The ADSO Summit draws C-level executives and team members from DSOs as well as Industry Partner representatives from more than 150 companies. These Industry Partners specialize in providing the products and services required to help DSOs grow strategically.

Editor’s note: When dentists receive good administrative support services, they can focus on patients, expand access to quality dental care and improve the oral health of their communities. In this issue, the Association of Dental Support Organizations (ADSO) reports on this spring’s 2018 Annual Summit.

The ADSO hosted their largest Annual Summit to date with nearly 1,100 attendees at the JW Marriott in Austin, Texas, which was held from April 18-20. The Summit featured sessions designed for every member of the team, with breakouts on topics such as leadership, marketing and public relations, human resources and recruitment, advocacy, and growth and development. DSOs and Group Practices of all sizes had an opportunity to benefit from the general sessions, breakout sessions, round table discussions, table-talk visits with industry partners, and networking receptions.

The conference also featured premier industry leaders and renowned speakers, including keynotes Martin Lindstrom, sponsored by Align Technology, and Josh Linkner, sponsored by Patterson Dental.

The ADSO Annual Summit is an unparalleled opportunity to learn and interact with all facets of the DSO industry during educational sessions and networking receptions. The event was host to dozens of breakout sessions where ADSO members and industry experts presented and offered an opportunity for discussion.

Receptions this year were held at Speakeasy and Stubbs BBQ, featuring live music and local BBQ.

Partnering for Growth conference ADSO’s Partnering for Growth conference is being held at the Grand Hyatt in Denver, Colorado. The conference, taking place from July 12- 13, provides educational content and networking opportunities geared specifically towards small and emerging groups looking to learn and share best practices to grow in the DSO industry.

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Efficiency In Group Practice : ISSUE 4 • 2018

2018 ADSO Summit Program Leading Change: Supporting and Developing Newly Affiliated Practices • S teve Bilt, Smile Brands, Inc., CEO, Smiles for Everyone Foundation, Chairman • K enneth Cooper, North American Dental Group (NADG), CEO & Founding Partner Future DSO Trends: Strategies to Address a Rapidly Changing Industry • Dr. Alan Acierno, DecisionOne Dental, CEO/Owner • Michael Bileca, Dental Care Alliance, President of Florida Operations & Main Street Dental • Scotte Hudsmith, Smile Doctors, CEO • Alistair Madle, D4C Dental Brands, Inc., CEO Connecting With the Broader Dental Community: A Panel Discussion Among Industry Leaders • Ann Battrell, American Dental Hygienists’ Association (ADHA), CEO • Dr. Martin Eichner, American Association of Oral and Maxillofacial Surgeons (AAOMS) • Dr. Richard Kao, American Academy of Periodontology (AAP), President-Elect • Dr. Dave Preble, American Dental Association, Senior Vice President of the ADA Practice Institute • Stephen E. Thorne, IV, Pacific Dental Services, Founder, President, and CEO

The Role of Dental Schools and Dental Student Practice Pathways • Dr. Leo E. Rouse D.D.S., FACD, American Dental Education Association (ADEA), Senior Scholar in Residence DSOs Worldwide: Challenges and Opportunities • Michelle Aquilina, Primary Health Care, Chief of Dentistry Legal Hot Issues for DSOs • Dennis LaGanza, ADSO, Sr. Vice President of Government Affairs • Donald Moody, Waller Law, Partner • Kelly Skeat, Benesch Attorneys at Law, Partner • David Slezak, Affordable Care, Vice President – Chief Legal Officer and Corporate Secretary Government Relations: Protecting and Enhancing the DSO Landscape • TJ Bolger, Centerpoint360, LLC, Senior Vice President • Tamra Kempf, Heartland Dental, Senior Corporate Counsel • Dennis LaGanza, ADSO, Sr. Vice President of Government Affairs • Lisa Steelman, ADSO, Vice President of Government Affairs

ISSUE 4 • 2018 : DentalGroupPractice.com

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Enhanced Practice

DSO Crystal Ball

By Heidi Arndt Heidi Arndt, RDH, BSDH has worked in the dental field for 18+ years. Her experience ranges from working as a treatment coordinator, dental assistant, and practice manager before graduating from the University of Minnesota with a bachelor’s degree in Dental Hygiene. In 2011, Heidi founded Enhanced Hygiene.

She is also the founder of Enhanced Practices.

8

The crystal ball for a successful group of dental practices may be an illusion, yet we seek the insight this legendary ball potentially has to offer. Removing the smoke screen and obtaining the clarity of this crystal ball requires the right focus by those operating the dental practices. This focus requires enhancing your dental operations systems – and this can be a daunting task. It is no secret that running your practice or a group of practices does not typically come with an instruction book, and not to mention, this evolvement must happen with current operations in progress.

One of the key items to have in place are operators with an open mind. Those who have the instinct to recognize that something needs to be modified for growth and then guiding everyone to see the bigger picture. Implementation is always more difficult than conceptualizing, as implementation requires understanding from those completing the processes. The evolvement of your practice or group is consistent whether those running it have the ability to see it or not. What is currently working may not always be what works and what is not working may work in the future. You may need to tweak it, or even create a whole new system. How is this evaluated?

Efficiency In Group Practice : ISSUE 4 • 2018

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Enhanced Practice

There are two very simple focuses that can provide great insight into your practices. They include your consumers and your boots on the ground team members. You are thinking, this is so obvious, yet many practices and groups fail to seek insight from both parties consistently.

How often have you asked your team members what they believe could enhance the practice and grow it to the next level?

How often have you asked your patients what drives their decision to complete their treatment with your practice?

Dentistry is a service business, and is run by people for people.

Investing in your team member’s needs, wants, and desires will provide great insight and clear up that crystal ball on next steps. As humans we all crave to be understood and appreciated. Your team members can provide you with understanding on operational flow, scheduling concerns, provider roadblocks, and believe it or not – critical items around team members effectiveness in their roles. In addition, seeking outside understanding from your peers and advisors within the industry to verify you are on the right track in your thinking can challenge your operational roadmap and guide you toward something that will yield even greater returns.

These results will come using their insight and assistance in enhancing current operational systems and best practices. Now, because you have involved your ‘boots on the ground’ team members, as they had a hand in writing this operational playbook with you - the buy-in for implementation will be easier and beneficial for all positions.

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Efficiency In Group Practice : ISSUE 4 • 2018

As humans we all crave to be understood and appreciated. Your team members can provide you with understanding on operational flow, scheduling concerns, provider roadblocks, and believe it or not – critical items around team members effectiveness in their roles.

As an emerging practice or group of dental practices, your operational playbook can evolve with the right people working alongside you toward the goals of your businesses. Enhanced Practices brings to life concepts that can be easily implemented into your daily operations and brings industry leaders with strong backgrounds in growing emerging groups to assist your efforts in growing into a flourishing into a Dental Service Organization. The goal of Enhanced Practices in your emerging group is to guide and nudge your thinking and processes into even greater returns and allow you to provide duplicatable operations in the markets you choose to provide services.

Leadership

How to Ignite Emotional Engagement

By Lisa Earle McLeod

Once you get past food and shelter, human beings have two fundamental needs: connection and meaning.

We all want to be part of something bigger than ourselves, and we want to know our work counts for something. These two needs transcend cultures, age, race and sex. If you want people to care, about your company or your cause, you need to find a way to help them fulfill these two fundamental needs. Too often, leaders proclaim goals without providing a framework for emotional engagement.

Here’s how to use connection and meaning to improve engagement:

1. Start with connection Connection is about our need to be aligned with others. Humans are hardwired with an innate need to belong. We crave connection. Our survival depends on it. Isolation is devastating to our brain. It makes us feel like an outsider, it’s threatening to our primal sense of belonging.

When an organizational culture feels like it is every man for himself, people go into survival mode. They focus on self-preservation instead of collective success. It’s critical for leaders to form a collective goal that includes stories about the team coming together.

2. The second big human need is meaning We want to know our individual contribution counts.

The more meaning people attach to their job, or a task, the more effort they will put into doing it.

Here’s an example of how to put connection and meaning into an IT project.

Imagine speaking to programmers who have to write code for lots of processes. The leader could say, “We need

all this done by next week. Put your heads down and crank it out.” The expectations are clear.

If the leader wants to leverage connection and meaning, they could say: “This project will transform daily business life for our customers,” then pull out a picture of a customer, put her on the wall and say: “This is who we’re doing this for. We’re going to save her an hour each day with these system improvements.”

The message is now framed as a group effort (connection) in the service of helping others (meaning). Which one of these is more appealing to you?

Now take it a step further. Imagine you are a programmer, and after hearing this framing, your boss says something specific to you. “Rachel, all that code you wrote helps this become seamless for the client. I’m so glad you are part of this team, it’s exciting.”

How do you feel about your job now? The words of the leader matter. When you let people know directly and often, exactly how their work is impacting the project, they engage in a more meaningful way.

This goes beyond simply thanking them for their deliverables. Instead, be clear about the impact they have on the larger whole.

A word of caution – trying to rally people around a financial goal doesn’t work, at least not long term. Making more money for stockholders doesn’t provide meaning and connection for team members.

Instead, spell out the impact your initiative will have on real live people. How does it help members, customers, or colleagues? How is this work making a difference?

You belong, and you matter. That’s what we all want to hear. When you infuse your projects with meaningful language, people get engaged, and stay engaged.

ISSUE 4 • 2018 : DentalGroupPractice.com 11

Hygiene

A Clean Finish

A high quality prophy paste leaves patients with a clean, polished feeling.

Patients desire the fresh, clean feel of polished teeth. Indeed, a bitter aftertaste may be all it takes to deter them from returning for their next cleaning!

With the right prophy paste, dental professionals can deliver the experience and results their patients expect.

Research supports that keeping teeth free of plaque and calculus is one of the best ways to prevent periodontal disease. A regular professional prophylaxis – or cleaning – using a polishing paste containing an abrasive, such as flour or pumice, to remove dental biofilm and extrinsic stains from the coronal surfaces is an important component of a healthy oral hygiene regimen.

But, not all prophy pastes are the same, according to experts. The handling characteristics, consistency and flavor quality of the paste can influence both professional and patient acceptance. Hygienists seek a low-splatter, flash-rinsing paste that leaves a clean surface, while patients look for a fresh, clean, smooth mouth feel, a pleasant taste experience and shiny, stain-free teeth. While most products make these claims, not all deliver, often resulting in a less-than-positive experience for both the clinician and patient.

Less mess, better feel, greater variety Prophy pastes today are designed to enhance the dental experience – both

for hygienists and their patients. Manufacturers, for instance, have added a variety of new flavors in addition to traditional mint and bubblegum. Younger patients in particular can enjoy the wide selection, leaving them with a positive feeling about their dental visits for many years to come.

Manufacturers have also worked to deliver prophy pastes less prone to splatter and grit. In the past, excessive splatter has made for a messier prophylaxis, as well as increased the risk of cross contamination and resulted in longer cleaning and preparation time between patients. And, patients have been known to complain of excessive grittiness, which can be deflating for hygienists striving to provide the best possible experience. Indeed, an easy chair experience and a smiling, satisfied patient can be the greatest validation of a job well done.

In recent years, many manufacturers have also placed additives, such as xylitol and calcium phosphate, in their paste to redeposit the building blocks of the tooth enamel. While many experts agree these are desirable ingredients, clinical studies have yet to support their therapeutic benefit.

Experts recommend that dental professionals sample products prior to purchasing them. Experiencing the paste’s performance in their hands and taking time to assess their patients’ reaction to the taste and feel of the paste can be key to providing predictable and desirable clinical outcomes.

A good investment A box of prophy paste can range from $15 to $65 for a box of 200 cups – the equivalent of paying just 7 to 37 cents for a 2-gram cup. But, saving a few pennies up front may not benefit the dental practice in the long run. While all prophy pastes contain the same active ingredients, the packaging, functionality, handling and flavor quality of lower grade products are often less than satisfactory for both professionals and their patients. One of the last things patients experience before leaving their dental visit – and scheduling their next appointment – is the taste and clean mouth feel of the prophy paste. A pleasant taste and a good feeling are much more likely to bring them back for a return visit.

Editor’s note: Efficiency in Group Practice would like to thank Preventive Technologies, Inc. for its assistance with this article.

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Efficiency In Group Practice : ISSUE 4 • 2018

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Looking Sharp A key to productivity, effective treatment and patient comfort in the hygiene department

The hygiene appointment is the most frequent interaction that dental practices have with their patients. All dental practices, particularly group practices, depend on the hygiene department to provide patients with a good experience and comfortable, effective treatment that will keep them coming back. In order to provide high quality treatment, hygienists must have the tools they need, which includes sharp instruments. Most practices recognize that it is important and cost effective to purchase scalers and curettes from a quality manufacturer, because they will stay sharp, perform better and last longer than off brand and low-end instruments.

All scalers and curettes, of any manufacture and any material, get dull with use and need to be sharpened.

Scalers and curettes that are coated with titanium nitride (thin, gold-colored material) cannot be sharpened and must be discarded and replaced when they become dull. Some scalers and curettes are made from more advanced formulations of stainless steel, such as Hu-Friedy EverEdgeÂŽ and Nordent XDURAÂŽ, and stay sharp longer than traditional stainless steels. However, these products will still dull with use and need to be sharpened. Therefore, keeping the instruments sharp becomes one of the greatest challenges for hygienists in every practice.

Many clinicians are not comfortable with their sharpening technique and put off sharpening because they are concerned they will sharpen the instruments incorrectly.

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Efficiency In Group Practice : ISSUE 4 • 2018

A time savings All hygienists know the value of working with sharp scalers and curettes. Sharp instruments provide the patient with a much more comfortable appointment, greatly reduce strain and fatigue for the hygienist, make procedures more efficient and add to productivity.

Most importantly, hygienists require sharp instruments to remove calculus cleanly and reduce burnished calculus, particularly subgingivally.

Maintaining a regular sharpening schedule is challenging for many offices. Many clinicians are not comfortable with their sharpening technique and put off sharpening because they are concerned they will sharpen the instruments incorrectly.

Sometimes multiple hygienists use and maintain the same instruments, each with a different sharpening technique. Sometimes there is disagreement within the office about how often each instrument should be sharpened.

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Over the past five years, Nordent has developed a system and materials to make the process fast and easy. They even provide a 24-hour in-house turnaround.

For most offices, the biggest challenge is TIME. As hygienists are required to provide a broader spectrum of treatment options and offices have become more focused on productivity, the demands on hygienists’ time have increased and maintaining regularly scheduled instrument sharpening has become challenging. When asked, many hygienists will say that they sharpen when they can or when they have a cancellation. However, many dentists and office managers require hygienists to make patient recalls or manage other activities during cancellations. Often, the result is that hygienists begrudgingly get used to working with dull instruments, and patient care and productivity suffers.

Nordent has developed a solution that fits today’s real world of dentistry. All Nordent XDURA and Relyant® scalers and curettes come with free, unlimited, professional sharpening for life. That means that at

any time, an office can send their XDURA or Relyant scalers to Nordent and they will be professionally sharpened, free of charge. Nordent also offers professional sharpening for all brands of instruments, in order to provide offices with a complete, hands-off solution.

In addition, when XDURA or Relyant scalers become too thin to use, they can be traded in for a new instrument at a 40 percent discount; these trade-in instruments also come with free sharpening. Over the past five years, Nordent has developed a system and materials to make the process fast and easy. They even provide a 24-hour in-house turnaround. Many offices have found that with the XDURA or Relyant system, they can ensure they are always using sharp instruments, they save time and frustration in the office, and they are able to devote more time to focusing on patient care.

ISSUE 4 • 2018 : DentalGroupPractice.com 15

Bythe Book As DSOs continue to attract attention of industry regulators, staying current and knowledgeable of the rules is an imperative

16

Efficiency In Group Practice : ISSUE 4 • 2018

Dental service organizations are increasingly popular among dental professionals looking to reduce the demands and costs associated with running a practice. Nevertheless, they are a relatively new phenomenon and, as such, continue to receive close attention from regulators.

Because of that, DSO leaders must continue to educate dentists and patients, policymakers and industry stakeholders about their benefits. At the same time, lawmakers must work to clarify the role of DSOs within existing regulations.

Efficiency in Group Practice spoke with two industry experts who address the impact of regulations on DSOs, as well as the impact of DSOs on the community.

North Carolina, Wisconsin, Washington state, Arkansas and Texas, to name a few.

Efficiency in Group Practice: Why are DSOs under increasingly more scrutiny?

Mark Hahn, vice president and general counsel, Mortenson Dental Partners: Even though DSOs may have increased in popularity, clinicians affiliated with DSOs still make up only a very small percentage of dental practices in the United States. Although certain states have taken regulatory measures, most of those measures have been aimed at clarifying existing laws rather than increasing scrutiny. However, any additional scrutiny stems from the fact that DSOs are a new way to think about dentistry, and anything new often receives heightened scrutiny.

Efficiency in Group Practice: Does there continue to be a misconception that clinical decisions in DSOs Mark Hahn come from management, rather than the dentists themselves? Is this misconception driving increased state regulations?

Hahn: I think some people have these misconceptions, but I believe they come from a lack of understanding about the Lisa Steelman clinician-DSO relationship and what DSOs actually do. I don’t think these misconceptions are driving regulations, because lawmakers generally understand the concept and they draft regulations to complement or clarify – rather than limit – the ability of DSOs to affiliate with clinicians. As DSOs are a relatively new concept, I believe the misconceptions come from a fear of the unknown, and any regulations are intended to address situations that were not in existence prior to the increase of DSOs.

Lisa Steelman, vice president of government affairs, the Association of Dental Support Organizations (ADSO): DSOs are not necessarily under increasingly more scrutiny than in years past. Granted, there is a great deal of misinformation out there, although that also appears to be changing. As more legislators, dental boards and dental societies learn the facts behind DSOs, many of them are coming to the conclusion that DSOs provide a service to the dentists that contract with them that, quite frankly, is needed.

Representatives of the public and of organized dentistry are also seeing the good that DSOs provide to dentists, which helps enable those dentists to make quality dental care available to many persons in their states and local neighborhoods who otherwise would not have that access. Increasingly, state legislators are clarifying their laws to ensure that dentists retain the right to hire DSOs and, by extension, help increase access to dental care.

Good reference points are recent changes to laws in

Steelman: Unfortunately, some misinformation (much of it older) still exists. The good news, however, is that the narrative is changing. As more and more thoughtleaders learn about the benefits that DSOs provide to the dentists, their conviction of maintaining a dentist’s right to choose how he/she practices increases as well. As we all know, the thousands of dentists who choose to practice in a DSO model maintain the same requirements and professional standards as dentists who perform ISSUE 4 • 2018 : DentalGroupPractice.com 17

Regulations

administrative and business tasks themselves or with the assistance of multiple service vendors and consultants. DSOs help enable dentists to be more attentive to patient care and allow knowledgeable business professionals to assist with the non-clinical administration of the practice.

to non-DSO-affiliated dentists. This is because DSOs can take advantage of economies of scale, similar to what physicians have been doing through MSOs for decades.

The 2012 study states, “[DSOs’] use of scale at the corporate level on aspects of the day-to-day business-like scheduling, purchasing, billing and regulatory compliance enable practices managed by DSOs to operate with Efficiency in Group Practice: Because DSO clinimuch lower costs than traditional dental practices. In cians have lower overhead, is it easier for them to turn, that lower operating cost has enabled some DSOs provide care to underserved communities? If so, to service Medicaid patients.” There is a general crisis in would the imposition of regulatory restrictions access to healthcare in the United States, including dencurtail these services? tistry. DSOs play a vital role in supporting dentists with Hahn: I would say the increase the non-clinical administrative and in clinicians affiliated with DSOs business functions of a practice, increase the access of dental care which in turn has allowed clinicians to the general public, as well as to to serve more patients and expand people from all walks of life. I think access to oral healthcare. the restriction of DSOs restricts the As we all know, DSOs proavailability of clinicians and, in turn, vide non-clinical support services. reduces the availability of dental care Attempts to regulate these non-clinto everyone. ical services as part of the regulations on the practice of dentistry do Steelman: While it is true that the not make sense, and do not extend cost savings DSOs provide enable protections to patients that do not dentists to lower their fees, that already exist. The only effect of regis only a part of the story of how ulating DSOs is to increase the costs DSO-supported dentists expand to the dentists that hire them, or to access to quality dental care to decrease the services that DSOs can underserved communities. In addiprovide to dentists; both have a dettion to lower fees, DSOs provide rimental effect on how a dentist can the non-clinical support services choose to operate his/her practice, – Mark Hahn, vice president necessary to a dentist to expand and in the ability of these dentists to and general counsel, access to care in other ways, such as help increase access to quality dental Mortenson Dental Partners with evening and weekend hours, care to underserved populations in and marketing efforts to make that the affected states. information known to underserved communities. Many of the dental underserved’s ability to find affordable care Efficiency in Group Practice: How do state regulaincludes the indirect costs of taking unpaid time off from tions protect DSOs and their clinicians and patients? work, or in caring for children or other family members, Hahn: I believe the regulations protect everyone involved which DSO-supported dentists help remedy by offering in the patient encounter, because these regulations address a non-traditional evening and weekend care hours. space that has not been previously addressed. By addressing A paper published in 2012 by Laffer and Associthese issues, everyone can gain a better understanding of ates looked at 100 percent of all Texas Medicaid dental how DSOs should support its affiliated practices. patients in fiscal year 2011 and found that DSO-affiliated dentists are providing dental care to some of the poorest, Steelman: The legislative landscape varies by state. Some most underserved populations, at lower costs compared states have taken active measures to ensure their laws are

“The main issue is to gain an understanding of the regulations that [already exist] and to help create guardrails to stay well within those regulations.

As an organization, we are constantly monitoring law changes that impact our affiliated practices.”

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Efficiency In Group Practice : ISSUE 4 • 2018

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Regulations

with the regulations. Fortunately, our challenges from a compliance standpoint have been minimal because our culture has always been focused on our affiliated clinicians. At the end of the day, the very fabric of our organization is woven around the fact that we only exist to support our affiliated clinicians and that the clinician’s responsibility is to provide outstanding patient care, while we pick up all of the administrative [details]. That way, our affiliated clinicians can focus on what they do best: Practice dentistry.

Steelman: ADSO believes that the biggest obstacle it faces is correcting the misinformation about DSOs that is out there. That misinformation and resulting lack of understanding is driving some people to seek solutions in search of a problem that really doesn’t exist. These efforts can take many forms, but the key is that all of them result in attempts to restrict how dentists can choose to – Lisa Steelman, vice president of government affairs, ADSO handle the non-clinical side of their practice, with the resulting decrease not misinterpreted to take away a dentist’s right to choose in access to quality, affordable dental care to members of how to practice. State legislatures that have recently taken their respective states and communities. As to format, we affirmative actions to protect a dentist’s right to choose have seen these issues sometimes raised as proposed legishow to operate his/her dental practice include Arkansas, lation or proposed dental board rules. Regardless of the Wisconsin, Texas and Washington state. Other states, form, the intended result of the proposals all are the same. such as Ohio, have taken action through their attorney The Federal Trade Commission has been very active in general in support of DSOs. support of expanding access to dental care through the services offered by DSOs, by issuing letters in regards to Efficiency in Group Practice: What are the biggest both proposed legislation (North Carolina and Maryregulatory issues impacting DSOs today, and how land) and rule-making (Texas). ADSO addresses this is your organization addressing these issues? matter by actively monitoring the legislative and regulaHahn: The main issue is to gain an understanding of the tory landscape and by offering to educate key decisionregulations that [already exist] and to help create guardrails and thought-makers involved in each matter. We believe to stay well within those regulations. As an organization, that it is through this education that areas of common we are constantly monitoring law changes that impact ground and understanding can be met, such as already our affiliated practices. The main focus of our organizahas occurred in many state legislatures and with state tion from the DSO regulatory standpoint is to stay current dental boards.

“As more legislators, dental boards and dental societies learn the facts behind DSOs, many of them are coming to the conclusion that DSOs provide a service to the dentists that contract with them that, quite frankly, is needed.”

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Efficiency In Group Practice : ISSUE 4 • 2018

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Regulations

COMPLIANCE Tracking and reporting systems enable DSOs and large dental practices to ensure all locations remain compliant with federal and state regulations.

Faced with the need to comply with federal and state infection control, dental waste and emergency preparedness regulations, DSOs are looking to experts for direction, according to Bryan Foss, product manager, environmental and infection control, HealthFirst. “A DSO is required to manage multiple locations, which can be in multiple states and require regulations specific to each state,” he says.

“This can make it very difficult for the DSO, which must

simple task, dental offices face several variables, such as staff turnover, illness or staff taking off for vacation, which can interfere with testing.” Sometimes, the staff forgets to test, he adds. “These issues are compounded when the DSO must manage biological monitoring compliance across multiple office locations.

“New online interfaces and technologies to support biological monitoring are now available to help dental offices and DSOs manage their infection control compliance needs for a single “ New online interfaces and technologies to practice, or across an entire support biological monitoring are now available organization,” Foss continues. to help dental offices and DSOs manage their “These interfaces do not only infection control compliance needs for a single track and report dental office spore testing results, they also practice, or across an entire organization.” integrate a much-needed – Bryan Foss, product manager, environmental task reminder solution, such and infection control, HealthFirst as HealthFirst’s own OnTraq online compliance manageconsistently manage a high level of compliance ment interface, which is tightly integrated with across its organization.” In his experience, it’s our BIOlogical spore test solutions.” becoming more and more common for DSOs to rely on outside companies for help doing so.

Waste management Dental practices must also comply with national Infection control regulations, such as OSHA sharps handling reguDental practices of all sizes face several challations or the new EPA dental amalgam rule, lenges, Foss says. For one, they must perform says Foss. And, they must adhere to local and biological monitoring – or spore testing – state regulations for the disposal of their dental weekly, per CDC recommendations, he says. waste streams, such as sharps and medical waste, “While biological monitoring is a relatively amalgam waste, pharmaceutical waste and lead

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Efficiency In Group Practice : ISSUE 4 • 2018

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waste. “Dental practices face increasing costs associated with the proper disposal of these waste streams,” he explains. “Traditionally, dental offices have used local waste management services to pick up and dispose of their waste. Often, they’ve had to sign long-term contracts, locking them into high-service costs that increase in time.”

Dental practices – particularly large DSOs – should consider mail-back waste disposal programs, notes Foss. “Mail-back programs enable them to cost-effectively dispose of their dental wastes, while staying compliant with today’s regulations,” he says.

“These programs not only include proper documentation to ensure compliance with waste tracking and reporting, they also offer offices flexibility to dispose of their waste when their containers are full, not when the pickup service is scheduled to come, thereby maximizing cost benefits.

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“Several mail-back services also provide online waste tracking and reporting programs, ensuring dental offices continuous access to their compliance documentation,” says Foss. “In addition, new auto-replenishment programs are benefitting dental offices in certain states that are required to dispose of their medical waste on a scheduled basis. These programs automatically send out new sharps or medical waste disposal kits, reminding the dental office that it is time to send in the used kits for disposal.

“All of HealthFirst’s dental waste mail-back solutions are tied to our OnTraq online compliance management interface, which provides dental waste tracking and reporting,” he continues. “They are available for auto-replenishment to ensure that dental offices never find themselves out of stock of critical items needed for their practice.”

ISSUE 4 • 2018 : DentalGroupPractice.com 23

Implantology

IMPLANTOLOGY 24

Efficiency In Group Practice : ISSUE 4 • 2018

As implant technology becomes increasingly more precise, doctors are encountering fewer complications and patients require fewer re-dos. That means fewer return visits and less chair time – a win-win for both doctor and patient.

“Implants have been greatly improved in the years I’ve been practicing,” says Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner in Louisville, Kentucky. Newer titanium alloys and the way implants are now prepared have made it easier for doctors to perform the procedure, he points out.

“Better implant abutment connections and platform switch

By Laura Thill design have led to a decrease in peri-implantitis.” Perhaps the most significant advance, however, has been the use of CT-guided implants and 3D imaging, enabling implants to be placed more precisely in the patient’s bone, he notes. Whereas two-dimensional imaging often fails to reveal when there is an insufficient amount of bone for the implant, with 3D imaging “I often can drill through the gingiva and place the implant to depth with very limited tissue exposure, which means faster healing and decreased pain,” he says. Indeed, patients are much happier when their implant is done right the first time, he adds.

“Digital workflow has greatly enhanced dental implant therapy,” says Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, Kentucky. “With the use of digital optical scanners, together with cone beam computed tomography, we can quickly treat implant cases, design and produce surgical guides, and create abutments and restorations. The improvement of implant alloys, drill designs and implant surface treatments have greatly enhanced initial implant stability and integration rates, leading to improvements in the size of implants and better predictability in immediate extraction and implant placement scenarios. Smaller-diameter and shorter

Advances in technology and digital workflow have led to easier implant procedures – both for doctors and patients.

ISSUE 4 • 2018 : DentalGroupPractice.com 25

Implantology

implant fixtures have proven to be very effective. These smaller dental implants can be utilized in situations where, in the past, the practitioner would have had to perform extensive bone grafting procedures to allow for traditionally sized dental implants.

“Digital workflow in dental implant treatment allows the practitioner to deliver quicker, more precise implant placement through surgical guides and faster fabrication of the restoration,” Nation continues. “Smaller, narrower dental implants reduce the need for costly bone grafting procedures.” This means fewer appointments and less expense for both doctors and patients, he points out.

Common challenges All that said, even the experts face challenges when it comes to implants. “One of the biggest problems I see in implant dentistry is the lack of proper diagnosis and treatment planning to facilitate the appropriate placement of implants, along with the proper restorative space to fabricate the prescribed prosthesis,” says Nation.

Indeed, a better understanding of restorative designs can decrease the risk of fracture overloading, notes Mortenson. “A Morse tapered connection provides a more stable connection than a butt joint connection and reduces the risk of infection. Additionally, placing an implant at the

right height and position helps reduce the risk of complications, he points out. Damage to surrounding nerves, blood vessels and teeth can be caused by improper planning, he explains, adding that a more accurate assessment can be made using CT scanning.

Many patients lack sufficient bone structure, making the implant procedure that much more challenging, according to Mortenson. Such cases require significant bone grafting. Whereas an implant in ample, healthy bone will be successful 95 percent of the time, an implant into grafted material is associated with a lower success rate, he points out. “I’ve encountered problems when an immediate load implant case has been sent to a dentist who does not understand he or she must place a crown that is not in occlusion.”

In such cases, it’s common for patients to return to his office with a failing implant due to the traumatic occlusion that the implant was not healthy enough to sustain, he says.

Finally, specialists can get frustrated when they place an implant, and a dentist less versed in restorative technique follows up with a restoration, according to Mortenson. “Many postoperative complications associated with restorations are largely due to a poor restorative design and limited knowledge of restorative issues – particularly occlusion, which is quite different with regard to an implant than a standard tooth,” he explains.

“Digital workflow has greatly enhanced dental implant therapy. With the use of digital optical scanners, together with cone beam computed tomography, we can quickly treat implant cases, design and produce surgical guides, and create abutments and restorations.”

– Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner

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The good news is that advances in implant technology have been associated with a lower risk of complications. “Titanium alloys have led to a decrease in fractures traditionally associated with dental implants,” Nation says. “Also, peri-implantitis, which traditionally has occurred when cement is placed too close to the implant fixture abutment connection, can be avoided by using custom or patient-specific abutments to place cement margins closer to tissue margins and clean away the cement appropriately.”

Successful implants largely depend on how well implant surgeons understand the characteristics of the implant system used at their practice, says Nation. “They must understand and teach whomever they work with the importance of cleaning and servicing the implant restoration and oral environment,” he explains.

“Most importantly, implant surgeons

“The best treatment involves adequate consultation and communication. Care should be initiated with a letter stating the desired treatment, followed by face-to-face or telephone conversations to ensure everyone is on the same page. Financial planning should be reviewed with the patient. This is something the patient must understand prior to beginning care to prevent surprises later on.”

– Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner

must carefully consider the esthetic desires of their patients. They must have an esthetic and oral diagnosis, and they must realize any existing challenges of the patient’s anatomy.

They must understand the restorative needs to enable fabrication of an esthetic, functional and serviceable prosthesis.” This applies to all restorations, from single implant to fullarch implant restorations, he adds.

“Most challenges can be remedied through good communication with the dental team,” says Nation.

“A restorative practitioner, a surgical practitioner and laboratory must work out the implant case together.

When more eyes are on a case at the beginning, fewer problems will be encountered in the end.”

Communication and support One of the best resources for dentists is the support of other dentists. “No ISSUE 4 • 2018 : DentalGroupPractice.com 27

Implantology

single practitioner, no matter what his or her field of dentistry, can meet the needs of every single patient,” says Nation. In a large dental practice, dentists can share their knowledge and insights with one another, he points out.

At a large dental practice, there are always other practitioners to rely on, consult with and ultimately provide patients with a comprehensive treatment plan.

“The best treatment involves adequate consultation and communication,” says Mortenson. “Care should be initiated with a letter stating the desired treatment, followed by face-to-face or telephone conversations to ensure everyone is on the same page. Financial planning should be reviewed with the patient. This is something the patient must understand prior to beginning care to prevent surprises later on. Oral Facial Surgery Group is one of the few organizations I’m aware of that has oral surgeons, prosthodontists and general dentists who can easily interact, see one another’s charts and discuss treatment.”

“Because dental implant treatment is a restorative procedure with a surgical component, there has to be a vision for the final restoration established prior to

treatment,” says Nation. “Whoever is responsible for restoring the case must properly diagnose and prescribe the appropriate restoration for the patient. This individual is wise to consult with the laboratory technician early in the process to help with the details of the intended procedures and ensure the proper materials and appointment times are used. Once this is established, the surgeon must have an understanding of the intended prosthesis and be able to plan for appropriate implant placement to accommodate it. This may require bone reduction, bone grafting, soft tissue grafting or a combination of each.

The laboratory can help with design to ensure cleansability as long as the appropriate type of restoration is selected, Nation continues. “The restorative doctor and surgeon must educate the patient on homecare, maintenance and possible re-care. If there is communication and a common understanding across the dental team of what is needed to treat the dental implant patient, there will be a high probability that the case will be successful.”

When can general dentists step in?

Advances in technology have made it easier for general dentists to complete more implant procedures. While this can be a convenience for patients, general practitioners must not take on more than they are comfortable with, warn experts. “As long as dentists have the appropriate training and feel comfortable, they can do any and all surgical components of implant dentistry,” says Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner in Louisville, Kentucky.

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“With that, I would recommend that average general dentists limit themselves to very straightforward cases, with adequate bone and no need for significant bone grafting.” With

reasonable training, however, in time they can add procedures, he says.

It’s important that general dentists fully assess the patient’s dental and medical history,

“ It’s important that general dentists fully assess the patient’s dental and medical history, determine the complexity of the case and understand patient expectations, before agreeing to perform the implant.

They must be confident that potential complications are well within their abilities.”

– Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, Kentucky

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determine the complexity of the case and understand patient expectations, before agreeing to perform the implant, says Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, Kentucky. “They must be confident that potential complications are well within their abilities,” he says. Surgical placement is only one part of a dental implant procedure, and single-tooth implant restorations typically are much more straight-forward than full-arch dental implant restorations.”

That said, dentists must have the knowledge to understand the dental restoration that is

appropriate for their patients, be able to select the appropriate restorative materials, and understand how these materials will perform in the patient’s oral environment, he adds.

“Specialists are necessary when the complexity of the case – medically or dentally – is beyond the general dentist’s experience, training and/or comfort level,” Nation continues. “Many times, implant cases require considerable grafting of hard and soft tissues to allow for proper implant placement and restoration. Full arch dental implant restorations require comprehensive diagnostics and treatment planning.

These procedures are time

consuming and quite technical, and many general dental practices do not have the practice flow or fee schedule to accommodate them.

“General dental practitioners must assess the impact of more complex, time intensive procedures, such as complex implant diagnostics, surgery, grafting or multistep implant restorative procedures, and consider how they might negatively impact their revenues, especially if there are complications,” Nation says. “Specialty practices are designed for specific procedures, and the office flow is not affected as it would be in a successful and busy general dental practice.”

ISSUE 4 • 2018 : DentalGroupPractice.com 29

Implantology

Endosteal vs. subperiosteal implants Both endosteal and subperiosteal implants have a history of success in dental implant, according to Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, KY. Subperiosteal implants are comprised of a large metal framework, which is custom fabricated to intimately fit a patient’s jawbone. They are placed on the alveolar bone, below the gum tissue, and usually have trans-gingival struts, which pass through the gingiva to connect to the intended prosthesis. Subperiosteal implants are known to achieve some level of integration and have proven to be effective in some cases.

Subperiosteal implants can be utilized in cases of minimal bone, and the bone is inadequate for endosteal implants. If bone height is deficient, a subperiosteal implant can be used since it resides on – not in – the bone. For patients unable to have bone grafts, a subperiosteal implant may be an alternative.

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Efficiency In Group Practice : ISSUE 4 • 2018

Endosteal implants are placed directly in the bone and have a connection, which allows for direct attachment to the implant fixture at bone level or tissue level, depending on the implant design. Endosteal implants are prefabricated and the patient’s bone is drilled to accommodate the implant.

When should they be used?

Subperiosteal implants can be utilized in cases of minimal bone, and the bone is inadequate for endosteal implants. If bone height is deficient, a subperios-

teal implant can be used since it resides on – not in – the bone.

For patients unable to have bone grafts, a subperiosteal implant may be an alternative.

Endosteal implants are the most common form of dental implants today and are appropriate to use when the patient’s bone is adequate to house the endosteal implant without impacting non-osseous structures, such as nerves. The patient must have the minimum bone required: Eight or more millimeters in height and at least six millimeters in circumference.

Endosteal implant procedures generally are less complicated than subperiosteal implant procedures, according to Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner in Louisville, Kentucky. “Subperiosteal implants generally develop some degree of peri-implantitis and require routine maintenance to help keep them healthy over time,” he says.

Also, placing – as well as removing – them often involves a more invasive surgery, he notes.

In contrast, there are a variety of restorative procedures that can be completed with endosteal implants, Mortenson says. “The complication rates are much lower using this style of implant and the longevity of the restoration is much higher.”

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Burs

Burs

Experts weigh in: Which bur is right for your dental practice?

From general practitioners to endodontists and prosthodontists, clinicians rely on burs – or rotary instruments – for a range of applications. “Burs have been a staple product for years within the dental industry,” says Michael Vranesevic, MBA, global product manager, Rotary and Private Label Business Unit, Coltene. Over the years the industry has seen technological improvements, such as the creation of one-piece carbide burs, eliminating the brazed joint of two-piece burs, he points out. More recently, new delivery methods have been developed, such as sterile packaged products, he adds.

“The combination of high-quality natural diamond and the diamond attachment process remains key,” says Dr. Jason Goodchild, director of clinical affairs, Premier Dental (who formerly taught at Creighton University and currently practices in Philadelphia part-time). “Manufactured or 32

Efficiency In Group Practice : ISSUE 4 • 2018

synthetic diamond quality has improved slightly, however the attachment process, which primarily is some form of electroplating, has not changed. The alternative to plated diamond is a braze technique, and the original brazed dental bur has undergone continuous quality improvements.”

Bur selection often is determined by the material being worked on, as well as the procedure. Tungsten carbide burs, for instance, are generally used for caries removal, rapid reduction of PFM (porcelain fused metals) materials and contouring/finishing prior to the use of polishers. Diamond burs are useful for such restorations as veneering, crown preparations, bridges and contact point adjustments. Zirconia burs can be used to create an access

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through a zirconia crown. Shape, too, factors into the choice of burs: Typically, round-shaped rotary burs are used to create an access, while safe-end burs are used to flatten and flare the access.

Efficiency in Group Practice asked the experts to weigh in.

Efficiency in Group Practice: What are the pros and cons of different types of burs?

Dr. Jason Goodchild: The two main cutting surfaces of burs are tungsten carbide and diamond. Stainless steel is typically used for the shank of modern burs because tungsten carbide is three times as hard as steel, making it a more useful cutting tool for tooth, bone and dental restorations. Both tungsten carbide and diamond burs come in numerous shapes and sizes. Rotary tooth preparation for crowns and bridges with quality diamond burs is often faster and more precise than preparations using carbides. One paper states “The enormous advantage of using diamond burs for grinding human teeth was found

by Westland in 1980. He discovered that under the same circumstances, the specific grinding energy is three

4/18/18 2:42 PM

times lower with diamond burs than with carbide burs.

Moreover, an increase in loading force did not change the outcome.” (Cohen BD, Bowley JF, Sheridan PJ. An evaluation of operator preference of diamond burs in coronal tooth preparation. Compend Contin Educ Dent 1997;18(2):160-4.

Michael Vranesevic: Carbide, diamond and zirconia burs each offer benefits, depending on the application.

It is important to understand the method by which each type of bur functions in order to achieve the desired outcome (i.e. caries preparation, crown removal, crown preparation, etc.). Carbide burs act in a cutting/chipping manner. Diamond and zirconia burs act in an abrasive wearing/grinding manner. Both of these mechanisms for reducing tooth structure – cutting/chipping and abrasive wearing/grinding – are beneficial when applied appropriately. For instance, metal cutting carbide burs with aggressive profile characteristics work well for rapidly cutting amalgam, metal, enamel and dentin. Both carbide and diamond burs work well on natural tooth structure (e.g., ISSUE 4 • 2018 : DentalGroupPractice.com 33

Burs

enamel and dentin), while zirconia burs are best utilized on a zirconia-based surface (e.g., a zirconia crown).

Efficiency in Group Practice: What applications are different shaped burs used for?

Goodchild: Form follows function in rotary tooth preparation. A football-shaped diamond is ideal for shaping the lingual aspect on anterior teeth, and the occlusal aspect on posterior teeth. It is important to remember that many shapes can be used to achieve the same restorative outcomes. It often comes down to what the clini-

Vranesevic: Burs can be used in various procedures.

Following are some of the more commonly used burs, as well as a few unique burs with potential applications. Of course, depending on the procedure at hand, the manner of application and/or burs used may differ based on the dental professional’s assessment.

Carbides • Round (i.e. 2, 4, 6): Caries preparation, removal of old fillings, working on fillings, and endodontic access creation.

• Pear (i.e. 330): Caries preparation and removal of old materials, such as amalgam.

• Cross cut fissure (i.e. 557): Creating preparation with straight, parallel sides and flat floors, as well as gaining access to carious dentin.

• Round end fissure cross cut metal cutter (i.e. 1558G): Rapid reduction of metal, amalgam, enamel and dentin.

• Endodontic burs (219EZ and 152EZ): Safe-end (non-cut– Dr. Jason Goodchild, director of clinical affairs, Premier Dental ting tip) burs used for flattening and flaring access points during root canal preparation. cian learned to use in school, or what they have become comfortable with in their clinical practice. For crowns Diamonds and bridges, often the type of restorative material helps • Football: Crown preparations and working on the to dictate the marginal finish design, as well as the approlingual and occlusal surfaces of the tooth, as well priate diamond bur tip shape and diameter to achieve that as adjustments. design. In addition, understanding the dimensions of any • Round: Caries preparation, working on fillings diamond bur (tip dimension, major diameter and cutting and endodontic access creation. length) used for crown and bridge preparation enables • Round end taper (851 Safe-End variation): Safethe dentist to gauge the proper occlusal reduction, based end (non-cutting tip) burs used for flattening and on the manufacturer guidelines. There are calibrated flaring access points during root canal preparation. depth guide burs, and some clinicians like the training • Round end taper: Crown preparation, as well as wheels approach they provide. However, they can add an crown cutting. extra step to the procedure and prolong chairtime. The • Occlusal reduction: Reduction of the occlusal primary advantage of calibrated reduction burs – not only surface during restorative procedures. for the occlusal, but for the facial of anterior teeth – is the ability to achieve a consistent balance between creating Efficiency in Group Practice: Do all burs have crossenough reduction for the intended restorative material cuts for greater efficiency? and preserving of natural tooth structure.

Goodchild: Additional cuts across the blades – or crosscuts

“ Form follows function in rotary tooth preparation. A football-shaped diamond is ideal for shaping the lingual aspect on anterior teeth, and the occlusal aspect on posterior teeth. It is important to remember that many shapes can be used to achieve the same restorative outcomes.”

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– can be added to increase cutting efficiency of tungsten carbide burs. These operative burs are either straightbladed or crosscut. Straight-bladed burs cut smoothly, but are slower, especially with harder materials. Crosscut burs can cut faster due to the lack of debris build-up.

In the case of diamond-coated burs, a smooth shape is created and a fine-, medium- or coarse-ground diamond coating is applied over it. (Little D. Handpieces and burs: the cutting edge. Available at: https:// www.dentalacademyofce.com/courses/1592/PDF/ HandpieceandBurs.pdf. Accessed February 12, 2018.)

Vranesevic: Not all carbide burs have crosscuts. The crosscut geometry is a feature of certain bur profiles, which can lend themselves to added cutting efficiency.

That said, greater cutting efficiency is not always the goal.

For example, in the finishing process, where a 30-bladed carbide may be used, the goal is not necessarily bulk reduction of the tooth structure, but refinement of the surface finish prior to polishing.

6/20/18 3:12 PM

Efficiency in Group Practice: Can the bur blade be positioned at different angles?

Goodchild: Yes, they can. This is particularly necessary in the back of the mouth, where access is a challenge in hard-toreach areas and complex preparation geometry is required.

Vranesevic: Whether burs are carbide, diamond or zirconia, they have unique profiles and angulations that aid in performing certain tasks. When utilizing burs during intraoral procedures, minimal space is available and only slight adaptations can be made to the position of the bur. These adaptions are made at the practitioner’s discretion, while working toward the ideal outcome for the given situation.

Efficiency in Group Practice: What is the cost, and how many burs do dentists need on hand?

Goodchild: Diamond burs are divided into lower-cost, single-use burs, which cost $1-2 each, and slightly more expensive, reusable types that cost $5-10 each. The costs of burs is not insignificant to dentists, however; it is ISSUE 4 • 2018 : DentalGroupPractice.com 35

Burs

considered a low overhead cost, which can impact the restorative outcome and patient comfort. (For example, efficient cutting burs work better and are more comfortable for the patient.) Typically, dentists routinely use 2-4 diamonds for a crown preparation, but often keep 10-12 shapes in their armamentarium for different sized teeth

perform most basic procedures, while additional specialty burs are added for more complex procedures.

Vranesevic: Rotary instruments can vary in price depending on the bur type, packaging and offering size.

Generally, the more unique the bur is and/or the more complex the geometry is, the higher the cost. For instance, a metal cutting US# 330 carbide bur typically will cost more than a standard friction grip US# 330 carbide bur. The number of burs dental professionals keep on hand varies based on the practice type and procedures performed. For instance, a handful of burs may be all that is needed to

Vranesevic: The average lifespan of a bur varies, depending on whether it is carbide, diamond or zirconia.

Factors such as the number of uses, time under use and material the bur is used on have the potential to impact lifespan. To ensure burs are still viable for use, practitioners should inspect them for wear routinely and replace them as necessary. Wear may present itself as dulled and/or chipped blades on a carbide bur and lessening of partial coverage on diamond and zirconia burs.

Efficiency in Group Practice: What is the lifetime of a bur?

Goodchild: Bur life is very difficult to quantify given the multiple factors involved, such as handpiece maintenance, the amount of water spray used, the pressure/load applied, the type/girth “ The average lifespan of a bur varies, depending on of the bur (e.g., very thin flame or whether it is carbide, diamond or zirconia. Factors such as large shoulder, or chamfer bur) and the number of uses, time under use and material the bur the material being cut. Brand and is used on have the potential to impact lifespan.” bur quality also play a significant role. Major manufacturers tend to – Michael Vranesevic, MBA, global product manager, Rotary and Private Label Business Unit, Coltene produce longer lasting, better quality burs, but at a potentially higher cost; and specialty procedures. The same is true for tungsten discount brand burs may not last as long, but they may be carbide burs. A typical restorative preparation may require less expensive. Because the bur quality can impact the clinseveral different shapes, and the clinician may carry a ical outcome and patient experience, it is recommended larger variety to account for usual clinical situations. that clinicians get the best tools they can afford.

Points to consider When considering trying a new brand or type of bur, it’s important to consider all aspects of the crown and bridge – particularly tooth preparation, tissue management and conventional or digital impressions. Clinicians should consider the type of crowns they recommend to their patients and what their favorite margin design is for those materials; their techniques for cavity prep and finishing; and the growing need for proper rotary instruments for crown-removal.

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Additional talking points may include: • How can switching to a new bur make your life easier?

• What is your ideal outcome for each procedure you perform?

• What are some of the most common procedures you perform on a daily basis?

• Where do you see an opportunity for improvement when using burs?

• What are some of the more difficult procedures you perform with burs?

What challenges do you face?

• When working with your current rotary instruments, what takes you the most time?

• How many burs do you use when performing an endodontic access?

• How many burs do you use when removing a crown?

Infection Control

Reprocessing Dental Handpieces Compliance with CDC guidelines for reprocessing is vital to the safety of the dental staff and patients.

There seems to be a lot of buzz about dental handpieces these days.

For whatever reason, the question of reprocessing these devices for patient use is once again a popular conversation in dental practices.

Dental handpieces are medical devices accompanied by instructions for use (IFU). As discussed in a previous article, IFU are provided for medical devices and products in accordance with federal Food and Drug Administration (FDA) standards and provide information on cleaning, disinfection and sterilization of patient care items.1 In any dental setting, IFUs must be strictly followed to ensure patient safety, as well as peak performance of the devices. Whether the organization is a DSO, a large group practice or a solo practice, there must be a sufficient number of instruments to serve the patient schedules in order to avoid shortcuts in reprocessing.

Categories of patient care items The Centers for Disease Control and Prevention sorts patient care items into three categories (referred to as the Spaulding classification), based on the potential risk for infection associated with their intended use: critical, semicritical or noncritical.2,3

By Katherine Schrubbe, RDH, BS, M.Ed, PhD Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent compliance consultant with expertise in OSHA, dental infection control, quality assurance and risk management.

She is an invited speaker for continuing education and training programs for local and national dental organizations, schools of dentistry and private dental groups. She has held positions in corporate as well as academic dentistry and continues to contribute to the scientific literature. Dr. Schrubbe can be reached at kathy@ schrubbecompliance.com.

ISSUE 4 • 2018 : DentalGroupPractice.com 37

Infection Control

lnfection-control categories of patient-care instruments Category

Definition

Dental instrument or item

Critical

Penetrates soft tissue, contacts bone, enters into or contacts the blood-stream or other normally sterile tissue.

Surgical instruments, periodontal scalers, scalpel blades, surgical dental burs

Semi-critical Contacts mucous membranes or nonintact skin, will not penetrate soft tissue, contact bone, enter into or contact the bloodstream or other normally sterile tissue.

Dental mouth mirror, amalgam condenser, reusable dental impression trays, dental handpieces*

noncritical

Radiograph head/cone, blood pressure cuff, facebow, pulse oximeter

Contacts intact skin.

* A lthough dental handpieces are considered a semi-critical item, they should always be heat-sterilized between uses and not high-level disinfected (246). See Dental Handpieces and Other Devices Attached to Air or Waterlines for detailed information.

Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings – 2003.

MMWR 2003;52(No. RR-17); 20.

At the ends of the spectrum are next patient may be exposed to There are no shortcuts the critical and noncritical patient potentially infectious materials.”4,5,6 to patient safety around In other words, there are no care items. According to the CDC, handpieces, including shortcuts to patient safety around all critical items should be heat sterlow-speed motors used handpieces, including low-speed ilized between patient use, as they primarily for hygiene motors used primarily for hygiene have the greatest risk of transmitappointments. Eleven states appointments. Eleven states require ting infection. Noncritical items, heat sterilization of dental handwhich pose the least risk of disease require heat sterilization pieces: California, Florida, Indiana, transmission, should be cleaned and of dental handpieces: Kansas, Missouri, New Mexico, disinfected with an EPA-registered California, Florida, Indiana, Ohio, Oregon, South Carolina, hospital disinfectant.2,4 Kansas, Missouri, New In the middle of the spectrum Virginia, and Washington.7 And, Mexico, Ohio, Oregon, are semicritical items. These items the CDC guidelines fully apply in South Carolina, Virginia, and come in contact with mucous – or the remaining 39 states. Additional Washington.7 And, the CDC non-intact – membranes, but they guidance from the CDC states, do not penetrate soft tissue, contact “handpieces and other intraoral guidelines fully apply in the bone, the bloodstream or other nordevices that can be removed from remaining 39 states.

2 mally sterile tissues. the air and waterlines of dental units Dental handpieces are considered semicritical items. should be cleaned and heat-sterilized between patients.

The CDC states, “dental handpieces and associated Follow the manufacturer’s instructions for cleaning, attachments, including low-speed motors and reuslubricating, and sterilizing these devices. These devices able prophylaxis angles, should always be heat sterilized include high-speed, low-speed, electric, endodontic, and between patients and not high-level or surface disinfected. surgical handpieces, as well as all handpiece motors and Although these devices are considered semicritical, studattachments, such as reusable prophylaxis angles, nose ies have shown that their internal surfaces can become cones, and contra-angles.”8 There is continuous debate about CDC guidelines contaminated with patient materials during use. If these and recommendations: Do practices need to follow them, devices are not properly cleaned and heat sterilized, the 38

Efficiency In Group Practice : ISSUE 4 • 2018

Is your steri-center up to SciCan SPEC s? ™

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If instruments do not efficiently flow into and out of it, the rest of the practice suffers. Your steri-center should improve Safety, ensure Predictable results, maximize Efficiency, and maintain Compliance.

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Infection Control

since they are just a guideline? The short answer is, yes. dental health care personnel (DHCP) should clean and All practice settings should follow these guidelines. DSOs heat-sterilize handpieces and other intraoral instruments and large group practices generally have the infrastructhat can be removed from the air and waterlines of dental ture to carry out best practices and, as such, can serve as units. This recommendation is based on studies that have a model of compliance. Unlike OSHA, the CDC is not shown that the internal components of air-driven dental a governmental regulatory body. Nevertheless, it provides handpieces (both low-speed and high-speed devices) can scientific evidence-based best pracbecome contaminated with patient tices for patient safety and reducing material during use, and this material disease transmission, and the Amercan then be expelled into the mouth The marketplace offers ican Dental Association endorses all of other patients during subsequent a variety of cordless, CDC guidelines for infection prevenuses. For handpieces and other intraslow-speed motors with tion in dental healthcare settings.6 oral instruments that can be removed sterilizable outer sheaths from the air and waterlines of dental that run on batteries CDC statement units, CDC continues to recommend On April 11, 2018, the CDC released that DHCP follow CDC guidelines and are fully compliant the following update regarding reproto clean and heat sterilize.” 9 with CDC sterilization The CDC goes on to say, cessing dental handpieces: “CDC guidelines. Dental “some handpieces are independent recognizes that the dental commupractices should evaluate of air and waterlines (e.g., cordless nity requires clear, consistent guidetheir supply of handpieces devices). For these devices, CDC lines on the best way to reprocess and perform a cost recommends that DHCP foldental handpiece devices between analysis to determine the low current FDA regulations, use patient encounters. CDC guideFDA-cleared devices and follow the lines for infection prevention and model type and amount validated manufacturer’s IFU for control state that, between patients, of equipment they need.

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Efficiency In Group Practice : ISSUE 4 • 2018

reprocessing (cleaning, lubricating, and/or sterilizing) these devices.”9 The marketplace offers a variety of cordless, slowspeed motors with sterilizable outer sheaths that run on batteries and are fully compliant with CDC sterilization guidelines. Dental practices should evaluate their supply of handpieces and perform a cost analysis to determine the model type and amount of equipment they need.

It should be noted that in 2015, the FDA released updated guidance for reprocessing medical devices in healthcare settings. This guidance provides manufacturers of reusable medical devices with recommendations for writing and scientifically validating reprocessing instructions. Reusable devices that received FDA clearance before 2015 might not have reprocessing instructions that meet the requirements of the 2015 guidance.9,10 According to FDA, “reprocessing instructions for some older, legally-marketed, reusable devices may not be consistent with state-of-the-art science and therefore may not ensure that device is clean, disinfected, or sterile.” It is incumbent on the device manufacturer to provide sufficient instructions on how to prepare devices for use on the next patient.9,10 Both the CDC and FDA state that if a dental handpiece cannot be heat sterilized and does not have FDA clearance with validated instructions for reprocessing, DHCP should not use that device.2,4,10

The updated guidance from the CDC provides a 3-point summary: 1. Clean and heat sterilize handpieces and other intraoral instruments that can be removed from the air lines and waterlines of dental units.

2. For handpieces that do not attach to air lines and waterlines, use FDA-cleared devices and follow the validated manufacturer’s instructions for reprocessing these devices.

3. If a dental handpiece cannot be heat sterilized and does not have FDA clearance with validated instructions for reprocessing, do not use that device.9 The guidance on reprocessing handpieces for all dental practice settings is clear. In order to be compliant with CDC recommendations, more than one handpiece is needed to ensure enough time for them to be heat sterilized between each patient. Saying it is too expensive to buy more than one handpiece is not an excuse the CDC is likely to entertain. A dental practice is a business, and to run a business there are costs. Purchasing equipment, such as handpieces, should be considered the cost of doing business.11 The size of the dental practice setting and its ability to comply to CDC guidelines for reprocessing and recommendations are vital to patient and staff safety.

References

1. Schrubbe K. Instructions for use. Efficiency in Group Practice. Available at http://www.dentalgrouppractice.com/instructions-for-use.html.

Accessed April 24, 2018.

2. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. MMWR 2003;52(No. RR-17); 20.

3. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 5th ed. St. Louis: Mosby Elsevier; 2013; 122.

4. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.

Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, March 2016.

5. Chin J.R., Miller C.H., Palenik, C.J. (2006). Internal contamination of air-driven low-speed handpieces and attached prophy angles. J Am Dent Assoc. 137(9):1275-80. Available at http://www.ncbi.nlm.nih.gov/pubmed/16946433. Accessed May 10, 2018.

6. American Dental Association. Oral health topics; infection control. Available at https://www.ada.org/en/member-center/oral-health-topics/ infection-control-resources. Accessed May 10, 2018.

7. The Dental Student Network list of state licensing agencies. Available at http://www.studentdoctor.net/dental/state_boards.html. Accessed April 24, 2018.

8. Centers for Disease Control and Prevention. Dental Handpieces and Other Devices Attached to Air and Waterlines. Available at https:// www.cdc.gov/oralhealth/infectioncontrol/questions/dental-handpieces.html. Accessed May 10, 2018.

9. Centers for Disease Control and Prevention. Statement on Reprocessing Dental Handpieces, April 11, 2018. Available at https://www.cdc. gov/oralhealth/infectioncontrol/statement-on-reprocessing-dental-handpieces.htm. Accessed May 10, 2018.

10. US Department of Health and Human Services. Public Health Service Food and Drug Administration. Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff. March 17, 2015. https://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm253010.pdf. Accessed May 10, 2018.

11. Vavrosky K. 5 infection control mistakes you may be making and not even realize. Dental Products Report, July 11, 2016. Available at http://www.dentalproductsreport.com/hygiene/article/5-infection-control-mistakes-you-may-be-making-and-not-even-realize?page=0,1.

Accessed May 10, 2018.

ISSUE 4 • 2018 : DentalGroupPractice.com 41

Health News

Health News & Notes All is not lost Scientists from Columbia University presented new evidence that our brains continue to make hundreds of new neurons a day, even after we reach our 70s, in a process known as neurogenesis, reports The New York Times. That’s the good news.

The not-so-good news? Researchers did uncover some differences in the brains of young people and older people. Specifically, they found that development of new blood vessels in the brain decreases progressively as people get older. They also discovered that a protein associated with helping new neurons to make connections in the brain decreased with age. This might explain why some older people suffer from memory loss or exhibit less emotional resiliency, according to researchers.

The cost of loneliness Loneliness can hurt productivity and profits. The share of American adults who say they’re lonely has doubled since the 1980s to 40 percent, according to a report in the Washington Post. Though the U.S. 42

Efficiency In Group Practice : ISSUE 4 • 2018

doesn’t track the financial effect of disconnected workers, researchers in Britain estimate the penalty to businesses can reach $3.5 billion a year, accounting for higher turnover and heftier healthcare burdens. A recent study in the Harvard Business Review found 61 percent of lawyers surveyed ranked “above average” on a loneliness scale from the University of California at Los Angeles. Other particularly lonely groups were engineers (57 percent), followed by research scientists (55 percent), workers in food preparation and serving (51 percent), and those in education and library services (45 percent).

on them. That’s important, because not only does chronic stress directly harm health – the physical responses to stress include spikes in blood pressure and blood sugar, along with suppression of the immune system – but if you also react strongly to stress, you’re more likely to use unhealthy short-term coping mechanisms such as smoking or numbing your feelings with food or alcohol. The study also found that self-compassionate people are more likely to adopt health-promoting behaviors and maintain them even if they don’t appear to be paying off in the short term.

Are you ready, boots?

Go easy on yourself A healthy dose of self-compassion actually helps us form habits that support good health, reports the Washington Post. A 2017 study published in Health Psychology Open found that people who have higher levels of self-compassion tend to handle stress better – they have less of a physical stress response when they are stuck in traffic, have an argument with their spouse or don’t get that job offer – and they spend less time reactivating stressful events by dwelling

Exercise does not have to be prolonged in order to be beneficial, according to a study published in the Journal of the American Heart Association.

It just has to be frequent. “Despite the historical notion that physical activity needs to be performed for a minimum duration to elicit meaningful health benefits, we provide novel evidence that sporadic and bouted [moderate-to-vigorous physical activity] are similarly associated with substantially reduced mortality,”

write the researchers. “This finding can inform future physical activity guidelines and guide clinical practice when advising individuals about the benefits of physical activity. Practitioners can promote either long single or multiple shorter episodes of activity in advising adults on how to progress toward 150 minutes-perweek of moderate-to-vigorous physical activity]. This flexibility may be particularly valuable for individuals who are among the least active and likely at greater risk for developing chronic conditions.

Obesity and cancer Doctors can’t always explain why one person gets cancer and another doesn’t. But research has shown that certain risk factors may increase a person’s chance of getting cancer, reports National Institutes of Health.

One risk factor is obesity, or having too much body fat. Many studies have found links between obesity and certain types of cancer. That doesn’t mean obesity is the cause of these cancers. People who are obese or overweight may differ from lean people in ways other than their body fat. Yet, studies have consistently linked obesity with an increased risk for several types of cancer.

Researchers are now exploring what biological mechanisms might link obesity and cancer.

No badge of honor Getting insufficient sleep and working while fatigued have become commonplace in the modern 24/7 workforce, with more than 37 percent of workers sleep-deprived, according to the National Healthy Sleep Awareness Project. Overworked and over-

tired employees experience cognitive for hoarding.” This is a type of talk declines and present employers with therapy that teaches people how to heightened safety risks and increased change their thinking patterns and economic costs. The National Healthy react differently to situations.

Sleep Awareness Project – including Sweet nothings partners the American Academy of Added sugars are almost everywhere Sleep Medicine (AASM), the Centers in the modern diet – sandwich bread, for Disease Control and Prevention chicken stock, pickles, salad dressing, (CDC), the Sleep Research Society crackers, yogurt and cereal, as well (SRS) and the National Safety Council as in the obvious foods and drinks, (NSC) – is launching the “Sleep like soda and desserts, according to Works for You” campaign, encoura report in the New aging employers to help York Times. The biggest workers avoid fatigue Sugar is the problem with added and develop healthy driving force sweeteners is that they sleep habits for long-term make it easy to overeat. success and well-being. behind the They’re tasty and highly diabetes Hoarding is caloric but they often and obesity a disorder don’t make you feel epidemics.

People don’t choose full. Instead, they can to be hoarders. And Health experts trick you into wanting they aren’t being sloppy even more food. Sugar recommend or lazy. “This is a very is the driving force that you focus real mental disorder,” behind the diabetes on reducing says hoarding disorder and obesity epidemics. added expert Dr. David F. Tolin Health experts recomof Hartford Hospital’s mend that you focus sweeteners – Institute of Living. “It like granulated on reducing added is important to recogsweeteners – like gransugar, high nize that people with ulated sugar, high frucfructose corn hoarding disorder have tose corn syrup, honey, syrup, honey, lost control of their maple syrup, stevia and decision-making abilimolasses. You don’t need maple syrup, ties,” says Tolin, whose to worry so much about stevia and research is funded by the sugars that are a molasses. the National Institutes natural part of fruit, of Health. Hoarding vegetables and dairy disorder can start during a person’s products. A typical adult should not teens or later. It may grow more eat more than 50 grams (or about severe over the decades. There’s no 12 teaspoons) of added sugars per effective medication for hoarding day, and closer to 25 is healthier. disorder, although studies are in progThe average American would need ress. Tolin says, “Right now, cognito reduce added-sweetener consumptive behavioral therapy is the only tion by about 40 percent to get down evidence-based treatment we have to even the 50-gram threshold.

ISSUE 4 • 2018 : DentalGroupPractice.com 43

INDUSTRY NEWS Guardian Life Insurance supports Children’s Health Fund in $1M partnership for oral health

Great Expressions Dental Centers affiliates with Middletown Dental Group (NY) Great Expressions Dental Centers (GEDC) (Southfield, MI) announced it will affiliate with Middletown Dental Group (Middletown, NY). Middletown Dental Group provides a wide variety of oral health care services, including hygiene, oral surgery and periodontics. With the partnership, Middletown Dental Group will expand into orthodontics while also providing patients access to GEDC’s Smile Protection Dental Plan. The affiliation will increase GEDC’s office footprint in New York to 21 locations.

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The Guardian Life Insurance Company of America and Children’s Health Fund have teamed up to ensure children do not fall behind in school because of their dental health.

Guardian has committed $1 million to provide quality dental care to children in underserved communities across the US. Guardian is a lead sponsor of Children’s Health Fund’s dental program and the donation will fund screenings, clinics, and mobile dental services for children in communities including New York, the District of Colombia, Dallas, and Idaho, over the next two years.

“This program brings together two organizations that are passionate about giving children the opportunity to be healthy,” said Dennis Walto, Chief Executive Officer of Children’s Health Fund. “Guardian’s support allows us to reach children

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In eleven states¹, state dental practice acts mandate the heat sterilization of handpieces. They don’t just recommend it. They require it. In the other 39 states, CDC Guidelines apply. And the CDC says, “Dental handpieces and associated attachments … should always be heat sterilized between patients,” adding, “If a semicritical item is heat-sensitive, DHCP should replace it with a heat-tolerant or disposable alternative.”² With the movement in compliance shifting toward sterilization, why buy a handpiece that’s not heat-tolerant? Instead, talk to us about ēsa and the lube-free ēsamate prophy system. Or, if you already own a Midwest Shorty®, Rhino® or Star® Titan®³ handpiece, then put an ēsa on it and be compliant wherever you work.

For samples of the ēsa DPA or more information, visit www.preventech.com/esa-dpa/ ¹State Dental Practice Boards in CA, FL, IN, KS, MO, NM, OH, OR, SC, VA and WA require semicritical items to be sterilized after every patient. ²“Summary of Infection Prevention Practices in Dental Settings,” Centers for Disease Control and Prevention, March, 2016, P. 14. ³ēsa is available for Star Titan, Midwest Shorty and Rhino handpieces. All third party marks – ® and TM – are the property of their respective owners.

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across the country with comprehensive health services and develop engaging programming that will help teach children and their families about good oral hygiene and the importance of dental health in a fun and integrated way.” Walto added, “…children with good oral hygiene practices is definitely something to smile about.”

Kool Smiles serves over 550 children in need during 4th annual Sharing Smiles Day More than 550 children in 13 states and DC received free dental care during Kool Smiles’ (Marietta, GA) 4th annual Sharing Smiles Day on May 20, 2018. Volunteer doctors and staff from 49 Kool Smiles offices participated in the free day of dental care for uninsured and underinsured children. Nationwide, more than 2,100 children have been served by the free care day since 2015.

“While Kool Smiles is proud to accept many forms of insurance, including Medicaid, TRICARE and Children’s Health Insurance Program coverage, we also recognize that too many children do not have access to dental care because they have inadequate insurance or face gaps in coverage,” said Dr. Brad Bryan, Managing Dental

Director for Kool Smiles. “Sharing Smiles Day is one way Kool Smiles is working to close this coverage gap and help all kids get the preventive dental care and treatments they need to have happy, healthy smiles.”

Birner Dental Management hires new hygiene director Birner Dental Management Services (Denver, CO) appointed Marisa Dolce as director of hygiene. In this role, Dolce will be responsible for expanding the company’s hygiene practice. She previously was the national director of hygiene for Great Expressions Dental Centers.

Argus Dental & Vision names new SVP of national sales Argus Dental & Vision (Tampa, FL) hired Jeremy Earp as SVP of national sales. As SVP, Earp will align sales and marketing efforts around the company’s goal to build networks of agents and brokers for Argus’ commercial products nationally. Earp holds life and health insurance licenses in several states and will leverage his experience to develop business through ISSUE 4 • 2018 : DentalGroupPractice.com 45

INDUSTRY NEWS national distribution channels. Earp most recently was regional sales director for Ameritas.

DN Orthodontics joins Smile Doctors Smile Doctors (Georgetown, TX) announced that DN Orthodontics joined its family of affiliated practices. DN Orthodontics spans 10 office locations across southeast Louisiana and Mississippi.

“We are thrilled to welcome DN Orthodontics to the Smile Doctors family,” said Dr. Scott Law, one of the founders of Smile Doctors. “Drs. Devereux and Nguyen and their team have built a phenomenal practice centered on outstanding patient care, and we look forward to continuing their reputation for excellence as we expand our footprint in the Gulf Coast region.”

All 10 DN Orthodontics locations will maintain their current team members and be rebranded as Smile Doctors. The offices are located in Houma, Hammond, Luling, Metairie, Harvey, Chalmette, Slidell, and Covington, Louisiana; and Gulfport, and Picayune, Mississippi.

“We have chosen Smile Doctors, a doctor-owned and managed team, to help us continue to provide the best care for our patients and a wonderful culture for our team,” said Drs. Devereux and Nguyen. “Both of our organizations believe in putting people first, and we are honored to join the Smile Doctors family so we can better serve our patients and community.”

KKR finalizes deal to acquire majority interest in Heartland Dental Heartland Dental (Effingham, IL) finalized its agreement with KKR (New York, NY), an investment firm.

With the agreement, KKR will acquire a majority interest in Heartland Dental from Ontario Teachers’ Pension Plan (Toronto, Ontario, Canada) and other existing shareholders. Under the terms, Ontario Teachers’ will 46

Efficiency In Group Practice : ISSUE 4 • 2018

retain sizeable ownership and will continue as a significant partner to the company. Patrick Bauer, President and CEO of Heartland Dental; along with Heartland Dental’s founder and executive chairman, Dr. Rick Workman; Heartland Dental’s executive leadership team; and supported dentists and employees will remain significant shareholders. In connection with the KKR agreement, Heartland Dental also recently completed a debt offering which improved its financial flexibility.

“We are excited to finalize this deal and move forward with both KKR and Ontario Teachers’ support. This opens up a multitude of opportunities for our company,” said Patrick Bauer, President and CEO of Heartland Dental. “It’s our vision to be the leader in dentistry. With our ongoing growth, we continue to work toward that goal each day. Ontario Teachers’ support and guidance over the past five years has helped the Company lead the way in dentistry. With KKR’s proven experience, expertise and resources this only adds another layer of benefit to what we seek to accomplish.”

New teledentistry association launches The American Teledentistry Association (ATDA) is a new association that focuses on using teledentistry to increase access to care. “The immediate goal of the ATDA is to educate dental professionals and the public about the benefits of teledentistry,” said Dr. Marc Ackerman, Executive Director of the ATDA. “Teledentistry has the ability to help patients get access to needed dental care they deserve, both affordably and conveniently. It’s our mission to modernize access to care through teledentistry with advocacy for the implementation of innovative teledentistry guidelines and solutions.” Ackerman is the director of orthodontics at Boston Children’s Hospital and an assistant professor of developmental biology at the Harvard School of Dental Medicine.

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