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From The Publisher

Clinical Advances..................................................... 4

2018 Annual Summit............................6 The Changing Face of Pediatric Dentistry Clinical advances help DSOs and their pediatric dentists address the needs of a growing patient base............................ 8

OSAP: 2018 OSAP Dental Infection Control Boot Camp™

Record breaking attendance reveals excitement for dental safety.................................... 11

Growing Efficient Practices...........12 Compliance a Must Waterline disinfection helps ensure a safe patient visit........................................ 20 Safe dental water… …should be a priority at every practice...........................................24 Evacuation Line Maintenance......26 Dental Unit Waterlines: Municipal Tap Water and Why it Should be Avoided...............30 A Look at OSHA

The Occupational Safety and Health Administration (OSHA) plays an important role in the dental industry......... 42

Measuring Up

Despite a rise in patient visits, dental services account for a small percentage of healthcare spending............. 45

How to Win Other People Over ................................48 Enhanced Hygiene hosts Dental Group Evolution conference........................................................50 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.

EDITOR Laura Thill • lthill@sharemovingmedia.com

PUBLISHER Bill Neumann wneumann@sharemovingmedia.com

MANAGING EDITOR Graham Garrison • ggarrison@sharemovingmedia.com ASSOCIATE EDITOR Alan Cherry • acherry@sharemovingmedia.com CIRCULATION Laura Gantert • lgantert@sharemovingmedia.com ART DIRECTOR Brent Cashman • bcashman@sharemovingmedia.com

ADVERTISING SALES Diana Craig dcraig@sharemovingmedia.com

ADVERTISING SALES Jamie Falasz jfalasz@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 2 • 2018 : DentalGroupPractice.com

From the Publisher

Clinical Advances As I write this publisher’s letter, I am on an airplane headed to the 153rd Chicago Midwinter meeting. The Chicago Midwinter is one of the largest dental shows in the United States. Equally important, the Midwinter meeting is typically viewed as a new product launch meeting. Dental manufacturers, distributors and technology companies will have their latest and greatest products and services on display for dental practices both large and small. I speak to many clinical directors and procurement managers of both emerging groups and larger more established dental support organizations who attend this meeting, as well as other dental trade shows. Many attend in order to schedule meetings with their vendor partners, and to experience the latest clinical advances that their group may want to adopt. If the Chicago Midwinter meeting was not on your travel itinerary for 2018, don’t worry because we asked key influencers in the dental group space their thoughts on 2018’s clinical advances. In this issue of Efficiency in Group Practice we highlight several clinical advances to watch, and get input and perspective from both DSOs and their manufacturer partners. It is important to understand that one of the key drivers of faster adoption by dental groups of these clinical advances and technologies are the realities that today’s patients are better educated, do more research online, and expect better service and outcomes. David Vieth, DDS, Chief Dental Officer of Kool Smiles talks about newer technologies such as 3D Imaging/ CBCT and digital radiography. Dr. Vieth points out that not only are patients more educated and expect these technologies, but not having these types of clinical advances in a DSO can hinder recruitment and retention of dentists and other clinical staff. Dr. Robert Brody, Chief Clinical Officer of Great Expressions Dental Centers addresses advancements in dental materials, refinements with intra-oral scanners, and practice management scalability. DSO Industry Partners, Ivoclar Vivadent and VOCO weigh in on how they and others continue the advancement of dental materials and technology and what that means to dental groups and their patients. Russ Perlman, Executive Director of Marketing & Communications at VOCO America hits on the common theme of highly educated patients and their equally high expectations. Focusing on advancements with universal adhesives, Perlman talks about the ability of dental groups to reduce adhesive inventories while increasing consistency and predictable results. Whether you made it to Chicago Midwinter or not, there are some can’t miss clinical advances and more content in this issue of Efficiency in Group Practice. Clinically yours,

Efficiency In Group Practice : ISSUE 2 • 2018

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2018 Annual Summit 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) presents its 2018 Annual Summit.

The Association of Dental Support Organizations (ADSO) has released the agenda for the 2018 ADSO Summit at the JW Marriott Austin in downtown Austin, Texas. The conference will begin the morning of April 17 and conclude Friday evening, April 20.

CEOs Pat Bauer, of Heartland Dental; Steve Bilt, of Smile Brands, Inc.; and Kenneth Cooper, of North American Dental Group, will lead a general session on Leading Change: Supporting and Developing Newly Acquired Practices.

Efficiency In Group Practice : ISSUE 2 • 2018

This year’s agenda is stacked with outstanding speakers who will cover a range of topics 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 will benefit from the general sessions, breakout sessions, round table discussions, talk table visits with industry partners and networking receptions. CEOs Pat Bauer, of Heartland Dental; Steve Bilt, of Smile Brands, Inc.; and Kenneth Cooper, of North American Dental Group, will lead a general session on Leading Change: Supporting and Developing Newly Acquired Practices, which will include information on best business practices, collaboration and learning opportunities. The ADSO Summit draws C-level executives and team members from DSOs, as well as industry partner representatives from more than 150 companies. The full agenda for the annual meeting can be found at: http://theadso.org/wp-content/uploads/2018/01/ ADSO_Summit_Program_2018_Print.pdf. For more information on the preeminent DSO event of the year, please visit www. theadso.org. If your organization is not currently a member, email us at membership@theadso.org to join and receive complimentary registrations for this event. Follow the conversation on Twitter and Facebook with #ADSOSummit.

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Pediatric Dentist

The Changing Face of Pediatric Dentistry Clinical advances help DSOs and their pediatric dentists address the needs of a growing patient base. Pediatric dental visits are on the rise, according to Marc A. Auerbach, DDS., Esq., a pediatric dentist with Kool Smiles. At the same time, access to care continues to be an issue. The good news is that dentists – including pediatric dentists – have more and better tools available to treat their patients, including the following: •S ilver Diamine Fluoride. Applying Silver Diamine Fluoride to the carious teeth of a young child allows dentists to delay definitive treatment until the child is older and better able to tolerate dental treatment. • Non-radiating fluorescent. The use of non-radiating fluorescent for caries diagnosis reduces the need for radiation. • Caries management by risk assessment (CAMBRA). CAMBRA enables dentists to develop a patient-specific preventive care plan. (Evidence-based dentistry further aids dentists in providing treatment shown to be scientifically effective.) 8

Efficiency In Group Practice : ISSUE 2 • 2018

• Zirconium crowns. Zirconium crowns for both anterior and posterior teeth result in a more natural looking tooth. • Innovative use of local anesthetic products, such as buffering of local anesthetic to make injections more comfortable and to facilitate faster anesthesia uptake. • Intranasal atomization of anesthetics for maxillary teeth, potentially eliminating the need for an anterior maxillary injection. • In-office general anesthesia for the uncooperative or pre-cooperative child with extensive dental needs. Using general anesthesia can help dentists complete treatment in one visit, reducing stress for both the child and parent.

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• Newer, in-office sedation techniques, utilizing safer and shorter-acting drugs, such as Midazolam. • Innovative isolation techniques. Traditionally the rubber dam has been used for tooth isolation. Today there are new, single-use systems designed to provide tooth isolation, as well as illumination, suction and jaw stabilization, in one device. • Advances in pulp therapy, such as the use of MTA for vital pulpotomies, which have reportedly led to successful results without the potentially toxic effects of formocresol. • Expanded use of sealants, which has helped prevent the development of caries on molars. • Newer and faster lasers designed to cut both hard and soft tissue.

The role of the DSO Dental service organizations can play a substantial role in helping their pediatric dentists become more comfortable in large group dental practices, according to

Auerbach. “The DSO can help integrate the pediatric dentist into the large group practice by facilitating the training of the referring doctors,” he says. “DSOs can locate and hire appropriate staff and provide adequate, appropriate equipment and supplies. They can interact with payors to aid in claims processing – Marc A. Auerbach, DDS., Esq., a pediatric dentist and to reduce denials.” with Kool Smiles At the end of the day, DSOs can make it possible for their pediatric dentists to remain focused on their patients, rather than be distracted with managing the office, he explains.

“The DSO can help integrate the pediatric dentist into the large group practice by facilitating the training of the referring doctors; locating and hiring appropriate staff; and providing adequate, appropriate equipment and supplies.”

ISSUE 2 • 2018 : DentalGroupPractice.com

Pediatric Dentist Sponsored: Crosstex/Accutron

The Pediatric Dental Visit

Low-profile nasal masks make it easier for pediatric dentists to administer nitrous oxide and offer their patients a more enjoyable experience.

Pediatric dentists work with a range of patients “Crosstex/Accutron helps pediatric dentists and – from infants and children to adolescents and staff by assisting in patient comfort,” Sanjai continues. special needs patients – many who are uncomThe company recently launched Axess®, a line of fortable being treated and fear returning for their low-profile nasal masks available in pediatric sizes next appointment. By ensuring that pediatric and designed for nitrous oxide sedation. “The patients have a comfortable design of these masks allows experience through the use pediatric dentists to more easily of nitrous oxide and scented access the oral cavity of the masks, dentists can help make patient,” she explains. “In additheir visits more enjoyable, tion, the lightweight tubing notes Deepti Sanjai, product fits neatly around the ears of manager for Crosstex/Accuthe patient, so movement of tron. Additionally, the use of the head during the procedure nitrous oxide can facilitate doesn’t disrupt the placement more efficient patient schedof the mask.” uling. “It has been shown “Crosstex/Accutron is – Deepti Sanjai, product manager for that offices that use nitrous committed to advancing the Crosstex/Accutron oxide are able to have a care of pediatric patients by higher turnover of patients, launching single-use scented while increasing patient comfort,” she says. “This masks with a low-profile design, available in pediultimately facilitates better patient care, since the atric sizes. We continue to advance our nitrous oxide pediatric dentist is able to focus on the treatment portfolio, with a focus on our core values of quality, of the patient.” safety, infection prevention and patient comfort.”

“It has been shown that offices that use nitrous oxide are able to have a higher turnover of patients, while increasing patient comfort.”

Efficiency In Group Practice : ISSUE 2 • 2018

Safest Dental Visit 2018 OSAP Dental Infection Control Boot Camp™ TM

Record breaking attendance reveals excitement for dental safety. The Organization for Safety, Asepsis and Prevention (OSAP) – a community of clinicians, educators, policy makers, consultants and industry representatives who advocate for the Safest Dental Visit™ – saw record breaking attendance for the 2018 Dental Infection Control Boot Camp™, held January 8-11, 2018, in Baltimore, MD. The OSAP Dental Infection Control Boot Camp™ is a foundation-building educational course covering all the basics in dental infection prevention and control, as well as patient and provider safety. This year, over 480 dental infection control personnel from a variety of dental settings attended the course and were provided with resources, checklists and tools addressing foundational elements of dental infection control and safety. Participants also had the opportunity to earn up to 24 hours of CE credit. The multi-day course structure included educational sessions centered around the principles and theories of infection control on topics such as OSHA, exposure risk determination and bloodborne pathogens, microbiology and regulatory guidance. The program also highlighted the nuts and bolts of day-to-day management, with topics such as sterilization and disinfection of patient care items and dental unit waterlines. The program’s interactive Boots on the Ground sessions helped to underscore application strategies through demonstration and hands-on exercises. Attendees also benefited from a vendor fair featuring over 25 dental infection and prevention companies and organizations, highlighting the latest dental safety and infection prevention technology, products and services. A distinct feature of the course

was the esteemed faculty of infection prevention experts providing detailed lectures, followed by enriching Q & As to address questions and reflect on the dental infection control and prevention topics reviewed. “Providing a crucial resource and outlet for professionals with infection control responsibilities to learn and engage is of utmost importance to OSAP and the Safest Dental Visit™,” says Christina Thomas, executive direcThe program’s tor of OSAP. “The success interactive Boots and growing interest in the on the Ground 2018 program would not sessions helped have been possible without to underscore the support of OSAP’s partapplication ners, dental infection control strategies through advocates, the innovation of demonstration our exhibitors and the guidand hands-on ance and expertise of our world class instructors. We exercises. will continue to provide an interactive and vibrant learning environment for course attendees and look forward to future courses.” For attendees looking to take learning to the next level and enhance their knowledge of late-breaking infection prevention and control topics, policy developments and networking, OSAP offers an Annual Infection Control and Prevention Conference, May 31-June 3, 2018 in Dallas, TX. The conference is richly constructed, combining world class education with valuable networking activities.

The Organization for Safety, Asepsis and Prevention (OSAP) focuses on strategies to improve compliance with safe practices and on building a strong network of recognized infection control experts. OSAP offers an extensive online collection of resources, publications, FAQs, checklists and toolkits that help dental professionals deliver the safest dental visit possible for their patients. Plus, online and live courses help advance the level of knowledge and skill for every member of the dental team. For additional information, visit OSAP.org. ISSUE 2 • 2018 : DentalGroupPractice.com 11

By Laura Thill

Dental practices work hard to provide the best patient care possible. That said, today’s patients are better educated, and they expect more and better service. In turn, dental practices are under more pressure than ever before to meet their patients’ growing demands.

New products and technology provide multi-site practices with the tools to streamline services and deliver higher quality, more efficient patient care. Their ability to keep pace with continual advances in technology, however, depends on their working closely with their manufacturers to receive proper education and training to attain the best results. Indeed, an industry that works together is most likely to achieve best practices and the greatest value – both for the group practice and their patients.

Efficiency In Group Practice : ISSUE 2 • 2018

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Clinical Advances

Greater Efficiency, Better Results

Continuous advancements in technology enable clinicians to deliver enhanced treatment outcomes. As dental technology continues to advance rapidly, clinicians have come to rely on better, more efficient treatment outcomes. In fact, “not incorporating these advancements detracts from a DSO’s ability to deliver care in accordance with their mission to enhance patient outcome and exceed expectations,” says Dr. Robert Brody, chief clinical officer, Great Expressions Dental Centers.

leads to more efficient delivery of quality dental care,” says Brody. “The subsequent sharing of ideas leverages the skills of specialists and general dentists to enhance treatment outcome.” In turn, they can deliver more successful multi-phase treatment plans with fewer patient appointments, he adds.

Some of the biggest game changEstablishing guidelines “Not incorporating Successfully incorporating new techers have included advancements in advancements in nology throughout a large dental pracdental materials (implants, zirconia, technology detracts tice depends on solid communication and universal bonding agents have between the DSO and its clinicians, expanded and improved treatment from a DSO’s ability as well as ongoing education and modalities), the refinement of digital to deliver care in support. “GEDC utilizes a Doctor intra-oral scanners and the ability of accordance with their Panel that reviews best practices the practice management software mission to enhance regarding cutting-edge advancements system to link all practices across the and develops guidelines to incorpoorganization, according to Brody. patient outcome and into the group’s delivery of care,” Intra-oral scanners provide a visual exceed expectations.” rate says Brody. “We rely on the experireference for patients, aiding in their ence and collaboration of the group’s understanding of the procedure, he – Dr. Robert Brody, chief clinical officer, Great Expressions Dental Centers doctors to establish the guidelines for points out. They also facilitate more the use of new technology.” precise and consistent preparations The DSO also provides conand impressions. “Digital intra-oral tinuing education (CE) on all new impressions are more accurate than technologies, including lectures, traditional impressions, less time-conoffice meetings with team members suming and less technique-sensitive,” and hands-on mentorship. “Ongohe says. The result is an enhanced ing support is similar to implementreatment outcome, as well as lower tation,” Brody explains. “In addition supply and lab costs, reduced chair to continuing education and mentime and greater patient comfort torship to our affiliated doctors, these doctors participate compared to traditional impressions.” in group-sponsored study clubs that share best practices.” Likewise, improvements in practice management When clinicians are able to use new products to their full software have led to greater collaboration among clinipotential, they can achieve the best treatment results for cians, who can more easily share diagnostic data and distheir patients, he adds. cuss treatment plans. “Instant access to patient records 14

Efficiency In Group Practice : ISSUE 2 • 2018

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Clinical Advances

Innovation in Group Practices As patient expectations – and the need for greater efficiency in group practices – continue to impact dental technology, Ivoclar Vivadent focuses on research, education and training.

In a competitive industry such as dentistry, where patient expectations continue to drive office efficiency and productivity, group dental practices have come to depend on high quality products and technology. “We have observed significant changes in the dental industry in the last five years,” says Shashikant Singhal, BDS, MS, director of professional services, Ivoclar Vivadent, Inc. As patients raise their expectations for longer lasting, higher quality dental restorations, clinicians are changing their practice model to offer best treatments to their patients faster, efficiently and with options that are more economical, he points out. New, innovative products, together with the digitalization of the dental workflow process, have made this possible, he adds. “Change can be observed both chairside in dental practices and in dental labs,” says Singhal – a prime example being computer-aided design/computer-aided manufacturing (CAD/CAM) systems. “Since the first chairside CAD/CAM system was introduced in the mid-1980s, this technology has improved significantly,” he explains. 16

Efficiency In Group Practice : ISSUE 2 • 2018

“Contemporary scanners are faster, smaller, efficient, accurate and userfriendly, making it easier for dental offices and labs to implement automation in their workflow.” At the same time, dental manufacturers now offer better restorative products, he adds. The result has been new treatment options for patients with regard to fixed and removable prosthodontics, dental implantology, orthodontics and oral surgery. That said, like all new technology, CAD/CAM systems require initial investment, and group practices must determine the level of technology that best supports their business model. Additionally, the office team must be trained and a digital workflow established to meet the needs of the office, notes Singhal. Often, dentists must expand their business model to incorporate new technology and ensure it facilitates increased efficiency, patient comfort and profitability. In the end, though, patients have a more positive chairside

experience. “Today, patients can view their treatment “Education provides the platform for cutting-edge planning by utilizing virtual software,” he says. “They can information on techniques, technology and clinical products be educated during various clinical steps and receive reswithin the market,” he continues. “Ivoclar Vivadent believes torations in a single visit!” Furthermore, it’s a marketing that education is the key component to success in helping opportunity for the dental practice, which can attract and dentists address the daily challenges they face within their retain more patients. practice.” Ultimately, this leads to optimal clinical outcomes, “In addition, compared to analogue techniques, satisfied patients and overall self-esteem, he adds. digital technology is cost effective,” Singhal continues. By providing innovation matched with educational “The dental office team can scan intra-orally, and design support to as many dental clinicians as possible, Ivoclar and mill restorations for single-appointment restoration. Vivadent strives to “increase knowledge and awareness Alternatively, scanned files can be digitally sent to dental of the various challenges that dentists face in their praclabs with the click of a button. The dentist can discuss tice,” Welch says. “Based on the type of structure of the a patient’s dental treatment with the lab and, in turn, DSO, the training will vary. Ivoclar Vivadent provides offer the patient an ideal solution, reducing the need for remakes and increasing efficiency, productivity, patient acceptance and profitability. And, at multidisciplinary group practices, digital technology can be effectively utilized by various specialties for multiple treatment – Shashikant Singhal, BDS, MS, director of professional services, Ivoclar Vivadent, Inc. modalities for better patient care.” industry-leading educational speakers, webinars and A mission to serve and educate online training, all of which are effective means to meet Ivoclar Vivadent’s mission to serve dentistry through the variety of educational needs of DSO practitioners.” “innovation, quality products and value-added service,” Ivoclar Vivadent collaborates with major dental learntogether with its commitment to dentists and patients ing institutions across North America, in addition to its alike, has enabled the company to develop “reliable prodtraining facilities located in New York, Florida and Ontario, ucts that maximize a group practice’s efficiency,” says Canada, according to Welch. The company also hosts Open Scott Welch, director of national accounts, Ivoclar VivaHouse programs for dentists and their key staff at its North dent, Inc. “We invest millions of dollars each year into American headquarters in Amherst, New York. These are research and development,” he says. “These clinical trials distraction-free formats where attendees can become thorare paramount to real practice success and efficiency oughly acquainted with the benefits associated with the Ivothroughout the industry. That’s what we feel doctors and clar Vivadent product line. “It’s a wonderful opportunity for patients understand, expect and deserve.” doctors to peek inside products and get to meet our people,” Indeed, in a busy group dental practice, where clinisays Welch. It’s also an opportunity for Welch and his colcians are continually evaluated on their performance and leagues at Ivoclar Vivadent to learn from program attendees efficiency, office time is often limited. As a result, training – including dentists, dental assistants and dental technicians and education – the foundation for providing successful – and to create “confidence and long-standing relationships” clinical outcomes – don’t always take precedence. Ivoclar with them. “Our internal education team spends countless Vivadent provides a variety of solutions to successfully hours creating instructional videos and hosting webinars, meet these challenges, says Welch. enabling our doctors to learn remotely,” he adds.

“We have observed significant changes in the dental industry in last five years, both chairside in dental practices and in the dental labs.”

For more information, visit the following online Ivoclar Vivadent apps: Cementation Navigation System. www.cementation-navigation.com/en Shade Navigation System (Apple iOS & Android). www.ivoclarvivadent.com/en/apps ISSUE 2 • 2018 : DentalGroupPractice.com 17

Clinical Advances

The Full Impact

DSOs and clinicians must work together to ensure new technologies are used to their full potential. for, say, impressions can be done in fewer steps, reducing the potential for error, he points out. That said, ensuring that the right technology is incorporated into a multi-site practice and that all clinicians are trained to properly use it requires collaboration on the part of the DSO and the clinicians. On one hand, a large DSO like Kool Smiles, which has more than 100 offices, “has a lot of leverage in terms of procuring the latest technology at more attractive prices and spreading the costs,” says Vieth. “Because we’re a large group practice, we’re in a position to test-pilot the latest and greatest at an office, or at a few offices, experiment with it, and then make a decision to Indeed, few consumers would offer that particular tool or technolturn down the opportunity to have ogy at all our offices. Smaller practices a crown placed in one visit, rather might not have the ability to do this. than making several return visits, In addition, DSOs tend to have their notes Vieth. “Simply put, pracown IT departments, with expertise tices that are behind the curve on and resources to help clinicians evaluadvancements and new technology ate and test new technologies.” stand to lose business,” he says. However, the DSO alone doesn’t drive advancements or the latest techThe impact of technology nology, notes Vieth. “We collaborate In addition to digital radiography and with our doctors and clinical leaders – David Vieth, DDS, chief dental officer CBCT, digital scanning technology to understand and identify what’s best of Kool Smiles has also impacted clinicians’ ability to for our dentists and our patients,” he provide better results than ever before. “The use of digital says. “In other words, the DSO isn’t pushing any technology scanning technology can reduce costs, while increasing effibut rather listening to – and partnering with – our doctors ciency and accuracy over traditional impression taking,” on what their needs and the needs of their patients are. Vieth explains. “This scanning process reduces errors by “We work hard to ensure that any implementation is as eliminating the impression errors, as well as the model being seamless as possible throughout our offices,” he continues. poured in stone and subsequent handling of the poured “We provide all training and ongoing support as needed. models. The result is greater efficiency, speed, cost reduction Once we implement any new tool or technology, the DSO and a tremendous increase in accuracy.” The quality of care is there to make sure everything is running smoothly so also improves dramatically, he adds. For example, scanning that our doctors can focus on patient care.”

Newer technologies, such as digital radiography and 3D imaging/Cone Beam Computed Tomography (CBCT) have contributed to better, more efficient patient care. And, doctors who are slow to adopt the latest tools risk losing their competitive edge, according to David Vieth, DDS, chief dental officer of Kool Smiles. “By not continually adding new tools and technology in their practices, an organization runs several risks,” he points out. “One such risk is to potentially lose the ability to recruit and retain doctors who have been exposed to newer, cutting-edge tools. Additionally, with media and social media so widespread, consumers are educated and savvy about what’s available in the market, and they expect practices to offer those things, as well as be competitive on pricing, convenience and a high-quality experience.”

“We collaborate with our doctors and clinical leaders to understand and identify what’s best for our dentists and our patients.”

Efficiency In Group Practice : ISSUE 2 • 2018

Raising the Bar Newer products, such as Universal Adhesives, help large group practices provide optimal patient care.

all substrates, delivering very similar bond strength levels and overall performance quality,” he says. “This allows practitioners who differ in preference to use one single adhesive for all clinical situations, which in turn reduces variables and increases consistency on multiple levels, creating more predictable results for both the practitioner and the practice.”

Patients continue to be more and more informed, thanks to the wealth of information available to them online. In turn, their expectations are higher than ever before, raising the bar for large group practices to provide the best service and treatment possible.

Without access to the newest technology, group practices may struggle to meet patients’ increased expectations, notes Russ Perlman, executive director of marSupporting the dental team keting & communication, VOCO America, Inc. “ManNot only must the dental practice have access to new techufacturers can assist their group practice customers with nology to offer optimal patient care, it must be educated on these new advancements by being an active participant manufacturer guidelines for proper use. VOCO partners in the processes of education, adaptation and implemenwith its group practice customers to ensure they are aware tation,” he says. “Together, group practices can maxiof the company’s new products, including the technology mize the opportunity to successfully leverage these new behind these products, notes Perlman. Additionally, VOCO advancements that can provide positive results, both on educates its customers to ensure they can “harness and the clinical side and the business side, impacting the level leverage the value of these products and underlying technolof quality patient care and business efficiency.” ogies to realize a return on investment A prime example is universal adhe“From a product perspective, on both the business and clinical sides sives, he continues. “From a product the advancement in adhesives of their practices,” he adds. perspective, the advancement in adhe– in particular, the introduction “We provide our group practice sives – in particular, the introduction of universal adhesives – has customers with continuing education of universal adhesives – has made a made a significant impact programs and work with our media significant impact on group practices,” on group practices.” partners to create online continuing he points out. “For instance, VOCO’s – Russ Perlman, executive director education opportunities through porFuturabond U Universal Adhesive of marketing & communication, tals such as www.vocolearning.com,” impacts group practices on multiple VOCO America, Inc. Perlman continues. “Furthermore, levels, including procurement, invenour dedicated special market sales team works closely with tory management and, of course, clinical dentistry. our local and regional reps to ensure our group practice “From a purchasing perspective, universal adhesives customers have the necessary resources to educate their allow the dental management team to streamline purpractitioners and implement these new advancements so chasing and reduce adhesive inventories, as well as some that the intended benefits are realized at the corporate, secondary product inventories that universal adhesives practitioner and patient levels. now share indications with, lowering overall costs,” says “With a fully developed product consultant team, in Perlman. Clinically, universal adhesives provide the quality addition to our in house Clinical Education team, VOCO and flexibility to meet the various preferences of multiple has been – and will continue to be – a part of the support practitioners within a group practice. “Universal adhesives team that our group practice customers turn to.” work in all cure modes and etch modes, as well as with

ISSUE 2 • 2018 : DentalGroupPractice.com 19

Waterline Treatment

Compliance a Must Waterline disinfection helps ensure a safe patient visit. By Laura Thill

standard best practices of infection prevention and control. “Waterborne pathogens exist in all forms of water that are not sterile, including distilled,” she says. “To quote a highly respected colleague, Dr. John Molinari, ‘If you’re not doing anything to treat the dental unit water, it’s contaminated!’” Ignoring water line treatment is neither ethical nor acceptable, she adds. “Dental unit waterlines (DUWL) must be effectively and efficiently treated to maintain acceptable safe and approved colony-forming-unit (CFU) counts,” Keefer continues. “For the past 50 years, Crosstex has been committed to focusing on safer patient care through innovative, high-quality solutions to ensure maximum compliance, in addition to offering an outstanding patient experience. It is critical for a client to understand the science behind the product, as well as following the validated product instructions for use (IFUs) for best performance.” Indeed, the performance of a product is only as good as the accuracy of implementation according to the product IFUs, Keefer continues. “Compliance with DUWL treatment and the manufacturer’s IFUs is an important safety issue for the patient, staff and practice. The IFUs address the comprehensive DUWL treatment protocol, which may include the product as well as issues of frequency related to shocking recommendations and monitoring of CFU count. If a practice is only implementing one of three recommended

Improperly or poorly treated waterlines can place dental patients and staff at risk for infection, as well as create a liability risk for the practice. Some dentists may believe they are taking sufficient steps to reduce the risk, when, in fact, they are not. Using distilled water, cleaning bottles daily and refilling them with fresh water, and installing filters are not enough, according to experts. And, while waterline cleaner tablets provide a good start, total compliance is required each time the water bottle is filled, and often the practice doesn’t follow up to ensure tablet protocols are followed consistently.

Once the source water – whether it is tap, filtered or distilled – reaches the narrow bore tubing of the dental unit waterlines, a perfect storm for biofilm growth develops, notes Leann Keefer, RDH, MSM, director, educational and professional relations, Crosstex. At the same time, microorganism counts exceeding the recommended 500 CFU/mL in the DUWL conflicts with the 20

Efficiency In Group Practice : ISSUE 2 • 2018

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steps or compromises on the frequency of treatment, the product is not being used in accordance with the IFUs.” (Daily-use products have a detailed list of protocols, which must be followed daily, weekly and quarterly to assure effective treatment outcomes.)

“Waterborne pathogens exist in all forms of water that are not sterile, including distilled.”

There are several DUWL treatment options available to dentists, including: • Intermittent. Routine chemical shocking protocol. • Continuous. Tablet protocol. •A utomated. Cartridge delivery protocol.

“While each method, used in Addressing best practices compliance with IFUs, can be effecAs a leader in infection prevention tive in managing CFU count, autoand control, Crosstex is committed mated treatment with the annual to scientifically based programming installation of a Crosstex Dentato address best practices of infection Pure® cartridge provides continuous treatment for dental unit waterlines, prevention to provide a safe dental – Leann Keefer, RDH, MSM, director, reducing the need for daily or weekly visit for the patient, clinician and educational and professional intervention,” says Keefer. “Denthe practice, says Keefer. Indeed, relations, Crosstex taPure cartridges reduce staff time the company is a big believer in while increasing compliance with protocol, decreases providing its dental customers with strong educational the incidence of human error, and reduces the exposure programs and sound solutions to help them protect their of the staff to potentially caustic and toxic chemicals.” patients and staff. ISSUE 2 • 2018 : DentalGroupPractice.com 21

Waterline Treatment Together with DentaPure cartridges, Crosstex Liquid Ultra® Solution helps ensure compliance with EPA standards for potable water, she adds. “DentaPure cartridges are EPA registered to provide water ≤200 CFU/mL. And, when used as directed, Liquid Ultra is EPA registered to provide water ≤500 CFU/ mL and it reportedly is the only EPA approved in-line product that kills biofilm bacteria,” she says. By providing educational resources to clinicians and distributor field sales reps and service technicians, and by arming sales reps with patient resources to share with customers, “Crosstex has created educational touchpoints in every arena of safe dental unit waterlines,” says Keefer.

“Dental unit waterlines (DUWL) must be effectively and efficiently treated to maintain acceptable safe and approved colony-formingunit (CFU) counts.” – Leann Keefer, RDH, MSM, director, educational and professional relations, Crosstex

“Crosstex is an AGD PACE-approved provider with CEU programs at national meetings and on-site practice-based learning events, and through VIVA Learning for live and on-demand CE webinars. Our Client Care team and educational toll-free STERILE Helpline (1-8558-STERILE) are ready to address both clinical and regulatory questions.” (Visit http://crosstexlearning.com/training. asp for the complimentary on-demand DUWL CE webinar.)

Easy maintenance Dentists appreciate the value of infection control protocols, including waterline treatment. But, some may express concerns about managing the compliance process and maintaining records.

Waterborne opportunistic pathogens in DUWLs While some organisms have been identified in dental unit water as a result of back-flow from patients (oral microorganisms) the majority of microbial species found in DUWL output water are Gram-negative aerobic (without oxygen) heterotrophic (live off of others/carbon loving) mesophilic (heat loving) environmental (waterborne) bacterial species. These opportunistic waterborne bacteria attached to the inner-surface of the tubing with an insoluble slime layer. As the microorganisms grow and multiply, they create a more complex and potentially pathogenic environment. Eventually pieces of the biofilm may break off and be carried through the dental tubing via the waterflow eventually delivered to the patient’s mouth. In the past it was recommended to flush dental waterlines at the beginning of the clinic day for several minutes to reduce the microbial load. However, studies have demonstrated this practice does not affect biofilm in the waterlines or reliably

Efficiency In Group Practice : ISSUE 2 • 2018

improve the quality of water used during dental treatment. Therefore, this has not been recommended since the publication of the CDC Guidelines for Infection Control in Dental Health-Care Settings in 2003. It is still necessary to discharge water and air for a minimum of 20 to 30 seconds after each patient, from any device connected to the dental water system that enters the patient’s mouth (e.g., handpieces, ultrasonic scalers and air/water syringes). This procedure is intended to physically flush out patient material that might have entered the turbine, air or waterlines. Even though the initial flush of the day is no longer indicated, it’s still a good idea to perform a quick flush of the lines before each patient to ensure everything is working (e.g., that the air/water syringe is attached correctly and water/air is flowing) before beginning patient treatment. (Reference: Centers for Disease Control and Prevention (CDC), Guidelines for Infection Control in Dental Health-care Settings, 2003. MMWR 2003; 52(No. RR-17):1–66.

Once installed, however, the Denta“ Compliance with DUWL treatment and the Pure cartridge requires no monitoring manufacturer’s IFUs is an important safety issue or shocking for 365 days, or 240L of water usage if records are maintained, for the patient, staff and practice. The IFUs address notes Keefer. “If an office is concerned the comprehensive DUWL treatment protocol, about monitoring CFU counts, we which may include the product as well as issues of recommend independent testing by frequency related to shocking recommendations an outside laboratory,” she says. “For offices that are concerned that the and monitoring of CFU count.” iodine level stays within the range – Leann Keefer, RDH, MSM, director, provided in the DentaPure cartridge educational and professional relations, Crosstex IFU, Crosstex offers iodine test strips.” Testing frequency – both for CFU counts and iodine levels – varies by practice, she adds. • Emptying independent water bottles nightly and setting them upside down to dry to avoid biofilm Crosstex strongly recommends the following best practices growth from untreated water remaining in the bottle. in conjunction with use of its DentaPure cartridges and • Wiping down the outside of the cartridge with a Liquid Ultra™ Solution: clean paper towel before replacing the bottle. • Flushing for 20 to 30 seconds between patients. • Filling bottles with fresh water (tap or distilled) • Sterilizing all handpieces after each use. each morning before each use. Editor’s note: All DentaPure claims based on use with potable water. ISSUE 2 • 2018 : DentalGroupPractice.com 23

Waterline Treatment

Safe dental water… …should be a priority at every practice. The quality of dental unit water has been a topic of discussion and research for many years. Indeed, outbreaks of infection linked to the dental waterline can be a health risk for patients and a liability risk for dental practices. It’s the ethical and professional responsibility of dental practitioners to provide safe dental water to their patients, and manufacturers, such as Hu-Friedy, make it a priority to keep them informed and provide optimal solutions for helping clean and maintain water used at their dental practice. Hu-Friedy offers a number of educational resources, including live continuing education courses, articles, on-demand webinars, stepby-step guides and customer service support. (To view their online resources, please visit: http://www.hu-friedy. com/education/infection-prevention-resources.) According to the 2003 CDC Guidelines, “Dental unit water that remains untreated or unfiltered is unlikely to meet drinking water standards (303-309).” Dentists have several options for ensuring safe water standards at their dental practice, such as the following: • Filtration devices with in-line filters to remove bacteria before water enters the handpiece or other devices attached to the waterline. • Independent reservoirs with chemical germicides or cleaners to remove microbial accumulations and prevent attachment of microorganisms, such as Hu-Friedy’s Team Vista Dental Unit Waterline Cleaner. • Devices or cartridges that provide a slow release of chemicals. Whichever method is chosen, it is critical to monitor waterlines on a periodic basis to ensure their efforts and product are working.

Common misconceptions Contrary to what some dental professionals may realize, ALL dental waterlines – regardless of how new or old 24

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they are – must be cleaned and maintained. According to the CDC, “Research has demonstrated that microbial counts can reach <200,000 colony-forming units (CFU)/mL within 5 days after installation of new dental unit waterlines (305), and levels of microbial contamination <106 CFU/mL of dental unit water have been documented (309,338). These counts can occur because dental unit waterline factors (e.g., system design, flow rates, and materials) promote both bacterial growth and development of biofilm.” Additionally, it’s essential for dental offices to understand that ensuring their source water meets CDC standards is a two-step process that involves both cleaning and maintenance. To help prevent waterborne organisms from attaching, colonizing and proliferating on the inner surfaces of water tubing, a complete dental unit waterline system should be used. Complete systems to control the quality of water delivered to patients include both periodic cleaning AND routine maintenance. The CDC offers several steps to help dentists ensure the safety of their dental water: •U se water that meets EPA regulatory standards for drinking water. •C onsult with the dental unit manufacturer for appropriate methods and equipment to maintain the recommended quality of dental water. •F ollow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product. •D ischarge water and air for a minimum of 20-30 seconds after each patient from any device connected to the dental water system that enters the patient’s mouth. • Consult with manufacturer on the need for periodic maintenance of anti-retraction mechanisms. Editor’s note: Sponsored by Hu-Friedy.

MOVING FORWARD. TOGETHER. Because Every Step Matters in Infection Prevention

UTILITY GLOVES

CLEANING & CARE

INSTRUMENT MANAGEMENT

CLEANING & STERILIZATION MONITORING

STERILIZATION PACKAGING

Waterline Treatment

Evacuation Line Maintenance Clean evacuation lines ensure that suction lines are safe and fully functioning. Proper maintenance requires only a small time investment on the part of the dental staff. By consulting with the manufacturer to ensure proper cleaning protocols are followed and the right cleaning products are used, suction lines will remain free of debris build-up, the suction flow will be uninterrupted and patients will receive the best possible care.

Efficiency In Group Practice : ISSUE 2 â&#x20AC;˘ 2018

Safe and economical In recent years, more cleaners have become available that feature a neutral pH, making them compatible with the officeâ&#x20AC;&#x2122;s amalgam separator. Natural ingredient-based products have also been introduced and will be further evaluated for use in the next several years. Still, some dentists have been reluctant to use them, objecting to the time investment and the risk of spillage. There has also been some objection to the cost of the cleaner and the need to adjust to a new dosage when switching to a new product. However, cleaning suction lines daily for both dry and wet vacuum systems is necessary to remove and prevent debris build-up and ensure proper suction flow. When cleaners are used appropriately, they provide a safe, economical solution. For instance, the use of a non-foaming cleaner generally is recommended for use with dry vacuums, as foam cleaners tend to leave the turbine coated with residue and debris, leading to lower performance, loss of suction and eventual pump failure. Dental providers should be aware of CDC recommendations to keep suction lines disinfected daily in case backflow occurs when using a saliva ejector. For more information visit https://www.cdc. gov/oralhealth/infectioncontrol/ faq/saliva.htm.

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Waterline Treatment In addition, they can refer to the book Infection Control and Management of Hazardous Materials for the Dental Team, which states: High-volume evacuation (HVE) during the use of rotary equipment and the air/water syringe greatly reduces the escape of salivary aerosols and spatter from the patient’s mouth, which reduces contamination of the dental team and nearby surfaces. One should clean the HVE system at the end of the day by evacuating a detergent or water-based-detergent disinfectant through the system. One should not use bleach (sodium hypochlorite) because this chemical can destroy metal parts in the system. One should remove and clean the trap in the system periodically. A safer approach, however, is to use a disposable trap.

These traps may contain scrap amalgam and should be disposed of properly. The dental team member must wear gloves, masks, protective eyewear and protective clothing when cleaning or replacing these traps to avoid contact with patient materials in the lines from splashing and direct contact. Disinfection of the trap by evacuating some disinfectant-detergent down the line, followed by water, is best before one cleans or changes the trap. Resource: Miller CH. Infection Control and Management of Hazardous Materials for the Dental Team, 5th edition. Elsevier/Mosby Publishers. Page 181. Editor’s note: Sponsored by Air Techniques

Dental effluent guidelines Mercury pollution is widespread and a global concern that originates from a number of sources, including dental offices. In fact, dental clinics are considered to be the main source of mercury discharges to publicly owned treatment works (POTWs), according to the Environmental Protection Agency (EPA). According to EPA estimates, approximately 103,000 dental offices use or remove amalgam in the United States, and almost all of these send their wastewater to POTWs. Furthermore, dentists discharge approximately 5.1 tons of mercury each year to POTWs, most of which is subsequently released to the environment. Mercury-containing amalgam wastes generally find their way into the environment when new fillings are placed or old mercury-containing fillings are drilled out and waste amalgam

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materials that are flushed into chair-side drains enter the wastewater stream. Mercury entering POTWs frequently partitions into the sludge – the solid material that remains after wastewater is treated. Mercury from waste amalgam therefore can make its way into the environment from the POTW through the incineration, landfilling or land application of sludge, or through surface water discharge. Amalgam separators are regarded as a practical, affordable, available technology for capturing mercury and other metals, before they are discharged into sewers that drain to (POTWs). Once captured by a separator, mercury can be recycled. In July 2017, the EPA passed its final rule specific to Best Management Practices for Dental Amalgam Waste, prohibiting the use of bleach or chlorine-con-

taining cleaners that may lead to the dissolution of solid mercury when cleaning chair-side traps and vacuum lines. The rule says, “…vacuum lines that discharge amalgam process wastewater to a POTW [publicly owned treatment works] must not be cleaned with oxidizing or acidic cleaners, including but not limited to bleach, chlorine, iodine and peroxide that have a pH lower than 6 or greater than 8.” (40 CFR 441.30(b)(2)). EPA expects compliance with this final rule will reduce the discharge of mercury by 5.1 tons each year, as well as 5.3 tons of other metals found in waste dental amalgam to POTWs. For more information visit the EPA website: https://www.epa.gov/eg/ dental-effluent-guidelines. Editor’s note: Sponsored by Air Techniques.

Waterline Treatment

Dental Unit Waterlines: Municipal Tap Water and Why it Should be Avoided By Jerod Mendolia, marketing assistant, and Reid Cowan, director of marketing, Sterisil

surface area is much greater relative to the volume of water flowing through the tubing. The smaller the tubing diameter, the larger the internal surface. This large volume of surface area gives bacteria and biofilm plenty of room to establish themselves. Bacteria and pathogens are opportunists, and they will exploit the nature of dental tubing to their advantage. According to The Organization for Safety, Asepsis, and Prevention (OSAP), “This proportional increase in the amount of potential biofilm relative to a given water volume is one of the major factors influencing dental water quality in unrelated systems.”1 Once biofilm are established, they can be difficult to eliminate. If left unchecked, biofilm will exhibit a resistance to common disinfectants, making the situation even more problematic.7 Consider other growth

It’s no secret in 2018 that dental unit waterline (DUWL) cleanliness is important. Every trade publication, tradeshow and continuing education summit offers some sort of crash course on the subject. The bacteria problem is widespread and omnipresent regardless of the practice type or equipment employed. If it runs water, the potential to be a problem exists. Given their nature, dental waterlines will grow bacteria beyond the 500 colony forming units per milliliter drinking water standard without some level of shock and maintenance. Opportunistic bacteria and the subsequent biofilm they produce are everywhere in the natural world. Every dental unit in use today employs a network of tubing to deliver both air and water to the handpieces. The typical tubing used in a dental chair is narrow in diameter and low in volume. This proportional relationship means the internal 30

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outbreaks related to flaws in premise plumbing have factors unique to dental systems, such as water temperature, increased in that time.4 flow rates and frequent stretches of stagnation. The culmiPrivately managed water treatment – or premises nation of all these factors allows the bacterial load in the treatment – are technically outside the jurisdiction of waterline to exceed the CDC and EPA drinking water stana water utility. The liability falls to building managers dard of 500 CFU/ml. to implement a strategy for maintaining waterlines So why is this a problem? According to OSAP, “As after the meter. According to the American Society for many as nine potentially pathogenic organisms associated Microbiology, “Health care settings, such as hospitals with opportunistic wound and respiratory infections have 1 and nursing homes, were the second most common outbeen isolated from dental unit water systems.” When coolant and irrigant water is used in conjunction with a break location in community systems, highlighting the high speed dental handpiece, the contaminated water is need for continued vigilance to ensure provision of safe aerosolized along with the bacteria. Now you really have water to locations that serve populations that are more a problem! If patients or the dental team inhales these vulnerable, such as hospitalized patients or nursing water droplets, they’ve now been exposed to whatever was growing Contaminated dental unit waterlines are a real threat in the dental unit. There’s also the to patient and staff safety. Their design, the nature good old fashioned way of exposed tissue (or dental pulp) being infected of dental procedures and the conditions within the when the site is irrigated with condental operatory prime them for bacterial colonization. taminated water. Either way, serious infections can be the result of a We know the problem can be exacerbated by using contaminated DUWL. So how can municipal water instead of purified or distilled water, clinicians mitigate these risks? They and the case data proves this point. can start with the water being supplied to the dental practice. home residents with preexisting medical conditions.”4 Most clinicians are not aware that municipal tap water For dental professionals in large healthcare facilities, could be contributing to their bacteria problems. Public it is certainly worth speaking with building managers water works that deliver municipal tap water are prone about the plans for water treatment within the buildto contamination and breaches in their own water quality ing. Systems of water quality monitoring and intermitstandards. A common watermain break or leak presents tent testing should be in place where the consequences an opportunity for pathogens to gain access to the public could be serious. works. According to a 2012 report, these types of failures have been the cause of several bacterial and viral outbreaks Maximum chemical control of Salmonella, Campylobacter, Shigella, E. coli O157:H7, 2,3 In 2015, reports began to circulate that a cluster of MycoCryptosporidium, Giardia and Norovirus. bacterium abscessus infections had been identified in As of 1971, the Centers for Disease Control and PreAtlanta, Ga. after nine pediatric patients were hospitalized vention (CDC), U.S. Environmental Protection Agency in the same facility. The CDC reported that the Georgia (EPA) and the Council of State and Territorial EpidemiDepartment of Public Health (GDPH) initiated an invesologists (CSTE) have been tracking and quantifying these tigation, which revealed that all of the patients (between waterborne disease outbreaks in the United States. The the ages of 3-11) had previously undergone a pulpotomy most interesting insight from the data they provide is that procedure at the same dental clinic. Upon visiting the over the 36-year period from 1971 to 2007, “a trend analclinic to evaluate their infection control policies, GDPH ysis found a statistically significant decrease in the annual staff indicated the practice used tap water for irrigation proportion of reported deficiencies that were associated during the pulpotomies. The report also indicated the with the inadequate or interrupted treatment of water practice lacked any level of monitoring or disinfection by public water systems.”4 Conversely, the amount of ISSUE 2 • 2018 : DentalGroupPractice.com 31

Waterline Treatment efforts as directed by the chair manufacturer. The report concluded that all seven operatories had bacterial counts above the 500 colony forming unit (CFU) drinking water standard and M. abscessus was identified in all samples.5 If a dentist intends to use their municipal water for dental water – and, yes, there is a difference – it would be advisable to have some level of water quality analysis before selecting the product. Variations in tap water quality are virtually infinite and, therefore, the dental practice should not rely on tap water for consistent disinfection results. The presence of municipal disinfectants and additives, such as chlorine and fluoride, complicates things further if the practice is trying to manage the chemistry, as it should to get the best results. By failing to do so, the dental practice has a concoction of different chemicals and additives mixing in the waterline. The byproduct of product is water that is neutral in pH, contains less than these unwanted mixtures is called precipitates, and their 10 ppm total dissolved solids, is disinfected and contains presence indicates the diminished effectiveness of whatsome variety of residual disinfectant. ever exists in the water to control microbes. Now the water is pure and bacteria free. So the treatSo what is the solution? To attain maximum chemical ment process is complete, right? Not even close! We havcontrol, distilled quality water is best. That said, distilled en’t gotten to the most important part – the dental water water from a distiller is not always optimal for dental use protocols. Without sound operating protocols, everywater. The nature of distillation requires that one heat thing the dental practice has done up to this point would the water to remove impurities. This hot distillate is now be for not. primed for recolonization by bacteria. Without immediate waterline treatment, this water will most assuredly be Dental water use protocols contaminated. Without the presence Manufacturers spend unmentionable of a continuously present residual amounts of money on development, disinfectant, that water will most Manufacturers spend EPA registration and validation for assuredly be a breeding ground for unmentionable their products. The EPA label will bacteria. Distillers themselves are amounts of money run down all the necessary steps often the source of contamination on development, needed to get the advertised disinfor many offices, as once the storfection level. Clinicians should not age tank is contaminated the water is EPA registration and go rogue on these protocols! When then distributed along with the bacvalidation for their it comes to quality assurance (QA), teria to the entire office. products. The EPA OSAP recommends procedures The best strategy is a pointof-use purification system using label will run down all that flush out user error.6 Let’s face it, people can make mistakes. Minor deionization to remove all the imputhe necessary steps investments like TDS hand meters rities without heating the water. needed to get the will allow some level of protocol QA. Ultraviolet disinfection can then be advertised disinfection For example, when using distilled employed to drastically lower the existing bacterial load with proven level. Clinicians should water in their bottles, clinicians should randomly check the TDS count and effectiveness.8 The water would not go rogue on then receive a low concentration ensure the result is less than 20 ppm. these protocols! of a residual disinfectant. The final If it’s greater than 20 ppm, they can 32

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is not a state of mind; it’s a state of being. The notion that purchasing a product and following the instructions puts one in compliance is just wishful thinking. A complete and thorough waterline assessment performed by a 3rd party lab specializing in dental water microbes will provide all the information necessary. TDS, pH, and HPC counts in CFU/ml are the general markers of waterline cleanliness. These test results can be used to make adjustments to the waterline protocol or confirm that clinician’s efforts are having the desired effect. It can be something as simple as a change in the daily staff use or as extensive as a complete overhaul of the regimen at large. Contaminated dental unit waterlines are a real threat to patient and staff safety. Their design, the nature of dental procedures and the conditions within the dental operatory prime them for bacterial colonization. We know the problem can be exacerbated by using municipal water assume the water in that bottle is instead of purified or distilled water, not distilled and that someone has and the case data proves this point. Most clinicians are not botched the procedure for refilling The most important takeaway from aware that municipal it. Protocol consistency and quality this piece is that whatever clinicians tap water could be failsafes are fundamental to getting do, they should be consistent. They all of this waterline stuff done should read manufacturers guidecontributing to their right. Consistency leaves nothing to lines and follow them, as there may bacteria problems. Public chance. This is also important, as be something they’ve been missing. water works that deliver manufactures design their products When they feel like everything is to work within certain parameters. going well, they shouldn’t assume it municipal tap water are We’ve already discussed the variis. Rather, they should order a test prone to contamination ability in water chemistry across the and know for sure. If clinicians miss and breaches in their own spectrum. Deviations in protocol, the mark, they should reevaluate water quality standards. like the example above, could mean their plan, retrain their staff and the dental practice is no longer operretest to confirm the change. Attainating within those parameters and, subsequently, it may ing the <500 CFU/ml standard in dental effluent water have contributed to contamination in the unit. is the culmination of forethought, execution, consistency So what is compliance under the current standards? The and vigilance. No excuses! acceptable standard set by the CDC and the ADA for bacEditor’s note: Sponsored by Sterisil terial content in a dental unit is ≤500 CFU/ml. Compliance Bibliography

1. B erdnash, Helene, et al. “Dental Unit Waterlines: Check Your Dental Unit Water IQ.” Dental Unit Waterlines - OSAP, www.osap.org/page/Issues_ DUWL_7XXXX/Dental-Unit-Waterlines.htm. 2. I ngerson-Mahar, M.; Reid, A. Microbes in Pipes: The Microbiology of the Water Distribution. System A Report on an American Academy of Microbiology Colloquium; ASM Academy: Boulder, CO, USA, 2012; p. 26. 3. R amÃrez-Castillo, Flor, et al. “Waterborne Pathogens: Detection Methods and Challenges.” Pathogens, vol. 4, no. 2, 2015, pp. 307–334., doi:10.3390/pathogens4020307. 4. C raun, Gunther F., et al. “Welcome to CAB Direct.” CLINICAL MICROBIOLOGY REVIEWS, vol. 23, no. 3, July 2010, pp. 507–528., www.cabdirect.org/ cabdirect/abstract/20103246391. 5. P eralta, Gianna, et al. “Morbidity and Mortality Weekly Report (MMWR).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Aug. 2017, www.cdc.gov/mmwr/volumes/65/wr/mm6513a5.htm.OSAP - Dental Unit Waterlines 6. A . Bridier, R. Briandet, V. Thomas & F. Dubois-Brissonnet. “Resistance of bacterial biofilms to disinfectants: a review” Biofouling Vol. 27 , Iss. 9,2011 7. C hevrefils, Gabriel, et al. UV Dose Required to Achieve Incremental Log Inactivation of Bacteria, Protozoa and Viruses. UV Dose Required to Achieve Incremental Log Inactivation of Bacteria, Protozoa and Viruses, Trojan Technologies Inc., 2006.

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Longer lasting, better looking St. Louis, Mo.-based Jack Griffin, DMD, has discovered advantages to using bioactive ACTIVA™.

With three dental practices, a team of 20 staff members and three doctors, and year-round teaching and lecturing commitments, Jack Griffin, DMD, depends on products that deliver efficiency, precision and are easy to use. So when it comes to selecting restoratives, he relies on Pulpdent’s ACTIVA™, a bioactive composite material designed to stimulate the natural remineralization process and better protect his patients’ teeth against caries. “I provide a lot of restorative dental procedures, as well as general care,” says Griffin, noting that his patients range from those seeking high-end aesthetic treatment to drug rehabilitation cases. “For years, my doctors and I used glass ionomers when treating our patients. I’ve since discovered ACTIVA BioACTIVE, which lasts longer, looks better and is much kinder to the gum tissues than glass ionomers.” Compared to traditional composites and glass ionomers, ACTIVA releases and recharges more calcium, 40

Efficiency In Group Practice : ISSUE 2 • 2018

phosphate and fluoride, he explains. Its enhanced physical and cosmetic properties make it especially versatile for a large dental practice, he continues. “We use ACTIVA for many of our large fillings, as well as for liner base, pediatric procedures, crowns, bridges and more. Particularly for deeper fillings, because ACTIVA can be light-cured or cure on its own, there is no interruption to the procedure. Nor is there a need for layering materials in deeper fillings, he adds. “ACTIVA can be placed in the entire filling. We can build the filling entirely, and continue to work on the outside of the tooth, knowing ACTIVA is curing on the inside. “Our dentists are confident that by using ACTIVA they can provide patients with faster, better healthcare,” says Griffin. “And they appreciate how intuitive the delivery system is!” Editor’s note: Sponsored by Pulpdent® Corporation.

ACTIVA™: The bioactive choice for dynamic dental care ACTIVA™ BioACTIVE is a durable, esthetic bioactive restorative material designed for both dentin and enamel replacement. ACTIVA responds naturally to changes in the oral environment while stimulating the formation of hydroxyapatite, chemically bonding to teeth and helping protect against decay. Dentists depend on ACTIVA to play a dynamic role in their patients’ mouths. These bioactive materials: • Stimulate the natural remineralization process, helping protect teeth against caries. • Provide a dynamic force in the presence of saliva, eliciting a biological response that forms a layer of apatite and a natural bond between the material and the tooth. • Are moisture friendly, transport water and release and recharge essential minerals, such as calcium, phosphate and fluoride. Dentists count on ACTIVA for its durability and esthetics, and its ability to mimic natural teeth.

Infection Control

A Look at OSHA The Occupational Safety and Health Administration (OSHA) plays an important role in the dental industry.

Editor’s Note: As of September, 2017, Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, has worked as an independent consultant with expertise in OSHA, dental infection control, quality assurance and risk management.

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

OSHA: It’s an organization that many dental employers fear! In fact, some dentists do not fully understand the importance of OSHA regulations and believe they make if difficult to deliver high-quality dental care. However, non-compliance can lead to injury, illness or harm to employees. For that reason, large group practices and DSOs make it their business to remain compliant with OSHA standards, often hiring quality assurance individuals to oversee compliance. This team is frequently charged with ensuring that OSHA standards are in place and being met throughout the practice. Furthermore, as a federal regulatory body, OSHA inspectors may appear at a dental practice unannounced and can issue citations and monetary fines for noncompliance and repeated offenses. These fines have recently increased, and they can be substantial, not to mention the potential damage to the practice’s reputation and credibility as a safe workplace.

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This article looks at OSHA’s history, inspection protocols and fees for noncompliance.

The history of OSHA In response to dangerous working conditions across the nation, and as a culmination of decades of reform, the bipartisan Williams-Steiger Occupational Safety and Health Act of 1970 was signed into law by President Richard M. Nixon. This law led to the establishment of the Occupational Safety and Health Administration (OSHA) on April 28, 1971. Since then, OSHA – along with state partners and employers, safety and health professionals, unions and advocates – has had a dramatic effect on workplace safety, showing a dramatic drop in fatality and injury rates. OSHA’s mission is to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.1,2 According to history, accurate statistics were not kept early on, but it is estimated that in 1970 about 14,000 workers were killed on the job – a number that decreased to approximately 4,340 in 2009. At the same time, U.S. employment has almost doubled and now includes over 130 million workers at more than 8 million worksites. Since the passage of the OSHA Act, the rate of reported serious workplace injuries and illnesses has declined from 11 per 100 workers in 1972 to 3.6 per 100 workers in 2009. OSHA safety and health standards, including those for trenching, machine guarding, asbestos, benzene, lead and bloodborne pathogens, have prevented countless work-related injuries, illnesses and deaths.1

Inspections Federal OSHA is a small agency, but with the state partners there are approximately 2,100 inspectors responsible for the health and safety of 130 million workers, which translates to about one compliance officer for every 59,000 workers.1,3 OSHA cannot inspect all 8 million workplaces it covers each year. The agency seeks to focus its inspection resources on the most hazardous workplaces in the following order of priority: 1. Imminent danger situations: Hazards that could cause death or serious physical harm receive top priority. 2. Severe injuries and illnesses: Employers must report all work-related fatalities within eight hours, and all work-related inpatient hospitalizations, amputations or losses of an eye within 24 hours.

3. Worker complaints: Allegations of hazards or violations also receive a high priority. 4. Referrals of hazards: From other federal, state or local agencies, individuals, organizations or the media receive consideration for inspection. 5. Targeted inspections: Inspections aimed at specific high-hazard industries or individual workplaces that have experienced high rates of injuries and illnesses also receive priority. 6. Follow-up inspections: Checks for abatement of violations cited during previous inspections are also conducted by the agency in certain circumstances.4 In dental practices, the most common trigger for an OSHA inspection is a worker complaint or referral. A current or former employee can call in a complaint and, depending on a number of circumstances, including inspection history, if any, and the gravity of the complaint, an inspection can be triggered by this one phone call.5 Thus, it is prudent to treat employee concerns seriously and make the necessary corrective action before the issue escalates into a formal complaint to OSHA. When dental staff feel that they are threatened in an unsafe workplace for any reason, management needs to take immediate action. Usually, OSHA conducts inspections without advance notice. However, employers have the right to require compliance officers to obtain an inspection warrant before entering the worksite.4 According to a national news report, OSHA has lost 40 inspectors through attrition since President Trump took office in January 2017, and as of early October 2017, the federal agency had made no new hires to replace them. The 40 vacant positions represent 4 percent of OSHA’s total federal inspection force, which fell below 1,000 this past October.6,7

Fines In 2015, Congress passed the Federal Civil Penalties Inflation Adjustment Act Improvements Act to advance the effectiveness of civil monetary penalties and to maintain their deterrent effect. This law directs agencies to adjust their penalties for inflation each year using a much more straightforward method than previously available, and requires agencies to publish catch-up rules to make up for lost time since the last adjustments.8 ISSUE 2 • 2018 : DentalGroupPractice.com 43

Infection Control In August 2016, for the first time since 1990, OSHA increased its fines – by 78 percent. As of this date, the top penalty for serious violations rose from $7,000 to $12,471, and the maximum penalty for willful or repeated violations increased from $70,000 to $124,709. Then, effective January 2 of this year, OSHA increased its penalties again by 2 percent to adjust for inflation (as required by the Federal Civil Penalties Inflation Adjustment Act), with a maximum fine of nearly $130,000. The new fines apply to all violations that have occurred since November 2, 2015, with penalties assessed after January 2, 2018.9.10 Type of Violation

Penalty pre-August 2016

Penalty as of August 1, 2016

Penalty as of January 2, 2018

Serious OtherThan-Serious Posting Requirements

$7,000 per violation

$12,471 per violation

$12,934 per violation

Failure to Abate

$7,000 per day beyond the abatement date

$12,471 per day beyond the abatement date

$12,934 per day beyond the abatement date

Willful or Repeated

$70,000 per violation

$124,709 per violation

$129,336 per violation

Penalties such as these would have a significant financial impact on a dental practice of any size, including a large group practice or DSO. From October 2016 through September 2017, there were 87 citations from federal OSHA (state issued citations are not included in this number) to dental offices. Of those, 49 were Since the passage related to the bloodborne pathogens standard and 21 of the OSHA were related to the hazard Act, the rate of communication standard.11 Dental practices are reported serious workplace injuries busy places, but remember, the OSHA Act was put in and illnesses has place to protect all workers, declined from including those in dental healthcare. A safe workplace 11 per 100 also an efficient workplace. workers in 1972 isImplementation of – and to 3.6 per 100 compliance to – the required workers in 2009. elements of the bloodborne pathogens and hazard communication standards must be in place to ensure dental healthcare worker safety. Although there is a decrease in the number of OSHA inspectors, legitimate worker complaints will eventually be addressed. Dental employers should not risk the possibility of an inspection or a citation with the new fees. They should be proactive and follow the federal standards for providing and maintaining a high-quality, safe practice setting for all dental healthcare workers.

Editor’s note: Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent 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. References

1. US Department of Labor. Occupational Safety and Health Administration. Timeline of OSHA’s 40 Year History. https://www.osha.gov/osha40/timeline.html. Accessed January 17, 2018. 2. US Department of Labor. Occupational Safety and Health Administration. OSHA Celebrates 40 years of accomplishments in the Workplace. https://www.osha.gov/osha40/OSHATimeline.pdf. Accessed January 17, 2018. 3. US Department of Labor. Occupational Safety and Health Administration. Commonly used statistics. https://www.osha.gov/oshstats/commonstats.html. Accessed January 17, 2018. 4. US Department of Labor. Occupational Safety and Health Administration. OSHA fact sheet. https://www.osha.gov/OshDoc/data_General_Facts/factsheet-inspections.pdf. Accessed January 17, 2018. 5. G arofolo R. OSHA compliance for the dental office. DentalTown; September 2014. http://www.dentaltown.com/magazine/articles/5025/osha-compliance-for-the-dental-office. Accessed January 17, 2018. 6. NBC News. https://www.nbcnews.com/politics/white-house/exclusive-number-osha-workplace-safety-inspectors-declines-under-trump-n834806. Accessed January 17, 2018. 7. OSHA Healthcare Advisor. General health and safety. http://blogs.hcpro.com/osha/category/general-safety-and-health/. Accessed January 17, 2018. 8. US Department of Labor. Occupational Safety and Health Administration. OSHA national new release. https://www.osha.gov/news/newsreleases/national/06302016. Accessed January 18, 2018. 9. US Department of Labor. Occupational Safety and Health Administration. OSHA penalties. https://www.osha.gov/penalties/. Accessed January 18, 2018. 10. OSHA Healthcare Advisor. A rundown of new, increased OSHA penalties. http://blogs.hcpro.com/osha/2018/01/a-quick-rundown-of-new-increased-osha-penalties/. Accessed January 18, 2018. 11. U S Department of Labor. Occupational Safety and Health Administration. NAICS Code: 621210 Offices of Dentists. https://www.osha.gov/pls/imis/citedstandard.naics?p_ esize=&p_state=FEFederal&p_naics=621210. Accessed January 18, 2018.

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Trends

Measuring Up Despite a rise in patient visits, dental services account for a small percentage of healthcare spending.

Spending on dental services, while on the rise, still accounts for only 4 percent of U.S. healthcare spending, according to the Centers for Medicare & Medicaid Services. Spending for dental services increased 4.6 percent in 2016 to $124.4 billion – a slight acceleration from 4.4 percent growth in 2015. Private health insurance, which accounted for 46 percent of dental spending, increased 4.8 percent in 2016 – the same rate of growth that occurred in 2015. Out-of-pocket spending for dental services, which accounted for 40 percent of dental spending, increased 4.3 percent in 2016 – a faster growth rate than the 3.4 percent increase in 2015. The big picture Total U.S. healthcare spending increased 4.3 percent to reach $3.3 trillion, or $10,348 per person in 2016, according to CMS. Spending growth decelerated in 2016 after the initial impacts of Affordable Care Act coverage expansions and strong retail prescription drug spending growth in 2014 and 2015. The overall share of gross domestic product (GDP) related to healthcare spending was 17.9 percent in 2016, up from 17.7 percent in 2015.

Spending by type of service or product in 2016 looked like this: Hospital care (32 percent share). Spending for hospital care increased 4.7 percent to $1.1 trillion in 2016, slower than the 5.7 percent growth in 2015. The slower growth in 2016 was driven by the slower growth in the use and intensity of services, reports CMS. Hospital care expenditures showed mixed trends across the major payers, with slower growth in Medicaid and private health insurance spending, stable growth in Medicare spending, and faster growth in out-of-pocket spending.

Physician and clinical services (20 percent share). Spending on physician and clinical services increased 5.4 percent to $664.9 billion in 2016. Although growth for physician and clinical services decelerated slightly in 2016 (from 5.9 percent in 2015), it outpaced the growth in all other goods and services categories. The growth in the use and intensity of physician and clinical services was a ISSUE 2 • 2018 : DentalGroupPractice.com 45

Trends driving factor in the overall growth in physician and clinical services, accounting for nearly three-quarters of the 5.4 percent increase. Prescription drugs (10 percent share). Growth in retail prescription drug spending slowed in 2016, increasing 1.3 percent to $328.6 billion. The slower growth in 2016 follows two years of strong growth in 2014 and 2015, – 12.4 percent and 8.9 percent, respectively. This strong growth reflected increased spending on new medicines and price growth for existing brand-name drugs, particularly for drugs used to treat hepatitis C, says CMS. Growth slowed in 2016 primarily due to fewer new drug

residential mental health and substance abuse facilities. Such spending grew 5.3 percent in 2016 to $173.5 billion after increasing 8.7 percent in 2015. The slowdown was driven by the slower growth in Medicaid spending, 57 percent of all spending in this category, which slowed to 5.7 percent in 2016 after 10.8 percent growth in 2015. Nursing care facilities and continuing care retirement communities (5 percent share). Spending for freestanding nursing care facilities and continuing care retirement communities decelerated in 2016, growing 2.9 percent to $162.7 billion, compared to 3.7 percent growth in 2015. The slower growth in 2016 was largely attributed to slower spending growth in both Medicare (1.2 percent in 2016 from 4.0 percent in 2015) and private health insurance (5.9 percent in 2016 from 14.3 percent in 2015).

Spending for freestanding nursing care facilities and continuing care retirement communities decelerated in 2016, growing 2.9 percent to $162.7 billion, compared to 3.7 percent growth in 2015. approvals, slower growth in brand-name drug spending as spending for hepatitis C drugs declined, and a decline in spending for generic drugs as price growth slowed. Other professional services (3 percent share). Spending for other professional services reached $92.0 billion in 2016, an increase of 4.7 percent. This was a deceleration from the 5.9 percent growth in 2015. Spending in this category includes establishments of independent health practitioners (except physicians and dentists) that primarily provide services such as physical therapy, optometry, podiatry, or chiropractic medicine. Other health, residential, and personal care services (5 percent share). This category includes expenditures for medical services that are generally delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and 46

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Durable medical equipment (2 percent share). Retail spending for durable medical equipment, which includes items such as contact lenses, eyeglasses and hearing aids, reached $51.0 billion in 2016 and increased 4.9 percent, which was faster than the 4.1 percent growth in 2015.

Other non-durable medical products (2 percent share). Retail spending for other non-durable medical products, such as over-the-counter medicines, medical instruments, and surgical dressings, grew 4.4 percent (about the rate of growth in 2015, 4.6 percent) to $62.2 billion in 2016.

Who’s paying? Meanwhile, CMS reports 2016 spending by major sources of funds: • Medicare (20 percent share): Medicare spending grew 3.6 percent to $672.1 billion in 2016, which was lower than growth in the previous two years when spending increased 4.8 percent in 2015 and 4.9 percent in 2014. The slower growth in 2016 was due to slower growth in spending for both the Medicare fee-for-service (2.2 percent in 2015 to 1.8 percent in 2016) and Medicare Advan-

tage (11.1 percent in 2015 to 7.4 percent in 2016) portions of Medicare.

The stronger growth in 2014 and 2015 was due in part to the initial impacts of the ACA’s expansion of Medicaid enrollment during that period.

• Medicaid (17 percent share): Total Medicaid spending decelerated in 2016, increasing 3.9 percent to $565.5 billion. This was much slower growth than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and 9.5 percent in 2015. The stronger growth in 2014 and 2015 was due in part to the initial impacts of the ACA’s expansion of Medicaid enrollment during that period. State and local Medicaid expenditures grew 3.2 percent, while federal Medicaid expenditures increased 4.4 percent in 2016.

• Private health insurance (34 percent share): Private health insurance spending increased 5.1 percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015. The deceleration was largely driven by slower enrollment growth in 2016 after two years of robust enrollment growth due in part to ACA coverage expansion.

Out-of-pocket (11 percent share): Out-of-pocket spending grew 3.9 percent in 2016 to $352.5 billion, faster than the growth of 2.8 percent in 2015. This was the fastest rate of growth since 2007 and exceeded the average annual of growth 2.0 percent from 2008-15.

Source: Centers for Medicare & Medicaid Services, https://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf ISSUE 2 • 2018 : DentalGroupPractice.com 47

Leadership

How to Win Other People Over By Lisa Earle McLeod

Would you ever stand in the way of a rocket going into space? Do you want to hold your country back, or help it move forward? These are important questions. They’re examples of how the milieu creates the meaning. Milieu is the social conditions and events that provide a backdrop in which someone acts or lives. Tapping into the right milieu is the secret to winning people over and getting big things done. In the movie Hidden Figures three African-American women are broken down on the side of a lonely road in rural Virginia. The year is 1961. The three women work as “computers” at NASA doing calculations to put a rocket into space. Unable to start their car, three black women in Virginia are understandably nervous when a police cruiser drives 48

Efficiency In Group Practice : ISSUE 2 • 2018

up. The officer, billy club in hand, approaches. He’s condescending and downright hostile until the moment Katherine says, “We’re on our way to work at NASA. Yes sir, getting our rockets into space.” The officer’s entire countenance changes. He moves from hostile to helpful. He fires up his siren and gives the ladies a police escort to Langley. Why the change in attitude? The officer’s hostility quelled because he wanted to be part of something bigger than himself. He didn’t want to be the guy who caused his country to lose the space race. The scene may be fictionalized, but the overarching story is true. John F. Kennedy set a big audacious goal, to put a man on the moon. He rallied the country around beating

the Russians. The ladies in Hidden Figures used that lens to their advantage. The social context of the times was terrifying for African-Americans. The officer’s social programming was likely racist, thus his immediate reaction to the ladies, was hostile. Instead of reacting, the NASA computers skillfully changed the frame through which they were viewed. They tapped into a different milieu.

Set the tone How can you use this concept in your own work? In an ideal world you’re Kennedy. You set the tone, you create the big audacious goal and you remind people of it every day. You provide the context and meaning for the work. But we don’t all live in an ideal world. Maybe you’re living with hostility or prejudice. Or maybe you’re dealing with apathy and ignorance. In real life, the three women computers, Katherine Johnson, Dorothy Vaughn and Mary Jackson, were diminished and harassed. Yet, they prevailed.

Instead of playing small, they played big. Instead of succumbing to the social expectations of the times, they set their sights on a different reality. They positioned themselves in the service of something of importance to people in power. It’s an important lesson. If you want to win people over, cast yourself as a vital force for advancing a cause they care about. Watching the three women in Hidden Figures walk the line between deferential and engaging is both painful and inspirational. It’s painful to think about genius having to be subservient in order to serve. Yet the true story is inspirational. Johnson, Vaughn Jackson and others advanced scientific discovery, and they moved the needle socially for the generations who came behind them. The milieu is always moving. We are the ones who create it, and we are the people who decide which aspect of the milieu we want to tap into. You can help launch the rocket. Or you can be the one who accepted the barriers.

Lisa Earle McLeod is a leading authority on sales leadership and the author of four provocative books including the bestseller, Selling with Noble Purpose. Companies like Apple, Kimberly-Clark and Pfizer hire her to help them create passionate, purpose-driven sales organization. Her NSP is to help leaders drive revenue and do work that makes them proud. ISSUE 2 • 2018 : DentalGroupPractice.com 49

News

Enhanced Hygiene hosts Dental Group Evolution conference By Enhanced Hygiene staff

Leading dental coach, consultant and CEO and Founder of Enhanced Hygiene, Heidi Arndt hosted the second annual Dental Group Evolution conference and announced the highly anticipated launch of Enhanced Hygiene’s sister company, Enhanced Practices – along with an invitation to join her in The Boardroom, a year-long mastermind program.

Dental Group Evolution, held January 12 – 13, 2018 in Austin, Texas, was specifically designed for new and emerging mid-size dental groups to gather together and get inspired by listening and learning from the country’s most successful health practitioners and clinical experts. During these two exclusive days, the 200+ attendees experienced cutting-edge and practical strategies and solutions based upon proven evidence to help them grow their dental group practices. Through 50

Efficiency In Group Practice : ISSUE 2 • 2018

Heidi Arndt

general sessions, panel discussions and a wide array of breakout session choices, attendees customized their conference experience – including being up close and personal with hand-picked, amazing sponsors and networking with the country’s best. In addition to the content, Arndt took the stage at the end of Day 1 to unveil her new company, Enhanced Practices – as well as to invite attendees to enroll in its year-long, exclusive inner circle program, The Boardroom. Arndt explained that Enhanced Practices is the answer to the broader struggles practices face while trying to grow, such as misalignment, multiple philosophies and no consistency between providers and locations. Whereas The Boardroom is the opportunity to address those issues on-demand and work closely with experts who are able to give guidance along the way to growth and success. From start to finish, Dental Group Evolution was full of ground-breaking concepts and opportunities, in which no one else is offering in the industry. If you’re interested in connecting with Heidi or learning about or working within her companies, or joining The Boardroom, please reach out to hello@enhancedhygiene.com.

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