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From The Publisher

Hygiene and its Importance to Your Group.............................................. 4

Partnering for Growth................................................................ 6 Selecting the Right Cement Advances in cements have made them easier and more efficient to use.......................................................... 8 Providing an Excellent Experience Hygienists today must provide exceptional clinical care – and great customer service................................................ 12 Hygienists in Large Group Settings A supportive dental team can help hygienists succeed in large group settings................................................ 14 A Culture of Safety No dental practice is complete without a comprehensive infection control program.............................................. 14 Relationship Builders Hygienists play a key role in helping the dental practice bond with patients...................................................... 16 Giving Back Cosmetic dentist donates his services to help survivors of domestic and violent abuse.......................................... 18 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.

Orthodontics

Orthodontists today stress patient education and the ability to serve an increasingly versatile patient base....................... 20

Sterilization Monitoring

Quality assurance processes and procedures are inherent to the infrastructure of DSOs and large group practices..................... 26

Cements 101

A working guide for dentists...................................................................... 32

OSAP partners to advance competency in dental infection prevention and control education New program enhances infection prevention and control knowledge........................................................... 36 Foundations for Your Growing Dental Group......................................................38 Industry News................................................................................40 A Method for Dealing with Change and Challenge............................................42

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, RDH 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 3 • 2018 : DentalGroupPractice.com

From the Publisher

Hygiene and its Importance to Your Group We did not know it at the time – actually, we didn’t even know each other at the time – but my wife and I went to the same dentist as children. When we had our own children, we decided to go back to the dentist that we both used as kids. Like many patients with good oral hygiene, we spent most of the time with the hygienist, and therefore had the relationship with her vs. the dentist. When our hygienist Janice retired, my family continued on as patients at the practice. Let’s just say Janice’s replacement was no Janice. The replacement hygienist did not create the same rapport with us, nor did she display the same gentle care that Janice did. We voiced our concern with the owner dentist who seemed indifferent to our concerns. After going to this dental practice for decades, we realized that the reason we went to the practice and drove the distance we did was because of Janice. We found our new Janice at another practice closer to home and have been happy with and loyal to the practice, not because of the relationship with the dentist, but because of our relationship with the hygienist. In this issue of Efficiency, we review the importance of the hygienist in a group practice setting. Marisa Dolce, national hygiene director at Great Expressions Dental Centers, focuses on educating the entire dental team, including the dentist, to support the role of the hygienist as it leads to “a positive atmosphere and patient confidence.” Marisa also talks about the organization wide standard of care and team mentality which hygienists need to adapt to if they are coming from a private practice setting. Andrea Edelen, Director of Dental Hygiene and Clinical Support for Mortenson Dental Partners, addresses the importance of the relationship the hygienists have with their patients and how the dentist and hygienist need to be in sync with their messaging for better treatment acceptance, which will in turn result in better oral health. Through education and communication, good hygiene programs lead to thriving dental practices through restorative opportunities. A.J Acierno DDS, CEO of DecisionOne Dental Partners again points to the trust that patients have in their hygienists. He also looks beyond the clinical aspects of the job and tells us that hygienists must be also be customer service focused, able to educate patients and prepare them for typical treatment options they can expect from a restorative or cosmetic standpoint. Good reading, Bill Neumann

Efficiency In Group Practice : ISSUE 3 • 2018

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AFTER

Partnering for Growth 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 Partnering for Growth meetings.

The ADSO’s first Partnering for Growth meeting was held last September at the National Harbor, just outside Washington D.C. The feedback from attendees was so positive that the ADSO has added two of these meetings to the 2018 schedule! These events are designed to provide strategies for growth and development to small and emerging DSOs and group practices. The agenda will include: • Keynote addresses from the nation’s most successful DSO leaders. • Round table discussions with industry peers. • Sessions on marketing, including social media, reputa-

tion management and patient recruitment. • Next generation technology sessions. • Strategies for doctor recruitment and retention. • Sessions on private equity, mergers and acquisitions. • I nformation on the role of clinical directors and dentist mentorship. The first meeting will be held July 12-13 in Denver, Colo., and the second will be held November 13-14 in New York, N.Y. For more information on these meetings geared towards small and emerging DSOs go to http://theadso.org/events.

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Efficiency In Group Practice : ISSUE 3 • 2018

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The ADSO’s first Partnering for Growth meeting was held September 21-22, 2017 and the feedback from attendees was so positive that we’ve added two of these meetings to the 2018 schedule! These events are designed to provide strategies for growth and development to small and emerging DSOs and Group Practices. The agenda will include: • Keynote addresses from the nation’s most successful DSO leaders • Round table discussions with industry peers • Sessions on marketing including social media, reputation management, and patient recruitment • Next generation technology sessions • Strategies for doctor recruitment and retention • Sessions on private equity, mergers and acquisitions • Information on the role of clinical directors and dentist mentorship If you’re interested in learning more about ADSO’s events or membership, please contact us: Membership@theADSO.org | 703-940-3860 1235 S. Clark Street, Suite #1210 • Arlington, Virginia 22202

ISSUE 3 • 2018 : DentalGroupPractice.com

Cements

Selecting the Right Cement Advances in cements have made them easier and more efficient to use. Cements today bear little resemblance to the early “Post-op sensitivity is usually related to the bonding prototypes. Newer resin-based cements require no mixing, procedure and pulp protection rather than the cement come in a variety of shades and fit all clinical scenarios, itself,” he adds. according to Dr. Rolando Nunez, Bisco, Inc. Their bioThere are two major categories of cements used compatibility, low solubility and enhanced physical propin dentistry, according to Nunez: resin-based and nonerties have made them more reliable, he points out. Stateresin-based. “Resin-based cements can be less soluble of-the art calcium-releasing cements than resin modified glass ionomers are designed to stimulate apatite for(RMGI) due to their higher resin mation and bond to metal and zircocontent,” he says. “Regular glass ionnia surfaces, without the assistance of omers (GI), in turn, are more soluble primers. And, auto-mix syringes are than resin-based and RMGI cements. easier – and cleaner – to use. Resin-based cements also have better “Clinicians depend on cements physical properties than glass ionto be as versatile as possible,” Nunez omers – again due to their higher continues. “A cement must be easy resin content. Bonded resin-based to use, easy to mix and easy to discements require the use of a dental – Dr. Rolando Nunez pense,” he says. The more versatile adhesive as part of the cementation the cement, the fewer products clinicians must stock procedure, whereas GI and RMGI cements do not.” in their armamentarium. “Versatility translates to ecoResin-based cements include both self-adhesive and nomic benefits, as one or two cement products should be bonded cements. With self-adhesive cements, there is no enough to address all clinical scenarios.” need to use a bonding agent prior to the cementation procedure, Nunez explains. Bonded resin-based cements, Selecting the right cement on the other hand, require a dental adhesive to be applied A working knowledge of cements enables clinicians to to the preparation prior to the cementation procedure. select solutions that best meet the needs of their practice. “The adhesive must be compatible with the cement in Film thickness, work and setting time, compatibility and the order to avoid polymerization hindrance,” he notes. ability to determine whether surfaces must be primed prior “Based on the polymerization mechanism, hydroto using the material all factor into the final choice. And, scopic expansion, pH and shade, cements will have difdepending on the type of restoration, they must understand ferent clinical applications,” says Nunez. “In general, dual how the curing mechanism will affect the final performance. cured resin-based cements and RMGIs can be used for full-coverage restorations, such as crowns and bridges. “Cements should be stable, meaning the working and For esthetic demanding restorations, such as veneers, a setting time should not be impacted by storage condilight cured resin-based cement is preferred. Based on the tions,” says Nunez. Additionally, they should be: restorative material, any cement will work on metal-based • Easy to clean to avoid excess cement subgingivally and restorations. For ceramic materials, a surface treatment is interproximally, which can lead to periodontal issues. required for optimum bonding; thus, a resin-based mate• Insoluble and stable in intraoral conditions. rial is better suited for such treatments. •A ble to achieve proper film thickness (less than 50 With the right cement solution, dental practices microns) to avoid interfering with proper seating can provide their patients with long-lasting, esthetically of the restorations. pleasing results.

“The adhesive must be compatible with the cement in order to avoid polymerization hindrance.”

Efficiency In Group Practice : ISSUE 3 • 2018

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In a constantly evolving marketplace, companies such as Flow Dental make it a point to continually update their development initiatives and training programs, ensuring their dental customers are positioned to provide the best possible patient care.

Efficiency In Group Practice : ISSUE 3 • 2018

“Over the years, we have adjusted our research and development to reflect the changing marketplace,” says Bill Winters, president, Flow Dental. At the same time, the company continually educates dental professionals on how to use new technology correctly and efficiently, he adds. “Some of our products are technique sensitive,” he points out, noting that busy staff members can be tempted to read the manufacturer directions after they’ve attempted to use a new product. “Improper use of a manufacturer’s product can lead to dissatisfaction and less-than-optimum outcomes,” he says. “For this reason, we ensure that our technique-sensitive products have thorough instructions included in each package. In addition, we have made available short instructional videos on several products.”

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Two examples of Flow Dental products that have led to greater efficiency – both chairside and in the front office – are the Perfect Fit universal camera sleeve and the Uni-Verse-All sensor positioner. “The Perfect Fit universal camera sleeve enables dental professionals to standardize and consolidate their intraoral camera sleeve inventory into a single SKU,” Winters explains. “Additionally, our new UniVerse-All sensor positioner offers benefits beyond those of traditional x-ray sensor positioners,” he says. “The Uni-Verse permits the imaging of anterior, posterior and bite-wing positions, without having to swap out rings, arms or bite blocks. “For PSP users, our Safe’n’Sure OPT preloads the recommended

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cardboard inserts to speed up plate reloading,” Winters continues. “When it comes to our product design, we try to keep in mind how our products are used and how we can improve efficiency at the user level.” For more information, visit http://www.flowdental.com. ISSUE 3 • 2018 : DentalGroupPractice.com 11

Providing an Excellent Experience Hygienists today must provide exceptional clinical care – and great customer service. By Laura Thill

Dental patients today expect excellent – and efficient – service. If they don’t find it at one practice, there’s nothing to stop them from looking elsewhere, according to Alan J. Acierno, DDS, CEO of DecisionOne Dental Partners. At the same time, patients spend “the majority of their time with the hygienist, developing a relationship,” he points out. “This relationship is vitally important to the success of the practice. So, in addition to providing excellent clinical care, hygienists are now expected to provide a high level of customer service.” The question is, how can hygienists, who are clinically trained, also provide excellent customer service and ensure patients spend as little time as possible in the chair, he continues. “Our patients lead busy lives and don’t want to spend all day at the dental office,” he says. “Finding that balance is extremely difficult and can only happen if the office works as a team to ensure it does.” 12

Efficiency In Group Practice : ISSUE 3 • 2018

Alan J. Acierno

Dentists – as well as the entire dental team – must keep in mind that “the majority of a patient’s dental experience takes place in the hygiene chair,” Acierno continues. “Patients place much of their loyalty and trust in their hygienist. Everyone in the office must take responsibility to make sure the hygienists are able to provide an excellent experience for their patients and ensure this loyalty and trust is established.” That said, hygienists should be trained to take photos, identify key symptoms and signs, and have a sense of how the dentist typically treats each case, he explains. Additionally, they should take time to educate their patients. “When it is time for the doctor exam, a system should be in place to ensure

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all of this information is delivered in an organized way.” So often when the dentist steps away from the operatory, the patient turns to the hygienist to confirm that the recommended treatment is truly necessary, he adds. Acierno is confident that dental professionals working in large group settings and DSOs have an advantage. “The best part about being a large group practice is that we can learn from one another by looking at best practices taking place at other offices within the group,” he explains. “This is why training and mentorship are so important. In my group, we have CE events specifically geared to our hygienists. This CE isn’t merely clinically focused. We also educate around such concepts as communication, relationship-building and leadership. We have identified our star hygienists and utilize them as mentors for our newer hygienists, as well as for those who require additional help.”

Patient perception The hygienist-patient relationship definitely influences a patient’s decision to return to a dental practice, notes Acierno. But, “if an organization does not provide an environment where everyone feels safe and comfortable, patients won’t return and staff will leave,” he points out.

And, a thorough infection prevention program is key, he adds. “I think this topic is often overlooked,” he says. “It’s not fun to talk about it, and it requires additional work and time to be done properly. However, the risks are just too great for infection prevention to be overlooked. Staff education is central to developing an infection prevention program, according to Acierno. The entire dental team must understand why protocols and decisions are made, and be on board with these decisions, he explains. “The dental team must understand that everything is done for their benefit and protection. Once they understand this and realize the organization is coming from a point of caring for their well-being, I think compliance will be much higher. “We have seen stories in the news of dental offices in which the staff is not following proper infection prevention methods,” he continues. “This type of publicity can be catastrophic to an office or dental group.” Particularly in today’s social media savvy culture, a negative review can draw a lot of attention. “In addition to the bad publicity, it will likely cause state and local regulatory boards to take note,” he says. “When this happens, audits and fines are likely to follow.” ISSUE 3 • 2018 : DentalGroupPractice.com 13

Hygienist

Hygienists in Large Group Settings A supportive dental team can help hygienists succeed in large group settings. Hygienists fill a unique role in large group dental settings and DSOs. Patients spend the majority of their dental visits with their hygienist, notes Marisa Dolce, national hygiene director, Great Expressions Dental Centers (GEDC). When the entire dental team – including the dentist – supports the role of the hygienist, it leads to “a positive atmosphere and patient confidence,” she says. “The dental team should collectively provide great patient care and a great patient experience, so enlisting the whole team to support hygiene is in the best interest of the practice.” The more educated the dental team, the better they can support their hygienists, Dolce continues. “Inclusion of support team members in the education process is key,” she says. Most large group practices employ hygiene directors or mentors, whose job is to train and educate

other team members in the practice when appropriate, she explains. “The whole team must be made aware that the hygiene-patient visit provides the well from which all dentistry comes. Great practices have great teams who support that all-important-hygiene-visit for their patients.” Particularly in large group settings or DSOs, where hygienists are accountable for adhering to an organization-wide standard of care, a team mentality can help foster a positive atmosphere, Dolce points out. Incorporating the hygiene staff into a large multi-site practice can be challenging, she notes. “I always inform new-hire hygienists that their day-to-day professional life within the practice will be much like that of any private practice, with the exception that we follow specific protocols of treatment. Here, the hygienist does not have to go it alone. They have a voice.”

A Culture of Safety

No dental practice is complete without a comprehensive infection control program. A successful infection control program is integral to a true culture of safety, according to experts. “Both are very important,” says Elaine Olejnik, compliance officer, Great Expressions Dental Centers (GEDC). “You cannot have one without the other. Careless infection control practices can place the entire dental team and patients at risk for such diseases as Herpes, Hepatitis, HIV, AIDS and Tuberculosis. Many of these infections are chronic, life-long and even life-threatening diseases – often carried by individuals who do not know they are infected or fail to share this with the dental team in their medical history. Great Expressions is fortunate in that we have both a culture of safety and a successful infection control program, allowing us to work as a team in providing a safe environment for our employees and our patients.” 14

Efficiency In Group Practice : ISSUE 3 • 2018

Doing so requires “constant team training,” Olejnik continues. “Although this isn’t a barrier, it can be demanding,” she points out. “Continually communicating the what, why and how of current infection control standards and compliance is mandatory.” Agencies such as the Centers for Disease Control and Prevention (CDC), the Organization for Safety, Asepsis and Prevention (OSAP), the Occupational Safety and Health Administration (OSHA) and the American Dental Association (ADA) can help dental practices implement and adhere to infection control standards. Additionally, Great Expressions has a number of supportive tools (an infection control coordinator within each office, compliance checklists, internal audits, spore test reports, compliance dashboards, etc.) that help ensure the success of its infection control program, she adds.

Hygienist

Relationship Builders Hygienists play a key role in helping the dental practice bond with patients. By Laura Thill

In a relationship-based business such as dentistry, hygienists play a key role in building patient trust and encouraging treatment compliance. Indeed, they have always been tasked with delivering excellent patient care, including preventive and periodontal services and patient education, notes Andrea Edelen, Director of Dental Hygiene and Clinical Support for Mortenson Dental Partners. But, today more than ever before, they have the ability to influence patients. “Patients tend to build strong relationships with their dental hygienist,” she says. “This is the provider they see at regular intervals, as well as the person in the office with whom they spend the most time. So, when the hygienist provides a message consistent with that of the dentist, treatment acceptance increases and overall oral health improves.” Patients who trust their hygienist tend to be more likely to return for regular checkups and cleanings, Edelen continues. “Much of the success of the dental practice rests upon the relationships built between hygienists and their patients,” she adds.

A united team It’s important to convey the value of hygienists to the entire dental team at a large group practice or DSO, according to Edelen. “A lot of the trust built between a practice and a patient starts with the hygienist, and everyone on the 16

Efficiency In Group Practice : ISSUE 3 • 2018

Andrea Edelen

team should work to support that relationship and to build on it. “Hygiene encounters are one of the most important elements of a thriving dental practice, because they drive restorative encounters,” she continues. “But the message can’t end there. Every team member should understand their role in supporting hygiene encounters, treatment conversion and the patient experience. Supporting treatment conversion promotes the overall health and wellness of patients and practice success, but this message is sometimes lost in translation. A clearly communicated vision with a destination and roadmap to get there is essential. Furthermore, there must be consistency throughout every patient encounter. If a hygienist knows a patient may be fearful, it is important that the entire team works together to alleviate those fears, not just the hygienist.” It takes a lot of communication and education to ensure the entire dental team is working together, says Edelen. “Every role in a dental practice is different, but equally important. Each role should complement the others, and together they can contribute to an exceptional patient experience and overall improvement of our communities’ oral health.”

Working through the challenges As large group practices and DSOs acquire new offices, it can sometimes be challenging to help hygienists transition into their new setting, according to Edelen. But it’s essential, she notes. “A comprehensive change management process can prepare and support hygienists for a transition,” she says. Compassion goes a long way, she adds. Even minor changes can radically affect hygienists, so it’s important to provide them with a realistic timeline for adapting to any changes. “It’s also important for management to provide transparency and relevant, timely key performance indicators, which are easily accessible and understandable.”

program, which is imperative for a group practice to flourish,” says Edelen. Hygienists – as well as all dental providers – “must complete the narrative for patients by connecting the dots between oral health and their overall health,” she contin-

“ Much of the success of the dental practice rests upon the relationships built between hygienists and their patients.”

A holistic approach The importance of hygiene can set the narrative for the dental practice, and hygienists are on the frontline. “A strong hygiene program leads to a strong restorative

– Andrea Edelen, Director of Dental Hygiene and Clinical Support for Mortenson Dental Partners

ues. “An unhealthy mouth can increase the risk of serious health problems, such as heart attack, stroke, poorly controlled diabetes and preterm labor. Decay, poor habits and nutrition are chronic in children. We must be diligent and empathetic in our approach to educate patients and communities, to make the connection between oral and overall health. A holistic approach will create synergy, and there is nothing more powerful than that.” ISSUE 3 • 2018 : DentalGroupPractice.com 17

Serving the community

Giving Back Cosmetic dentist donates his services to help survivors of domestic and violent abuse. By Laura Thill

If a smile speaks a thousand words, so too does the lack of one. The National Coalition Against Domestic Violence (NCADV) estimates that more than 10 million people living in the United States experience physical domestic abuse each year. “Domestic violence is prevalent in every community and affects all people regardless of age, socio-economic status, sexual orientation, gender, race, religion or nationality,” the organization states on its website. “Domestic violence can result in physical injury, psychological trauma and even death. The devastating consequences of domestic violence can cross generations and last a lifetime.” Dr. Michael Fulbright’s affiliation with the American Academy of Cosmetic Dentistry (AACD) has taught him that while an abuse victim’s healing may begin in a hospital emergency room, it’s often Michael Fulbright not complete without a major dental restoration. For the last 10 years, the Redondo Beach, California-based cosmetic dentist and owner of Fulbright Cosmetic & Reconstructive Dentistry has participated in the AACD Charitable Foundation’s Give Back a Smile program, providing advanced dental treatment to survivors of domestic abuse free of charge. “This has been a great opportunity,” says Fulbright. “I have never turned a patient away and always provide treatment above and beyond the basic necessities. I figure, if I can do more for patients, why not?”

An emotional ride Working with survivors of abuse has been fulfilling, notes Fulbright; at the same time, the experience has been an emotional one. “These patients have gone through a lot,” 18

Efficiency In Group Practice : ISSUE 3 • 2018

he points out. “Many of them are missing their front teeth.” Ideally, he works to restore their ability to smile, but sometimes, that can be challenging. For instance, he had a recent patient who was a victim of domestic abuse in 1975. When the woman’s husband passed on, she was finally willing to contemplate a restoration, however she was concerned about losing her few remaining teeth. In another case, a man was beaten up by his partner, and Fulbright provided a fullmouth restoration. “He was a street performer, so this was essential,” he says. In a third case, he treated a man who was beaten up in nearby Long Beach, California while walking with his partner. “Abuse is a difficult, traumatic thing to get past,” he says. “But, I like that I can give these patients a second chance.” Indeed, Fulbright has seen his patients move on to new relationships and job opportunities. Some have even become regular patients at his practice. “Once I complete a restoration, I’m not liable for future care, but I always make it a point to follow up with patients,” he says. After all, he explains, patients must demonstrate a substantial level of commitment to be admitted into the program. Not only must they submit to a strenuous vetting process by NCADV, they risk being kicked out of the program if they fail to return a call to Fulbright’s practice or don’t show up to their dental appointment. “NCADV tracks these patients carefully, as well as the amount of work and expenses I donate,” he says. “This has been a great experience for me. These patients have been through a lot and [they deserve] the ability to smile.

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Give Back a Smile The Give Back a Smile (GBAS) program began in 1999. Since then, AACD member dentists, dental laboratories and other dental professionals have volunteered their time and expertise pro bono to provide care to over 1,600 patients, at a value of $16+ million in donated dental services. To be eligible, patients must: •B e 18 years or older and receive dental injuries to the smile-zone from a former intimate partner/spouse or family member. This includes sexual assault and rape victims. •B e away from all abusive relationships with an intimate partner or spouse and/or living in a separate home from an abusive family member, for a minimum of one year. • Wait one year after a sexual assault.

• Meet at least once with a domestic violence/ sexual assault advocate, case manager, counselor, faith leader, therapist or doctor with experience in counseling survivors of domestic violence/sexual assault. The program does not help with dental neglect (such as cavities), gum disease, jaw injuries or orthodontic treatment (braces, shifted teeth, and/ or spaces between teeth). Nor does it replace or fix previous dental work completed by any dentist. In order to apply for the program, patients must pay a $20 application fee or complete 10 hours of community services. For more information visit https://www.aacd.com/ index.php?module=cms&page=1932.

ISSUE 3 • 2018 : DentalGroupPractice.com 19

Orthodontics

Orthodontics Orthodontists today stress patient education and the ability to serve an increasingly versatile patient base. By Laura Thill

Patient education has always been a priority for dental professionals. But, as social media continues to influence the public, and more and more people rely on Google for expert advice, specialties like orthodontics are finding it more important than ever before to connect with patients early on. “Today, we have teenage and adult patients who trust a post or smartphone app as the authority on most topics, including their orthodontic care,” says Carl Gioia, DDS, an orthodontist with Louisville, Kentucky-based BracesBracesBraces, which is a Mortenson Dental Partners brand. “Educating my patients and their families on what we do and why we do it has become my top priority, because in a time of endless information consumption, we need to make sure our relationships with our patients are built on trust. At BracesBracesBraces, we say eight is great, Carl Gioia meaning it’s important to begin educating our referred patients – as well as their parents – at the age of eight, long before their orthodontic treatment actually begins.” Will Engilman, CIO, president of support services, Mortenson Dental Partners, and an orthodontist and founder of BracesBracesBraces, agrees. “Ten years ago, the focus was on building relationships in our physical community,” he says. “Now it is about being engaged in both our physical and digital community.” Particularly given the increase in general dentists offering different forms of orthodontic treatment – from Invisalign to Six Month 20

Efficiency In Group Practice : ISSUE 3 • 2018

Will Engilman

Smiles – and the growing number of lab-to-consumer offerings, such as Smile Club and SmileLove, “we are now tasked with educating patients about what orthodontists can do for them, long before they come into our office,” he says. At the same time, the orthodontic market is seeing a shift from primarily pre-teen/teenage patients to a balance of pediatric, young adult and even middle-age patients. “As more esthetic-conscious, middle-age people are looking to have a great smile, in addition to the traditional teenage patients, it’s becoming more important to have a practice

versatile enough to cater to patients of all ages,” says Gioia. Advances in technology have made it easier for orthodontists to measure their performance and quantify the patient experience, adds Engilman. “With these newer resources, we can focus on what’s important to our patients – what they truly value – and how we can deliver these services.” Indeed, technological advances have made it easier for orthodontists to customize patients’ treatment more efficiently, Engilman continues. “Every case is different, and now we can hyper-target each patient with a specific care plan that is best for him or her.” “We have tailored our orthodontic appliances to work in concert with each patient’s biology,” Gioia points out. “The biologic tooth movement tends to be most efficient for our patients. Whether we are working with newer wires or clear aligner therapy, we’ve been trying to apply more light, continuous forces, which hopefully will increase the efficiency of the tooth movement.”

Communicate, communicate, communicate As orthodontic practices become increasingly focused on patient education, they depend on the dental teams

at general practices to deliver a consistent message to patients. “There is nothing more reassuring to a parent than when a general dentist refers [their son or daughter] to our orthodontic practice, and they receive the exact same information with regards to a diagnosis or possible treatment,” says Gioia. “It’s a powerful tool in building our patient base and it builds a sense of trust between the families in our community and our dental colleagues. As orthodontic specialists, we need to spear-head that conversation in our communities.” “I would add that great communication is a team effort,” says Engilman. “All members of the dental team have an opportunity to help convey the message of oral health, and how orthodontics plays a part. This builds patient trust and ease of mind. That said, the orthodontist should work toward adding value to the referring dental practice with outstanding patient care, education and delivering piece of mind to the parents and patient regarding treatment. We work very hard to preserve our relationship with all of our referring dentists, as well as the dentist-patient relationship.”

An empowered team Being part of a large DSO like Mortenson Dental Partners has enabled Carl Gioia, DDS, an orthodontist with Louisville, Kentucky-based BracesBracesBraces, to focus on building relationships with his patients and providing above-and-beyond patient care. “At the end of the day, my worries are about the people who come into my office and how we can get them the smile they want,” he says. “I’m not bogged down by IT or software glitches that may arise, and I’m not worried about administrative burdens of the business. I get to focus on taking care of my patients – both young and old. If our team puts our full effort behind that motivation, the success of our practice will follow.” “At Mortenson Dental Partners, we have empowered all of our team members at all levels to think like an owner,” adds Will Engilman,

CIO, president of support services, Mortenson Dental Partners, and an orthodontist and founder of BracesBracesBraces. “To do so, we employ open book management. All levels of our organization can see into the performance of each function and use this data to make the best decision for their patient, their team and the company. “One of the biggest ways we can support our providers is to give them the tools and resources to be successful and to deliver care to their patients,” he continues. “We want our providers to focus on their patients – not payroll, marketing or human resources. By supporting them with experts in these functions, we give them the opportunity to deliver high quality, consistent care for each patient, at every visit.”

ISSUE 3 • 2018 : DentalGroupPractice.com 21

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Turning Back the Clock

How lab/dentist collaboration and high-quality denture materials created a youthful smile

Today’s dental patients are becoming increasingly savvy and more discerning about the materials and techniques used in their treatments. Edentulous patients requiring implant-supported full-arch restorations are no exception. In such cases, collaborative communication between the laboratory and the dentist can result in functional outcomes that simultaneously satisfy clinical needs and patient demands. Case presentation By Dr. Amy Scott, Chestnut Hills Dental and Tom Taylor, NDX Albensi Dr. Amy Scott graduated from Carlow University with a BS in biology, after which she received her doctorate in 1995 from the University of Pittsburgh School of Dental Medicine. Committed to educating her patients about their overall dental health and needs and providing them with the best care possible, Dr. Scott has worked in various practice settings over the past 22 years. She is currently employed by a group dental practice and also works part-time performing mobile dentistry for underserved school children. A dedicated mother of three who enjoys spending time with her husband and children, Dr. Scott is an avid self-taught cook and baker who loves to plan/host family events.

An edentulous man in his mid-60s presented for restoration of implants that had been placed approximately 18 months earlier by a periodontist. After experiencing multiple dental problems throughout his life, he stopped seeing his dentist for regular check-ups and hygiene appointments. In pain and uncomfortable with his appearance, he eventually decided to re-engage with a dentist to learn about his options and how to improve his oral health. The option he chose was to have his teeth extracted and to ultimately have implants placed by a periodontist. However, despite having two completely edentulous arches, the patient chose not to adopt provisional dentures. As a result, bone resorption occurred, which presented challenges to the oral surgeon when the implants and healing caps were placed (i.e., in the areas of teeth Pre-op. Pre-treatment view of an edentulous patient ##3, 6, 11, 15, 18, 22, 27, 30). It also who’d already undergone implant placement and now created the need for longer healing desired full-arch dentures. time to ensure osseointegration. After researching implant-supported dentures (i.e., teeth and base materials), he was now seeking the best full-arch denture options for his implants and budget. His research led him to SR Phonares denture teeth and Ivobase acrylic (Ivoclar Vivadent, Amherst, NY). He actively sought out these materials by calling the manufacturer and opting for treatment at our practice (Chestnut Hills Dental), in collaboration with NDX Albensi. NDX Albensi uses only these materials for their denture bases and denture teeth based on their favorable characteristics for patients, including life-like esthetics and durability to withstand mastication forces from implants.

Efficiency In Group Practice : ISSUE 3 • 2018

Impressions and evaluation Preliminary impressions were taken in order to proceed with the case. Using the impressions and the patient’s dental health as the basis, the case was evaluated and it was determined that removable attachment Locator abutments (i.e., Locator R-Tx, Zest) would be the best option for the patient. This removable attachment system would enable the patient to remove the dentures for proper oral hygiene.

Denture fabrication The laboratory fabricated custom trays that were subsequently used for final impressions. After the laboratory technicians fabricated models based on these impressions, the proper removable attachment locator abutments were selected. The wax record bases were fabricated, and these were used to establish the bite and identify landmarks for tooth arrangement. Because the patient had been without teeth for such a long time – and given his previous history of very poor oral health – this process was challenging. Fortunately, the patient’s wife provided the laboratory with a photograph that was taken of him when he was much younger and had served in the U.S. Post-op. Post-insertion view of the patient with his maxillary and mandibular implant-supArmy, which was many years prior to him ported SR Phonares and Ivobase full-arch dentures. becoming edentulous. This was an excellent visual aid that could be used to select and position the denapproval, and he was thrilled. The fit and finish of his ture teeth (i.e., SR Phonares). dentures were exceptional, and he indicated that his smile During the patient’s next appointment, the wax looked like it had decades earlier. His wife’s and family’s try-in of both arches was performed. The healing caps reactions also were extremely positive. were removed, and the removable attachment system A life-changing transformation abutments were placed into the proper position in the The patient’s life-changing transformation was realized patient’s mouth. Some minor adjustments were made in as a result of collaborative communication between the the dental office to the anterior arrangement to satisfy dentist and laboratory, as well as the use of high-quality the patient. However, the bite and esthetics were othdenture materials (i.e., SR Phonares, Ivobase), which erwise very much consistent with the patient’s preferimproved his appearance and ability to eat properly, ence. Therefore, the dentist and patient both approved and helped him experience a better quality of life. The the case for final fabrication. treatment process was a positive experience for both the The denture insertion appointment proceeded members of the dental team and the patient – one that flawlessly. The healing caps were removed, after which resulted in a more youthful appearance and greater functhe Locator abutments were placed. The finished SR tion than he’d had in decades. Phonares/Ivobase dentures were inserted for the patient’s ISSUE 3 • 2018 : DentalGroupPractice.com 25

Infection Control

Sterilization Monitoring Quality assurance processes and procedures are inherent to the infrastructure of DSOs and large group practices. Quality assurance measures provide the basis for sound protocols that meet the standard of care for patient treatment, as well as compliance to stated guidelines and recommendations outlined by important agencies, such as the Centers for Disease Control and Prevention (CDC) and professional organizations, such as the American Dental Association (ADA), the Association for the Advancement of Medical Instrumentation (AAMI) and the Organization for Safety, Asepsis and Prevention (OSAP).

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. 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.

The correct reprocessing of reusable dental instruments in any practice setting is the foundation for patient safety. It’s important to monitor this process to ensure certain parameters are met during sterilization and to directly challenge the sterilizer in killing spores. As part of the quality assurance program, the practice should comply with CDC guidelines, which recommend three types of sterilization monitoring to ensure reusable dental instruments are safe for patient use1-3: • Mechanical • Chemical • Biological

Mechanical monitoring Mechanical techniques for monitoring involve evaluating the cycle times and temperature – or pressure – that is reached in the sterilizer by actually viewing the

Efficiency In Group Practice : ISSUE 3 • 2018

gauges or displays on the machine. Many newer models of sterilizers have computerized recording type devices, such as flash-drives, which can provide printouts of stored information related to mechanical monitoring. Dental team members should know the correct readings for all sterilizers so that inconsistencies are easily recognized and addressed. Mechanical monitoring does not confirm sterilization; however, incorrect readings can be a first clue for sterilizer malfunction.1-3 Dental team members must remember that mechanical monitoring has to do with the processes occurring inside the sterilizer chamber, rather than the conditions of the packages, pouches or cassettes. Thus, mechanical monitoring will not detect problems that result from overloaded sterilizers, improper packaging materials or the use of closed containers.4

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Infection Control Chemical monitoring Chemical monitoring should be implemented on a routine basis. The goal of chemical monitoring is to determine whether instrument packages – including the instruments inside these packages – have been exposed to the sterilizing conditions.4 Chemical indicators (CIs) change color or physical form when a certain parameter is reached inside the sterilizer. Heat- or chemical-sensitive inks in the indicators change color when one or more sterilization parameter (e.g., steam-time, temperature, and/or saturated steam; ETO-time, temperature, relative humidity and/or ETO concentration) is present.3 Chemical indicators are available in different designs, including tape, strips and special markings on packaging pouches. The CDC states, “a chemical indicator should be used inside every package to verify that the sterilizing agent (e.g., steam) has penetrated the package and reached the instruments inside. If the internal chemical indicator is not visible from the outside of the package, an external indicator should also be used. External indicators can be inspected immediately when removing packages from the sterilizer. If the appropriate color change did not occur, do not use the instruments. Chemical indicators also help to differentiate between processed and unprocessed items, eliminating the possibility of using instruments that have not been sterilized.”2 Chemical indicators should not replace biological indicators, as only a biological indicator consisting of bacterial endospores can measure the microbial killing power of the sterilization process.5 The AAMI offers the following table to explain the six types of chemical indicators.6 (It is important that all dental team members are trained on the chemical indicators being used in their dental practice.)

Many dental professionals and staff are familiar with autoclave tape from dental school or their training programs. Autoclave tape is often used on the external packaging of wrapped cassettes or instrument packs. The tape is considered a Class 1 chemical indicator and usually reacts to one variable: temperature/heat. Using only a Class 1 tape chemical indicator on the external packaging does not meet the full requirements for chemical indicator protocols established by the CDC.1-3 Also, this type of external chemical indicator does not indicate that sterilization – let alone a complete sterilization cycle – has occurred. For instance, it’s possible the sterilizer reached the appropriate temperature and then immediately malfunctioned after the chemical indicator already changed color.4 In addition to the Class 1 chemical indicators, other types of chemical indicators commonly used include the multiparameter CI, which may be a Class 4 that reacts to more than one parameter (time, temperature or the presence of steam), and the integrating CI, which is a Class 5 that reacts to all three parameters. Many manufacturers make dual-indicator pouches, which have both internal and external Class 4 CIs built into the packaging, meeting the criteria set by the CDC. Integrating chemical indicators in the form of strips should be used for cassettes and are available through a variety of vendors. Integrating indicators should be placed inside the cassette prior to placing it in a large pouch or wrapping. After opening each processed pack, pouch or cassette, the dental team must immediately observe the internal chemical indicator. If the appropriate change has not occurred, the sterilizing agent has not penetrated the packaging material or the package has not been

The AAMI Standards list six types of chemical indicators: Type Type 1 Type 2 Type 3 Type 4 Type 5 Type 6

Indications for Use Process indicator for use on the exterior of packages. For use in specific test procedures, i.e. Bowie-Dick type test to check for proper air removal of pre-vacuum steam sterilizers. Single-variable indicator that reacts to one critical variable, i.e. time or temperature. Multi-variable indicator that reacts to 2 or more critical variables. Integrating indicator that reacts to all critical variables and is equal in performance to a biological indicator, but does not replace routine biologic monitoring. Emulating indicator that reacts to all critical variables for a specified sterilization cycle.

ANSI/AAMI ST79:2010/A4:2013 Comprehensive guide to steam sterilization and sterility assurance in health care facilities – http://www.aami.org/productspublications/ProductDetail.aspx?ItemNumber=1383 28

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Infection Control processed through the sterilizer,4 and the items should not be used on a patient.

Biological monitoring Sterilizer monitoring – together with the proper sterilization of instruments and materials – is an essential part of any in-office infection control program,5 according to the ADA. Biological indicators (BIs), or spore tests, are the only process indicators that directly monitor the lethality of a given sterilization process. Spores used to monitor a sterilization process have demonstrated resistance to the sterilizing agent and are more resistant than the bioburden found on medical devices. B. atrophaeus spores are used to monitor ETO and dry heat, and G. stearothermophilus spores are used to monitor steam sterilization, hydrogen peroxide gas plasma and liquid peracetic acid sterilizers.3 Biological monitoring should be completed on a weekly basis1-5 and results should be logged. Maintaining accurate records ensures cycle parameters have been met and establishes accountability in the practice.2 Dental team members responsible for conducting weekly spore testing must be trained and take their responsibility seriously. Many larger practices and DSOs have dedicated sterilization staff to carry out these duties, which helps to ensure consistency and calibration that positively impacts patient safety. Instructions for use (IFU) should be followed for the specific biological indicator used in the practice, and both the control and test biological indicator must be from the same lot number. Miller outlines the general procedure for use of biological indicators:4 1. Insert the biological indicator inside a pack, pouch or cassette and complete the packaging procedures. 2. Place the pack, pouch or cassette in the center of the load (unless otherwise indicated by the sterilizer IFU) and process as part of a normal load cycle. 3. Record the date of the test, type of sterilizer, temperature and time of the cycle, nature of the References

packaging and name/initials of the staff member conducting the spore test. 4. Retrieve the test biological indicator and mail it with the control biological indicator to the monitoring service, or follow the protocol for in-office incubation of the biological indicators. 5. Receive/maintain records of the results. Biological monitoring should also be completed:6 • When running the first cycle after a repair to a sterilizer. (Release the load only after a passing biological indicator. AAMI recommends attaining three passing biological indicators before putting the sterilizer back into service.) • On all implantable devices. (This is not applicable for most dental settings, as implants are delivered sterile by the manufacturer.) • At the initial use of a sterilizer. • During the training of new staff. • When a loading procedure has changed. • When processing hazardous waste on-site. Dental practices may question how long they should maintain sterilization records. The CDC recommends that practices maintain sterilization records for three years, but it stresses the importance of researching any local or state regulations that may apply.3 The three types of sterilization monitoring all play an important role in the quality assurance program of the practice. Dental team members must have a clear understanding of these procedures and a rationale to carry out these tasks, which highly impact patient safety. It is important in all practice settings to ensure the correct staff members are placed in the correct areas of the practice and that they are well trained. DSOs and large group practices in particular can serve as models for demonstrating the commitment to best practices in sterilization monitoring and compliance to guidelines for safe patient care.

1. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings – 2003. MMWR 2003;52(No. RR-17); 24-25. 2. C enters for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, March 2016. 3. C enters for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008); last update: February 15, 2017. Available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf. Accessed March 11, 2018. 4. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 5th ed. St. Louis: Mosby Elsevier; 2013; 135-141. 5. A merican Dental Association. Oral health topics – infection control. Available at: https://www.ada.org/en/member-center/oral-health-topics/infectioncontrol-resources. Accessed March 11, 2018. 6. O rganization for Safety, Asepsis and Prevention. OSHA and CDC Guidelines; Combining safety with infection control and prevention for Dentistry. Interact Training System; 5th Ed, 2017.

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Cements

Cements 101 A working guide for dentists

Many factors contribute to achieving an optimal restoration, including selecting the right cement. The type of restoration (i.e., veneers vs. crowns), the restorative material used, tooth preparation design, necessary bond strength, clinical implications (inflamed soft tissue, isolation, etc.), retentive vs. non-retentive implications and the desired esthetic outcome all determine what cement will work best. Depending on the clinical requirements and material selection, dentists may place restorations using either conventional or adhesive cementation techniques. Conventional cementation combines preparation design, such as retention/resistance form to lute restorations to the underlying tooth structure. Adhesive cementation, on the other hand, produces a micromechanical and chemical bond between the tooth structure and the restoration. Dentists therefore need a thorough understanding of not only the restorative material used in the fabrication of a dental restoration, but also the cementation options and protocols for predictable clinical outcomes. 32

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Conventional cements

Conventional cements lute restorations with underlying tooth structure by creating a hardened cement layer between the restoration and the tooth. Conventional cements most notably include zinc polycarboxylate, glass ionomers, resin-modified glass inomers and zinc phosphate cements. These materials provide limited-to-no chemical bond with the tooth structure; hence, retentive preparation designs should be taken into consideration. Clinicians use these cements to lute high-strength ceramics and metal-based restorations. The physical and mechanical properties of cements varies, depending on their chemistry. The zinc polycarboxylate cement consists of metal oxides and polyacrylic acid. The dry mixture is mostly used as a powder, which is mixed with water for processing. The complicated setting reaction takes place by the reaction of metal oxides with the polyacrylic acid. The comparatively high solubility of the cement and mild

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Cements pulpal reaction is a substantial disadvantage. Contrary, glass-ionomer cements consists of fluoroaluminosilicate glass and liquid containing polyacrylic, itaconic acid and water. They demonstrate the advantage of being able to release fluoride ions. Setting reaction takes place with the help of an acid-base reaction. Clinical experiences with glass-ionomer cements have been gathered for more than 20 years, however it produces low retention rates and hence is indicated for retentive tooth preparations. The resin-reinforced glass-ionomer cements were formed by replacing part of the polyacrylic acid in conventional glass ionomer cements with hydrophilic methacrylate monomers. This group of luting agents includes a number of hybrid cements, the physical and clinical properties of which vary strongly, depending on the composition of the individual components. Their adhesion to the tooth structure is often weak, and when applied to moist dentin, produce little post-cementation thermal sensitivity.

Generally, adhesive resin cements require the tooth preparation to be etched and rinsed, and then conditioned with an adhesive bonding agent and cured. Etching removes the smear layer and demineralizes the tooth surface, whereas the bonding agent forms an interpenetrating network with free collagen fibers (the hybrid layer). Adhesive resin cements have significantly superior mechanical properties; however, when proper isolation can’t be achieved, conventional cements are recommended.

Adhesive resin cements

Self-adhesive resin cements

These cements don’t require the application of conditioners or bonding agents on the prepared tooth surface, making the system easy to use and error-prone.

Adhesive resin cements are superior options for all-ceramic restorations. They are methacrylate-based and consist of monomers and inorganic filler particles. Their setting reaction is based on a cross-linking of the polymer chains, which is initiated chemically (self-cure resin cements) and/or by light (dual-cure or light-cure resin cements) and provides chemical bonding between the tooth and the indirect restoration. These resin cements demonstrate high mechanical properties (greater wear resistance and resistance to the oral environment) and offer outstanding aesthetics given the wide choice of shades. 34

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Adhesive cements are further classified according to the following curing options: • Self-cure resin cements (chemical cure). • Dual-cure resin cements (chemical and light cure). • Light-cure resin cements (light cure only). Dual-cure and light-cure resin cements require light energy for complete polymerization of cement. However, restorations made of metals, metal alloys and opaque ceramics, such as traditional Zirconia oxide, are impervious to light, contraindicating the use of dual-cure and lightcure resin cements for cementation. As such, self-cure resin cements are indicated in these clinical conditions. By comparison, the cementation of highly esthetic restorations, such as veneers in the anterior region, requires materials that ensure long-term color stability for high quality esthetics. One option is to use amine-free resin cements.

Self-adhesive resin cements combine some of the advantages of resin cements with the convenience of conventional cements, including moderate level bond strengths. These cements don’t require the application of conditioners or bonding agents on the prepared tooth surface, making the system easy to use and error-prone. However, given the comparatively lower bond strength and mechanical properties, these cements are not highly recommended for low strength glass ceramics.

Preparation design and restorative materials The preparation design and restorative material largely determine what type of cement is used. Preparation design is significant in cement selection. Depending on the inclination/taper of the axial wall of the prepared tooth in relation to the longitudinal axis of tooth, the

preparation design is generally classified as retentive or Speaking the language Because different cements are suited to different non-retentive. Depending on the height of the prepared clinical situations, dentists require a thorough undertooth (>4mm), the preparation design is classified as a standing of their attributes and limitations – including short preparation. Retentive preparations feature an restoration type (veneer, crown, inlay, onlay), restorinclination/taper between 4 to 8 degrees, with a longiative material (low or high strength, or opaque), tooth tudinal axis of tooth. This feature provides additional prep (retentive or non-retentive) and conditions such mechanical retention, which facilitates the cementation as isolation – in order to select the material best suited of a restoration, either using adhesive or conventional to their practice. cementation techniques. Adhesive resin cements are recommended for all clinWhile adhesive cementation is known to provide a ical situations, except when an ideal isolation cannot be strong bond and good marginal seal, the luting forces of conventional cement are sufficient to lute restorations with retentive tooth prep design due to additional mechanical retention achieved by the tooth preparation design. At the same time, non-retentive preparations feature an inclination/taper in excess of 8 degrees and lack retentive features. Given their limited or no-chemical bonding propThe preparation design erties, conventional cements are and restorative material not ideal for this clinical scenario. Rather, adhesive resin cements are largely determine what type of recommended due to their ability cement is used. Preparation design to chemically bond with the restois significant in cement selection. ration and tooth. The restorative material used also determines cement selection. Indirect restoratives include: • Metal and metal-based (metal alloys and porcelainfused-to-metal restorations). • Intermediate-strength ceramic (feldspathic, leucitereinforced and fluoroapatite restorations). • High-strength ceramic (lithium disilicate, alumina and zirconia restorations). • Indirect composite (reinforced composites) Intermediate strength glass ceramics, such as those with a high glassy content, obtain additional support from adhesive bonding and must be adhesively cemented using resin cements. Therefore, feldspathic, leucite-reinforced and fluorapatite ceramic restorations should be cemented with adhesive resin cements.

maintained. Conventional cements are considered highly versatile. And light-cured resin cements are indicated for thin veneers due to their high color stability, while selfcure resin cements are ideal for opaque restorations, such as metals or opaque thick zirconia restorations. A clinician looking to achieve an intermediate bond strength and ease-of-use can use self-adhesive resin cements. In fact, the presence of MDP in selective self-adhesive resin cements has eliminated the need for a primer application on zirconia restorations. As such, these cements are the product of choice for cementing zirconia restorations with retentive prep design. Regardless of what type of cement the practice relies on, it is essential for clinicians and their dental staff to read the instructions for use to ensure the most predictable, successful clinical outcome.

Editor’s note: Efficiency in Group Practice would like to thank Ivoclar Vivadent for its assistance with this article. ISSUE 3 • 2018 : DentalGroupPractice.com 35

Safest Dental Visit

OSAP partners to advance competency in dental infection prevention and control education New program enhances infection prevention and control knowledge Over the years, several infection control breaches in dental settings have made national headlines. To help address this issue, the Organization for Safety, Asepsis and Prevention (OSAP), the Dental Assisting National Board (DANB) and the DALE Foundation have formed a collaboration to create a multi-faceted infection control education and credentialing initiative. Together, the three partners bring expertise in infection control (OSAP), certification and credentialing (DANB) and research and online education development (the DALE Foundation). This initiative will produce a unique set of vetted and validated certificate and credentialing programs to help advance knowledge and support infection control compliance and safety in dental settings. The first program launched is the OSAP-DALE Foundation Dental Infection Prevention and Control Certificate ProgramTM. In four steps, the assessment-based certificate program is designed to enhance baseline knowledge in infection prevention to advance dental safety. Steps 1 and 2 of the program are available now, and steps 3 and 4 of the program will be available later in 2018. There are four educational components leading to the OSAP-DALE Foundation Dental Infection and Prevention Control Certificate: Step 1 •C omplete one of the following dental infection control education programs:

• OSAP’s Dental Infection Control Boot Camp (3-day, in-person meeting). • CDC Guidelines: From Policy to Practice by OSAP (online or paper). • OSAP’s OSHA & CDC Guidelines Interact Training System (online). • The DALE Foundation’s DANB® ICE® Review course (online). Step 2 • Complete the OSAP-DALE Foundation online CDEA® module: Understanding CDC’s Summary of Infection Prevention Practices in Dental SettingsTM. (Available at www.osap.org/?page=SDVCDEA) Step 3 • Complete the OSAP-DALE Foundation Dental Infection Prevention and Control eHandbookTM . Step 4 • Complete the OSAP-DALE Foundation eHandbook AssessmentTM. OSAP, DANB and the DALE Foundation will be releasing additional details on the education and credentialing initiatives in the coming months. To learn more about these education initiatives for dental safety, visit www.osap.org, www.danb.org or www.dalefoundation.org.

About OSAP: 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. The organization’s annual conference is May 31-June 3 in Dallas, TX. For additional information, visit www.OSAP.org. About DANB: The Dental Assisting National Board, Inc. (DANB) is recognized by the American Dental Association as the national certifying board for dental assistants. DANB’s mission is to promote the public good by providing credentialing services to the dental community. DANB exams and certifications are recognized or required by 39 states, the District of Columbia, the U.S. Air Force and the Department of Veterans Affairs. For more information, visit www.danb.org. About the DALE Foundation: The DALE Foundation – the official DANB affiliate – benefits the public by providing quality continuing education and conducting sound research to promote oral health. The DALE Foundation offers interactive e-learning courses and study aids to help dental assistants and other dental auxiliaries expand their knowledge and grow their careers. To learn more, visit www.dalefoundation.org. 36

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Enhanced Practice

Foundations for Your Growing Dental Group It’s hard to accomplish anything without a plan. Whether you’re coaching a football team, cooking Thanksgiving dinner, or running a small business, you need a strategic plan.

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

A strategic plan looks at all the things your dental group could do and narrows it down to the things it is actually good at doing. A strategic plan also helps dental group leaders determine where to spend time, human capital, and money. But, how should a new dental group approach strategic planning? There are hundreds of business books dedicated to the topic. We’ve read most of them. We put the others on our bookshelf just for show, and there are some that we have read and re-read because of the excellent tips it provides. Here are some quick steps we feel are essential to start your process.

Step 1: Where are you today? This is harder than it looks. Some people see themselves how they WANT to see themselves, not how they actually appear to others. Many small businesses get snared in this same trap. For an accurate picture of where your business is, conduct external and internal audits to get a clear understanding of the marketplace, the competitive environment, and your organization’s competencies (your real – not perceived – competencies).

Step 2: Create a Mission Statement Your Mission Statement is a statement about what your company actually does. It should be short and easy to memorize. A lot of companies get this wrong and end up using big fancy words that don’t tell us anything. Your mission statement should also be specific enough that people understand what you do and how it may differ from your competitors.

Efficiency In Group Practice : ISSUE 3 • 2018

For example: Public Broadcasting System (PBS): To create content that educates, informs and inspires. Google: To organize the world’s information and make it universally accessible and useful. Make-A-Wish: We grant the wishes of children with life-threatening medical conditions to enrich the human experience with hope, strength and joy. Shareholders, leaders and employees are generally the target of the mission. It should help workers within the organization know what decisions and tasks best align with the mission of the company. A mission statement offers insight into what company leaders view as the primary purpose for being in business. Some companies have profit-motivated missions, while others make customers a focal point. Other firms use a mission to point out more altruistic intentions that ultimately lead to profits.

Step 3: What are your Core Values? Your Core Values are what you believe in, what your team believes in and holds true. Think of this as if your entire organization was hanging out on a bus together – your values would be how you treat each other on the bus. Values are what you will use to hire the right people. It is how you will allow, and expect, your team to show up every day. Most dental groups have a list of Core Values, but how do you use them? How do you ensure your team is focused and acting on the core values? Your Core Values need to be communicated and lived each day. Core Values are behavioral, so they need to be part of your performance management system, reward team members for living out the values, and include your Core Values in staff meetings, morning huddles and everyday communication.

Step 4: Create a Vision Statement: This is what

your company aspires to be; which can be much different than what a company is (Mission Statement). When done right, your vision statement can and should help drive decisions and goals in your company. Your vision statement focuses on this question. “Where are you going?”. What will your group look like in 3-5 years? What does success look like? What mountain are you climbing and why?

Here are some examples of some good vision statements: Disney: To make people happy Ford: To become the world’s leading Consumer Company for automotive products and services. Avon: To be the company that best understands and satisfies the product, service and self-fulfillment needs of women – globally. Your vision statement is your outcome: A picture of the future. Where your organization is going? Your north star? So, why is this all important? Strategic Management Process: The development of vision and mission statements is an essential part of the strategic management process. Having clearly defined the vision and mission of the organization, you can set strategic objectives that are aligned with the company’s long-term goals. You will take and translate these strategic objectives into an operational strategy that can be implemented, monitored and evaluated. The outcome of the evaluation will determine whether any revision of the vision statement, mission statement, objectives or operational strategy is required. Alignment: Well-written vision and mission statements ensure that each element of the strategic management process is aligned to the company’s long-term goals. Managers use clear and concise vision and mission statements to communicate their aspirations to stakeholders. Employees understand where to focus their efforts if they align their daily work with the vision and mission. Clear vision and mission statements allow doctors, staff, suppliers and shareholders to choose whether or not they want to do business with the company. You may have a mission, vision and core values already established within your group. But the question remains, is it accurate and does our team know, understand and live it every day? If not, you need to go back to the steps above and ensure this is alive and well in your dental group. If you are looking for assistance with developing your dental groups strategic plan, you can contact the team at Enhanced Practices to help guide the way. www.enhancedpractices.com or contact Jennifer @ jennifer@enhancedpractices.com. ISSUE 3 • 2018 : DentalGroupPractice.com 39

INDUSTRY NEWS American Dental Association announces policy changes to combat opioid epidemic The American Dental Association (ADA) (Chicago, IL) announced a new policy on opioids, supporting mandates on prescription limits and continuing education. The three policy changes are: •T he ADA supports mandatory continuing education in prescribing opioids and other controlled substances. •T he ADA supports statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain, consistent with the CDC evidence-based guidelines. •T he ADA supports dentists registering with and utilizing Prescription Drug Monitoring Programs (PDMPs) to promote the appropriate use of opioids and deter misuse and abuse. “As president of the ADA, I call upon dentists everywhere to double down on their efforts to prevent opioids from harming our patients and their families,” said ADA President Joseph P. Crowley, D.D.S. “This new policy demonstrates ADA’s firm commitment to help fight 40

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the country’s opioid epidemic while continuing to help patients manage dental pain.” Most opioids prescribed to patients in the U.S. are written by physicians and other medical professionals for management of chronic (long-term) pain. Dentists with an appropriate license may also prescribe opioids, and do so most often for management of acute (short-term) pain such as severe tooth decay, extraction of teeth and root canals. In 1998, dentists were the top specialty prescribers of opioid pain relievers, accounting for 15.5 percent of all opioid prescriptions in the U.S. By 2012, this number had fallen to 6.4 percent. For more information on how the ADA is working to combat opioid abuse, visit www.ADA.org/opioids.

Aspen Dental to open office in NY Aspen Dental Management Inc (Syracuse, NY) announced it will open a new Aspen Dental-branded practice in Hudson, New York on March 29. The new dental office is led by Dr. Aldo Lomanto. Lomanto and his team will provide dental services ranging from dentures and preventive care, to general dentistry and restoration.

Cornerstone Dental Specialties unveils new app and endo fellowship Cornerstone Dental Specialties (CDS) (Irvine, CA) announced it would release the Cornerstone Dental Specialties app, CDS Connect. The app will reportedly change the way the DSO’s clinicians communicate within their network, manage their schedules, drive education, and manage their supply chain. The app will be the main platform Cornerstone will use to drive efficiency and support scale. Additionally, the company will offer The CDS Endodontic Fellowship, a paid private endodontic fellowship program. The fellowship program is designed to help the recently graduated endodontist make the final transition into clinical practice. The 16-month process will “allow clinicians the opportunity to hone their skills and make the transition from academia to private practice.” The company plans to unveil these new offerings at the upcoming annual meeting of the American Association of Endodontists (AAE).

Delta Dental names new VP The Delta Dental Plans Association (Oak Brook, IL) named Joseph Dill as its VP of dental science and network strategy. Dill was most recently VP of professional services and dental director for Delta Dental of Virginia.

HHS taps CVS Caremark VP to oversee drug pricing effort HHS Secretary Alex Azar selected CVS Caremark VP Daniel Best to lead the agency's push to curb drug prices, a source familiar with the matter told Politico. As leader of HHS' effort to lower drug costs, Best will manage daily tasks associated with the initiative. He currently oversees industry relations for CVS' Medicare Part D arm. He joined the company in 2011 when CVS acquired Universal American's Part D business.

Great Expressions Dental Centers speaks out against oral cancer Great Expressions Dental Centers (GEDC) (Southfield, MI) launched the Speak Out Against Oral Cancer campaign to help lower the risk of being diagnosed with oral cancer. As part of the campaign, the company released some basic tips to help the public avoid the disease. Participating GEDC offices are also providing free Advanced OralID Cancer Screenings for every patient who visits in April. Additionally, as

part of its commitment to funding research for a cure, GEDC will make a monetary donation to the Oral Cancer Foundation.

Dental implants and prosthesis market worth $13.01B by 2023 According to a new market research report, "Dental Implants and Prosthesis Market by Type (Dental Implants, Bridge, Crown, Abutment, Dentures, Veneers, Inlay & Onlays), Material (Titanium, Zirconium, Metal, Ceramic, Porcelain Fused to Metal), Type of Facility, and Region - Global Forecast to 2023,” published by MarketsandMarkets, the Dental Implants and Prosthesis Market is expected to reach $13.01 billion by 2023 from an estimated $9.50 billion in 2018, at a CAGR of 6.5%. The key factors driving the growth of this market include the growing geriatric population and corresponding dental disorders; rising incidence of tooth decay and edentulism across the globe; growing dental tourism in emerging markets and increasing government expenditure on oral healthcare. Titanium dental implants accounted for the largest share of the Dental Implants Market in 2017. By price, premium implants accounted for the largest share of this market in 2017. Dental bridges held the largest share of the Dental Prosthesis Market in 2017.

Bisco introduces REVEAL HD BULK Bisco announced the introduction of REVEAL HD Bulk, a light-cured bulk fill composite designed to improve the quality and timeliness of restorations. REVEAL HD Bulk is optimized to allow for easier, faster posterior restorations by combining superior levels of handling, placement, and depth of cure. The exceptional easeof-use allows for simple and convenient placement of the composite in the prep, while the category-leading depth of cure ensures a solid restoration from the top-down so you can cure with confidence. BISCO’s HD Filler Technology allows REVEAL HD Bulk to improve the predictability and durability of posterior restorations by providing category-leading depth of cure and strength, while providing exceptional handling, to create a restoration that is quick, easy, and high-quality. REVEAL HD Bulk comes in 3g syringes and 0.25g unit-dose tips. It is available in shades A1, A2, A3 and B1. For more information, call 800-247-3368 or visit reveal.bisco.com. ISSUE 3 • 2018 : DentalGroupPractice.com 41

Leadership

A Method for Dealing with Change and Challenge By Lisa Earle McLeod

The common belief is, people don’t like change. If that were true, no one would ever have a baby or get married. The truer point is: people don’t like change that makes them feel unsafe. Change we don’t choose, or can’t control pushes our buttons. For example, deciding to get married can be exciting. Having someone tell you, you’re getting married and I’ve chosen your spouse, is terrifying. In business, people deal with change and challenges every day. I’m lumping change and problems together because they’re both disruptions. From legislation and regulations to competitors and mergers to mistakes and scandals, problems and changes happen every single day. The primitive part of our brains doesn’t like it one bit. Your lizard brain thinks, no change, no risk. I was safe today, so if I want to stay safe tomorrow, I should do the exact same thing. Unfortunately, listening to your primitive brain is quite risky. People and organizations that don’t proactively address change and challenges become obsolete. To be clear, being proactive doesn’t mean embracing every harebrained idea someone puts in front of you. It means recognizing new circumstances and dealing with them. If you do cool things, in work or life, change and problems are inevitable. You can be the person who resists, who must be dragged kicking and screaming into a new reality. Or you can be someone who makes thing happen, and who helps others.

If your team has made an error they need to fix, or you’re asking them to do something challenging, you want them to be confident.

Here’s a simple three-part technique, we teach our clients for dealing with change and challenges. We call it the AMB method.

1. Articulate reality. If something is changing, acknowledge it. For example, if you notice a competitor taking away business, simply say, “We’re losing share. Let’s discuss how we can stop this. If there’s a problem, state it without shame or blame. If someone made a big mistake, say, “The customer is upset. Let’s talk about how to fix it.” If you are caught off guard by someone else introducing a change or problem, instead of emotionally reacting, ask a question. For example, if you hear, “We’re merging” ask, “What’s the timeline, and how will it impact the 42

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organization?” This helps you clarify exactly what is going on. As a leader, be factual. This is especially important if the issue has potential negative consequences. Your team will have emotion; don’t amplify the intensity.

2. Move it forward. We began using this phrase a few years ago to describe how you can add positive energy and momentum to a situation, even if you can’t control the change itself. Language like “How can we still reach our goals in the face of this change?” will make a change feel more manageable. Instead of feeling paralyzed yourself, or asking others to blindly accept, find a place where you can take positive action.

3. Build confidence. This is particularly important for leaders. If your team has made an error they need to fix, or you’re asking them to do something challenging, you want them to be confident. Ask questions like, “What will it take for us to get this done? How can I help you? Do you want to practice in advance?” You want people to leave the conversation confident they can handle what’s next. Remember, AMB. Articulate reality, move it forward, and build confidence. It’s the best way to deal with this ever-changing world.

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