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Editor’s Note

The Dash to the 2019 Finish Line

Embracing Change................................................................................ 4

4 steps to implementable success....................................................... 34

2019 ADSO Summit: A Huge Success with Members

Engineering and Work Practice Controls

Compliance, recruitment and retention, leadership and technology trends were just a few of the topics covered at this year’s Summit.......... 6

Key elements of Bloodborne Pathogens Standard are often overlooked............................................................ 42

Dental Group Practice Meetings: An Overview Safe Water, Safe Patients DSOs have year-round educational and networking opportunities........ 10 Growing attention to the hazards of contaminated dental unit water has led more and more dental clinicians Pedodontists to take the necessary steps to protect their patients............................ 46 Advanced technology, together with experience and a measure of sensitivity, enable pedodontists to provide the best possible care for their young patients.......................... 20

Kid-Friendly Dentistry

Treating young children requires a unique skill set............................. 24

Instructions for Use: They’re Meant to be Read!

Assumption of knowledge is a dangerous thing................................. 50

Implantology

Your DSO Accelerator

Improvements in implant technology are making them increasingly attractive to doctors and patients.................................... 28

How to maximize the tremendous value your hygiene team brings to the group practice................................. 54

All the Right Moves

News............................................................................................. 56

For Eric Shirley, the best solutions lie beyond the obvious answers.....30

EDITORIAL BOARD

A.J. Acierno, DDS, CEO, DecisionOne Dental Partners Kristine Berry, RDH, MSEC, NextLevel Practice Coach Brad Guyton, DDS, MBA, MPH, Vice President, Clinician Development, Dean, PDS University™ – Institute of Dentistry, Pacific Dental Services Brandon Halcott, Co-Founder and President, Tru Family Dental DeAnn McClain, Executive Vice President of Operations, Heartland Dental Kasey Pickett, Sr. Director, Communications, Aspen Dental Management, Inc Heather Walker, DDS, Mortenson Family Dental

EDITOR Laura Thill • lthill@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 Partin dpartin@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 Phone: 770-263-5257 • Fax: 770-236-8023 www.dentalgrouppractice.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 2019 by Share Moving Media All rights reserved. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publishers. Publishers cannot accept responsibility for the correctness of an opinion expressed by contributing authors.

ISSUE 4 • 2019 : DentalGroupPractice.com

Editor’s Note

Embracing Change Recent efforts to educate families on the importance of early oral care and the need to make treatment more accessible have paid off, both for pediatric patients and the pedodontists treating them. That’s good news, but it has presented a few challenges for dental professionals. Pediatric-focused dental outreach programs for preventative dental care, such as the American Dental Foundation’s Give Kids a Smile and America’s Tooth Fairy, as well as the availability of health insurance to more families, have resulted in more children receiving higher quality oral healthcare, according to Rolando Mia, vice president of customer success at Zyris. At the same time, Laura Thill many dental owners are challenged with investing in newer technology and providing their teams with more and better training. Silver diamine fluoride (SDF) for caries prevention and treatment, digital X-rays, digital and laser cavity detection devices and aids, hard and soft tissue laser Fortunately, a number of industry designed to painlessly treat cavities and decay, CAD/ organizations – from the Association CAM impression technology, painless injection systems of Dental Support Organizations and improved isolation and retraction devices all have facilitated better care. But, as some pedodontists have (ADSO) to the American Academy noted, new technology can be disruptive. “It requires a of Dental Group Practice (AADGP), dedicated effort, and when technology is set aside and Dentist Entrepreneur Organization forgotten, it’s a wasted investment,” says Mia. Then again, some would argue that staying cur(DEO), Dykema, Scaling Up and rent on new technology and embracing change is at the more – offer year-round educational essence of following best practices and providing optimal healthcare. Fortunately, a number of industry organizaand networking opportunities tions – from the Association of Dental Support Orgaspecifically geared to dental nizations (ADSO) to the American Academy of Dental service organizations. Group Practice (AADGP), Dentist Entrepreneur Organization (DEO), Dykema, Scaling Up and more – offer year-round educational and networking opportunities specifically geared to dental service organizations. Indeed, just as the professional culture and daily goings-on within a group practice have a huge impact on patient care, what happens outside of the practice often matters just as much. Join us this issue for an overview of group practice dental meetings that have taken place or will do so before the end of the year. In addition, we invite you to hear what the experts have to say regarding such topics as pediatric dentistry, implantology, infection control and more.

Efficiency In Group Practice : ISSUE 4 • 2019

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2019 ADSO Summit: A Huge Success with Members Compliance, recruitment and retention, leadership and technology trends were just a few of the topics covered at this year’s Summit. The growth and development of dental service organizations was the primary focus of the Association of Dental Support Organizations (ADSO) 2019 Summit, held March 28-30 at the Manchester Grand Hyatt San Diego, San Diego, California. Members attended presentations on advocacy trends, compliance best practices and the latest developments in the DSO industry.

Following pre-conference events for industry partners in sponsorship roles and participating DSO representatives, the meeting opened with a Leadership Panel: CEO to CEO – New Horizons. Panel speakers included Steve Bilt, CEO, Smile Brands; Ken Cooper, CEO, North American Dental Group; Mitch 6

Efficiency In Group Practice : ISSUE 4 • 2019

Olan, CEO, Dental Care Alliance; and Dr. Sulman Ahmed, CEO, DECA Dental Group. The first day concluded with a sponsored Talk Table Exhibit and networking event, followed by a reception at San Diego’s Seaport Village headquarters. Guests were invited to celebrate the opening of the ADSO

2019 Summit by exploring the 14-acre waterfront shopping hub and the dining and entertainment complex, modeled after a century-old harbor setting. Day two opened with breakfast and a Leadership Panel: Developing a C-Suite Leadership Team. Speakers included Pat Bauer, CEO, Heartland Dental; Alistair Madle, CEO, D4C Dental Brands; Bob Fontana, president and CEO, Aspen Dental Management; and Steve Thorne, president and CEO, Pacific Dental Services. Attendees took advantage of a full day of presentations, featuring a range of topics and speakers: • Compliance: Victoria Harvey, SVP and chief legal officer, Smile Brands, and Dr. Andrew Matta, DMD, North American Dental Group. • DSO Models: Integrating Specialties. Merritt Drake, CEO, Rock Dental Brands. • Growth & Development: Do we Have to do Something Different to Make a Difference. Dr. AJ Acierno, CEO and president, DecisionOne Dental, and Steve Bilt, CEO, Smile Brands.

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• Leadership: Women in the DSO Industry. Dr. Yashu Singh, owner dentist, Sing Orthodontics; Tanisha Wicker, SVP human resources, Smile Brands; and Jody Martin, chief marketing officer, Smile Brands. • Recruitment & Retention: Improve your Bottom Line. Lisa Nguyen, program manager, UCLA School of Dentistry, Community Based Clinical Education, and Bill Piskorowski, associate dean, UCLA School of Dentistry, Community Based Clinical Education. • Technology: Foresight 20/20: Actionable Insights for Operations, Marketing & IT Success. Amol Nirgudkar, CEO, Patient Prism. • Clinical Systems: Creating a Culture of Clinical Excellence. Dr. Shalin Patel, chief clinical officer, DECA Dental Group. • Compliance: Building an Actionable & Practical Compliance Program. Andy Lyness, general counsel & chief compliance officer, D4C, and Dr. Rodney Alles, partner & chief of clinical affairs, DECA Dental. • DSO Models: One Size Does Not Fit All. Emmet Scott, CEO, Community Dental Partners. • Future Trends: Teledentistry. Brant Herman, CEO, MouthWatch, and Dr. Rick Workman, founder & executive chairman, Heartland Dental. 8

Efficiency In Group Practice : ISSUE 4 • 2019

• Growth & Development: Structuring for Growth, Scale & Sale. The Waller Law Team. • Operations: Developing an Operational Infrastructure. Dr. Scott Luene, CEO, Breakaway Practice. • ADSO Dental Plans: Building a National Network Together. Steve Thorne, president & CEO, Pacific Dental Services, and Matt Hall, president & COO, Wellfit. • Clinical Best Practices: Doctor Recruitment & Retention. Dr. Michael Acierno, president & chief medical officer, DecisionOne Dental Partners. • DSO Models: Emerging DSO Panel. Steven Jones, founder & chief development officer, CORDENTAL Group, and Brandon Halcott, president, Tru Family Dental. • Future Trends: The Future of Dentistry and its Impact on DSOs and Group Practices. Marko Vujicic, PhD, chief economist & vice president, American Dental Association. • Marketing Panel: Bill Neumann, CEO, Group Dentistry Now; Paul Benson, senior consultant, Apex Revenue Technologies; Stacy Medena, creative manager, DecisionOne Dental Partners; and Susan Schramm, marketing coordinator, DecisionOne Dental Partners.

• Recruitment and Retention: Catch & Release: Why Your Talent Strategy is Flawed John Whitaker, vice president, talent acquisition, DecisionOne Dental Partners • Growth & Development: Creative Dental Equity Structures. Benesch Law Team.

Guests who joined the rooftop viewing party had the opportunity to watch the Padres play the San Francisco Giants. The closing general session on day three featured internationally recognized artist, TED speaker and No. 1 bestselling author Eric Wahl. Wahl looked at the use of disruption as a competitive advantage, and his takeaway message was clear: If businesses don’t embrace innovation and creativity, they risk being left behind.

The closing reception that evening was held at Petco Baseball Field. For more information visit www.theadso.org.

ISSUE 4 • 2019 : DentalGroupPractice.com

Events

Dental Group Practice Meetings:

An Overview

DSOs have year-round educational and networking opportunities at Planet Hollywood, Las Vegas, Nevada. In addition, AADGP celebrated its 45th anniversary. This year’s speakers featured a number of industry standouts, including: AJ Peak, CEO and founder of Peak Dental Services. Under AJ Peak’s leadership, Peak Dental Services has developed 27 locations since 2008. Peak shared his strategic leadership skills to help attendees rapidly and effectively grow their group, as well as tactics designed to improve productivity, key success factors to launching de novo practices, and much more.

The professional culture and daily goings-on within a group practice have a huge impact on patient care. What happens outside of the practice often matters just as much. Indeed, staying informed about the industry, educated about new technology and connected to one’s peers can give dental professionals the perspective they need to provide patients with optimal care and a great experience – a true measure of success for the practice. Following is a sample of industry meet10

Efficiency In Group Practice : ISSUE 4 • 2019

ings and conferences that take place throughout the year to help dental clinicians, executives and managers expand their professional horizon.

American Academy of Dental Group Practice (AADGP) The AADGP Expo 2019 took place January 30-February 2, 2019,

Benjamin Dyches, DDS, JD. After 13 years and six start-up practices, Dr. Benjamin Dyches recognized a need at the intersection of healthcare and law. Today, he educates healthcare providers across the country on successfully navigating the legal climate. In his presentation, Dr. Dyches empowered providers with an understanding of liability and lawsuits, and their far-reaching impact and the legal corporate structures that protect assets from being taken in a lawsuit. Stewart Levine, founder of Resolution Works. A resolutionary mediator, trainer and author, and widely recognized for creating agreement

and empowerment in the most challenging circumstances, Stewart Levine counsels and trains executives and managers to resolve workplace conflicts. He recognizes that, by doing so, they can reduce costs, improve efficiency and increase job satisfaction. Stewart Gandolf, CEO, creative director and Co-Founder of Healthcare Success. Stewart Gandolf is a national speaker to thousands of healthcare clients across North America. He boasts over 20 years of experience in creating marketing programs for providers and corporations. Gandolf shared his expertise in healthcare advertising and marketing, educating attendees on how this can be applied to the dental industry. Jeromy Dixon, DMD, founder and CEO of The DSO Project. Jeromy Dixon was formerly the CEO and founder of Smiles Services LLC and Smiles Dental Group PC. During this time, Smiles Dental was recognized three years in a row by INC Magazine as one of the fastest growing privately held companies in the U.S. Under his leadership, Smiles Dental roughly tripled the number of locations, revenue, EBITDA and organizational valuation. Dr. Dixon educated his audience on what private equity looks for in group practice and DSO investments. Brian D. Tortolano, CPA, partner at Rosen & Associates, LLP. Brian Tortolano has primarily served clients within the dental and healthcare industries for over 15 years. His industry-specialized expertise ensures he understands the specific

accounting, tax and business needs of dental and medical professionals and their businesses. Genevieve Poppe, co-founder of Stepping Stone Dental Partners, an organization that facilitates practice acquisition. Genevieve Poppe’s expertise is proven by years of success in all aspects of practice operations. She has built and facilitated numerous practice acquisitions, transitions and relocations. Poppe shared her approach to generate growth and create stability in order to create a thriving practice of any size. Kip Rowland, RDH, MS, strategic account manager for Practice Analytics, a dental technology company. Kip Rowland has published research in the Journal of American Dental Hygienists Association and served on the advisory boards of various dental hygiene and assisting schools. AADGP will be returning to Las Vegas in 2020. Dental Group Expo ’20 will be held February 19 – 22, 2020 at MGM Grand. For more information visit www.aadgp.org/ annual-expo/.

Henry Schein Dental The Henry Schein DSO Education Forum took place May 17-18, 2019, at the Aria Resort & Casino, Las Vegas, Nevada. Following last year’s event, which drew over 600 attendees, from over 140 group practices & DSOs between the United States and Canada, at press time, Henry Schein

was working to exceed those attendance numbers in 2019. The Forum featured two dozen speakers representing three unique tracks: ational and Emerging DSO. •N The National and Emerging DSO track was geared toward executives within DSOs of all sizes. •D SO Hygiene. The DSO Hygiene track was geared toward hygienists, chief hygiene officers and team members responsible for hygiene across all locations. The track focused primarily on scaling and increasing workflow and profits across locations. • L eadership Development. New in 2019, the Leadership Development track was perfect for anyone responsible for managing or leading a team, including office managers at one location, regional managers responsible for several locations, as well as CEOs and COOs looking to broaden their leadership skills. Whether attendees were new to a leadership position or a seasoned leader, the track catered to all experience levels and demonstrated best-in-class team coaching, mentoring skills and how to build team harmony within one location, or across many. The session featured interactive activities, as well as keynote lectures from world-class leadership development experts, and COOs, regional managers and executives from DSOs. The 2019 keynote speaker was Julie Rice, an entrepreneur best known for co-founding the fitness (Continued on page14 ) ISSUE 4 • 2019 : DentalGroupPractice.com 11

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Robert A. Lowe, D.D.S., F.A.G.D., F.I.C.D., F.A.D.I., F.A.C.D., F.I.A.D.E., F.A.S.D.A. Diplomate, American Board of Aesthetic Dentistry Restorative materials are constantly under biological assault due to acid attack and the effects of demineralization on tooth structure. Clinical outcomes can vary from patient to patient due to the individual’s oral environment (pH), quality and quantity of saliva, acidic challenge to the tooth-restorative interface (margin), and the patient’s ability to keep these surfaces plaque free (level of home care). Rather than actively repair teeth, the majority of today’s dental restoratives are designed merely to occupy space. Bioactive restoratives, on the other hand, participate in an ionic exchange of calcium, phosphate and fluoride that helps neutralize acid attack and supports the natural remineralization process. Bioactive materials like ACTIVA BioACTIVE-RESTORATIVE respond to changes in pH by releasing and recharging essential minerals to help protect teeth against acid attack.

1 Figure 1: A preoperative occlusal view of tooth # 4 which has an existing DO composite with recurrent decay and tooth # 5 with occlusal pit and fissure decay.

3 Figure 3: Total etch protocol for 15 seconds, then thoroughly rinsed with water.

Class II Restorations Cavity preparation for ACTIVA BioACTIVE-RESTORATIVE is similar to that for conventional composite materials (Figures 1 and 2). Placement is easy using the automix syringe and dispensing cannula (the latter can be bent to an appropriate angle for ease of delivery). The viscosity of ACTIVA is similar to heavy-bodied flowable resins and will adapt well to the internal geometry of any cavity preparation. A sectional matrix system is recommended for Class II placement to limit the material to the preparation and avoid proximal excess. Anatomic detail can be obtained by using rotary instrumentation. A narrow “bullet type” 20 fluted finishing carbide (SS White) is recommended to carve precise anatomic detail.

Efficiency In Group Practice : ISSUE 4 • 2019

Figure 5: Placement of an adhesive resin on all preparation surfaces is shown.

2 Figure 2: Cavity preparations for tooth # 4 DO is made using a carbide # 330 (SS White) and tooth # 5 using a fissurotomy bur (SS White).

4 Figure 4: An occlusal view after etching and drying the preparations.

6 Figure 6: ACTIVA BioACTIVERESTORATIVE is dispensed into the cavity preparation of tooth # 4. The sectional matrix (Biofit:Bioclear) confines the restorative material precisely to the cavity preparation.

7 Figure 7: A sable artist’s brush is used to adapt the restorative material to the cavity margins and remove excess material prior to light curing. Note: ACTIVA BioACTIVE-Restorative is a dual cure material.

8 Figure 7: An occlusal view of the completed ACTIVA restorations on tooth #’s 4 and 5.

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Events

phenomenon, SoulCycle. Rice served as co-CEO at SoulCycle from 20062015 before becoming the chief brand officer at WeWork in November 2017. In addition to the three education tracks, a few panels were scheduled: •D ental Industry Titans. Dental Industry Titans was moderated by Brian Colao, director, Dykema DSO Group, and featured Stanley Bergman, chairman & CEO, Henry Schein; Marc Berendes, CEO of Kulzer GmbH; and Donald Casey, CEO of Dentsply Sirona. The panel primarily revolved around the importance of a positive team culture within an organization, and ensuring team culture is consistently on the minds of leadership. • DSO Executive Panel. A DSO executive panel was moderated by Jake Meadows, vice president of sales, Henry Schein, and included three executives from DSOs of varying sizes. • Women’s Leadership Panel. A women’s leadership panel was moderated by Julie Rice. Panelists included Kim Diamond, senior director, Henry Schein; Melissa Marquez, COO, DentalOne Partners; Jen Naylor, executive vice president, Hu-Friedy; and Lori Noga, CEO, Tranquility Dental. Among the topics discussed were women’s leadership within the DSO Community, recruiting women into your C-Suite and more. 14

Efficiency In Group Practice : ISSUE 4 • 2019

Steve Thorne, CEO, Pacific Dental Services, closed out the DSO Education Forum. For more information visit www. henryschein.com/us-en/dental/ Default.aspx?did=dental.

Dentist Entrepreneur Organization (DEO) The 2019 DEO Summer Summit: The Emerging Future of Group Dentistry took place June 27-29, in Phoenix, Arizona. This year marked the organization’s seventh Summit. Nearly 400 dentists, group executives and dental professionals, as well as 38 sponsors dedicated to the group space, attended the Summit. Attendees represented small and emerging group practices, midlevel DSOs (50 to 100 practices), suppliers, vendors and capitalists. The Summit was designed to help attendees understand what’s coming and how to prepare for it by discovering practical tools for a successful group practice business. Attendees had the opportunity to network with: • Dentist-entrepreneurs with growing practice portfolios. • Equity partners investing in managed-group practices. • Upper senior executives. • Leading groups in North America. • Executives growing groups outside of North America. • Regional managers for group practices and brands. • Office managers for group practices and brands. • Senior advisors leading the growth of managed groups.

• Capital investors looking to expand. • Equipment suppliers to managed groups. • Consultants specializing in growing groups. • Constituents from the entire group practice supply chain. There was also an opportunity to earn Continuing Education (CE) credits. The 2019 DEO Summer Summit offered a wide range of presentations, including: The Future of Evidence-Based Dentistry: 2019 and Beyond Speaker: Dr. John C. Kois, The Kois Center Dr. Kois addressed what treatment planning will look like in the future, and what dental professionals and entrepreneurs will need to do to meet the requirements. For instance, how will upcoming changes in tech change how dentists practice? How will it change the way they market? How will evidence-based dentistry affect their bottom line? The Future of Emerging Groups & DSOs Speaker: Dr. Richard Evangelista, CEO and founder of Dentalforce With over 15 years of proven success in dental-practice management, Dr. Evangelista discussed the future for emerging group practices. He addressed such questions as: Where might multiples be going? What is the outlook for private equity in the emerging-group space? What growth strategies will win out in the near future? What can group practices do now to set up their businesses for

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Events

future success? What’s changed in the DSO world in the last few years? What’s driving the growing number of DSOs? What trends are we seeing among DSOs? The Future of Integrating Medical and Dental Health in Group Dentistry Speaker: Dr. Maryam Beyramian, Founder & lead dentist, Westwind Integrated Health Dr. Beyramian discussed how Westwind Dental is forging the future of dentistry through an integrated medical and oral health model. She addressed such questions as: What does an integrated model look like? What are the opportunities for practicing dentists and dental groups in systemic health integration? Where is the crossover exactly between medical and dental, and how can dentists today position themselves for the future? The Future of Blockchain in Group Dentistry Speaker: Dr. Peter Boulden, Bulletproof Dental Practice Dr. Boulden discussed “blockchain,” and how it is affecting dentistry. He addressed questions such as: How does blockchain change aspects of the dental experience? What opportunities does blockchain open for group practices? What are the potential pitfalls this new technology will create? What can group practices do now to take advantage of this inevitable wave? The Future of Top-Line Revenue Growth in Dental Groups Speaker: Margaret McGuckin, Co-Founder and principal, i3 Ignite 16

Efficiency In Group Practice : ISSUE 4 • 2019

Margaret McGuckin discussed how she increased top-line revenue as COO of ClearChoice Dental Centers. She addressed questions such as: What are the most innovative ways large groups can attract and convert new patients? What are sophisticated methods to convert new patients – on the phone and in the chair? Where is the lowest-hanging fruit in most dental groups? The Future of Teledentistry in Group Dentistry Speakers: Richard Lee, CEO and Dr. William Jackson, COO, Virtual Dental Care Jackson and Lee discussed how teledentistry is being utilized today and where it is headed in the future. Attendees learned how teledentistry has evolved and increased patient convenience, enhanced peer-to-peer communications, and helped the entire dental industry reach a higher level of patient care. Jackson and Lee addressed questions such as: How are dental offices utilizing teledentistry now, and how will it be used in the future? How can the average dental group leverage teledentistry and position themselves for the future? The Future of Payments in Group Dentistry Speakers: Matt Hall, MBA, president and COO of Wellfit, Joe Feldsien, senior vice president of professional partnerships, Pacific Dental Services Matt Hall and Joe Feldsien addressed the current state of paying for dentistry. It hasn’t changed in over five decades, and it is filled with complexity, misunderstanding and lack of transparency. As a result,

it creates stress, friction and frustration, which breaks down trust between providers and patients. The introduction of new innovative financial technology (FinTech) offers solutions for building trust between providers and patients. The Future of Dental Patients’ Retail Experience in Group Dentistry Speaker: Dr. Ryan Hungate, Orthodontist/Founder and CSO, Simplifeye Dr. Hungate addressed how technology can be used to automate the patient experience, and how software can increase new patient flow, decrease patient check-in times, decrease insurance verification times, decrease accounts receivable, and increase payment collections. The right technology not only enhances the patient experience, but it’s also preferred by patients, as they seek more Amazon Go-like customer service automation options, according to Dr. Hungate. The Future: Bringing Dental Care to Patients – the Floss Bar Model Speakers: Eva Sadej, founder & CEO and Farhad Attaie, CSO Floss Bar In their presentation, Eva Sadej and Farhad Attaie explained the Floss Bar model, which offers portable dental units that come into corporations, workspaces or residential buildings to offer onsite dental care. Floss Bar, which also partners with local dentists and hygienists, has scaled quickly to more than 40 states in the past year. Striving to make dental care more accessible, Floss Bar also seeks to help change the disease model that has been

at the core of dental-care delivery, causing 50 percent of Americans to avoid the dentist. People who don’t seek dental care often suffer from gum disease-related conditions such as diabetes and heart disease. By providing mobile dental care, Floss Bar’s aim is to help close the fundamental divide most patients feel between their body and mouth – the medical/dental connection. Special Panel: Association of Dental Support Organizations: Associate Ownership Models: Is the ’Employee-Dentist’ Model Dead? Panelists: Ken Cooper, CEO, North American Dental Group; Tarek Aly, BDS, MBA, co-founder and COO, OrthoDent Management, LLC; Merritt Dake, chief executive officer, Rock Dental Brands. Ken Cooper, Tarek Aly and Merritt Dake discussed their approaches to researching and creating associate ownership plans, including successes and failures, best practices, and tips and advice for group-practice owners who are exploring their options or rolling out similar models. Special Panel: Pitfalls to Avoid When Growing a Group from 1 to 3 to 5 Locations and Beyond Host: Dr. David Janash, president & CEO Underbite Dental Management Dr. Janash hosted this panel and also offered his insight on the most common issues and decisions growing groups face, including: the biggest challenges getting through the first few locations; current obstacles; and future hurdles when growing a dental group. Panelists included:

• Dr. Marc Adelberg, owner, Adelberg Montalvan Pediatric Dental, PC. • Dr. Lori Noga, DMD, founder & CEO, Tranquility Dental Wellness. • Scott Guest, Co-founder and COO New Horizons Dental Practice Management. Emmet Scott, CEO, Community Dental Partners, acted as the special guest emcee for the 2019 DEO Summer Summit. The 2019 DEO Fall Summit will follow this November 7-9, 2019, in Orlando, Florida. For more information visit www.Deodentalgroup.com.

Dykema The Dykema DSO Conference 2019 – The Definitive Conference for Dental Support Organizations – is scheduled for July 10-12, at the Omni Dallas Hotel in Dallas, Texas. This highly anticipated conference offers opportunities to learn about current best practices in the areas of legal, regulatory, compliance, tax, consumer finance, billing, operations, M&A, financial reporting and other industry-specific issues. It is an immersive event for practice owners, executives, investors and in-house counsel. For those who are new to DSOs or would like to expand or improve their current organization, this event offers solutions for various levels of their organization. To learn more about the Dykema DSO Conference 2019 once more information becomes available, visit www.dykemadso.com.

Scaling Up The Scaling Up Group Dental Symposium 2019

The 5th annual Scaling Up Group Dental Symposium is scheduled for August 21-23, 2019. The event will be held at the Omni Hotel in downtown Louisville, Kentucky. Last year’s event hosted over 350 attendees representing 66 dental service organizations and 2,310 dental offices from 30 states. The two-day event promises to feature great content covering a wide variety of topics important to growing DSOs. Attendees will have the opportunity to get up-close and personal with Dr. Wayne Mortenson, founder, Mortenson Dental Partners, as he hosts a Q&A breakout session. The breakout session will be in a small group setting, and the conversation will be led by attendees based on what they want to know from this formative leader in dentistry. The event opens with a behindthe-scenes tour of the Mortenson Dental Partner Support Center. A networking reception is scheduled Thursday, August 22, 2019 at the Muhammad Ali Center, Louisville, Kentucky. Cocktails and hors d’oeuvres will be served overlooking the beautiful Ohio River and Louisville skyline. The Muhammad Ali Center will also be open for tours that evening. Presenters will include: • Jason Barger, author, Thermostat Cultures. • Bill Becknell, CEO, Mortenson Dental Partners, “Developing Your DSO Strategy.” • Brian Colao, director of Dykema’s Dental Service Organizations Industry Group. • Steven L. DeLong, CEO, Bluetree Dental. • Andrea Edelen, director of dental hygiene and clinical ISSUE 4 • 2019 : DentalGroupPractice.com 17

Events

support, Mortenson Dental Partners, “Leveraging Hygiene to Drive Peak Performance.” • Dr. William Engilman, DMD, MS, president and chief information officer, Mortenson Dental Partners, “Data Science in DSO Dentistry: Elevating Patient Care & DSO Performance.” • Corby Ewing, director of business intelligence, Mortenson Dental Partners, “Data Science in DSO Dentistry: Elevating Patient Care and DSO Performance.” • Nicholas Partridge, president, Five Lakes Professional Services, “Trends in Payor Relations.” • Cheryl Penava, vice president practice excellence, Mortenson Dental Partners, “Leadership Session: Developing Your Executive Presence.” • Cecile Schauer, president of strategic accounts, Patterson Dental. • Melissa Thomas, director of business operations, Mortenson Dental Partners, “Leveraging Hygiene to Drive Peak Performance.” Breakout Speakers will include: • Colin Carr, CEO, CARR Healthcare Realty, “Managing Your Real Estate to Maximize Practice Profitability.” • Karan Garg, managing director, Houlihan Lokey Healthcare Group. • Christopher Grimm, director of information systems, Mortenson Dental Partners. • Jacqueline Guinn, doctor recruiter, Mortenson Dental 18

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Partners, “Teaching with a Twist: Doctor Recruitment.” •B ryan Hildreth, chief human resources officer, Mortenson Dental Partners. • Andrea Kartch, director, Professional Skills and Leadership Programs, Mortenson Dental Partners, “The Power of Great Coaching.” upinder Kaur, doctor •R recruiter, Mortenson Dental Partners, “Teaching with a Twist: Doctor Recruitment.” •D r. Wayne Mortenson, founder, Mortenson Dental Partners, “Q&A with Wayne Mortenson: An Intimate conversation with Mortenson Dental Partners Founder.” •C heryl Penava, vice president practice excellence, Mortenson Dental Partners, “Leadership Session: Developing Your Executive Presence.” • S herri Toohey-Taylor, director of human resources, Mortenson Dental Partners, “Tips on Finding Talent in a Tight Labor Market.” hristy Williams, director, •C learning & development, Mortenson Dental Partners, “Leadership Session: Developing Your Executive Presence.” • Kristen Wilson, human resources business partner, Mortenson Family Dental Specialty, “Tips on Finding Talent in a Tight Labor Market.” For more information visit https://scalingupgroupdental.com/ ?gclid=EAIaIQobChMIwLyP2NPk4QIVBdbACh3jqgirEAAYASAAEgIGW_D_BwE.

DentalForum DentalForum USA 2019 will open September 11-12, 2019, at the Gaylord Opryland Resort in Nashville, Tennessee. The Opryland Resort features 9 ½ acres of indoor gardens and waterways. The Forum will be the organization’s 4th for the U.S. market. With time-efficiency at the forefront of the agenda, attendees can expect a personalized schedule of one-to-one speed meetings, connecting them with future partners in a personalized agenda built around their priorities. The OpenRoom team has been busy constructing a tightly-packed schedule of business content. Details are available on the DentalForum website, or you may follow them on Twitter or LinkedIn. DentalForum 2019 will offer DSOs a number of opportunities, including: • An opportunity to network with peers and meet with new and current suppliers. • An individualized meeting program. • An opportunity to engage with the leading minds in the industry. There are benefits to suppliers as well, including the opportunity to: • Collaborate with meeting organizers to develop a schedule that matches each DSO’s priorities. • Interact with the primary decision makers from each DSO. • Engage with – and learn from – both the DSOs and other manufacturers. • Relax and meet customers on a personal level. For more information visit https://www.openroomevents.com/ dentalforum-usa-2019.php.

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Efficiency In Group Practice : ISSUE 4 â&#x20AC;¢ 2019

Pedodontists

Advanced technology, together with experience and a measure of sensitivity, enable pedodontists to provide the best possible care for their young patients.

For pediatric dentists, patient care can be a fine balance between treating a child’s oral health and creating a safe, welcoming environment. The recommended age for a child’s first dental visit has dropped from three years to 12 months in recent years, making it more important than ever before for pedodontists to determine a treatment plan tailored to each patient’s needs. Indeed, pedodontists must approach their patients with a unique level of clinical experience that enables them to manage each child’s behavior while also assessing his or her growth and development. “It is important that we meet each child to determine his or her needs for behavioral management, and put together a treatment plan that best suits that child,” says Kim Hansford, DMD, a pediatric dentist at Middletown, Kentucky-based Kid’s Dentistree, a Mortenson Dental Partners partner. “We see ourselves as primary care providers, much like pediatricians. Our goal is to provide a dental home for each child.”

The battle against tooth decay Pediatric healthcare can be frustrating, both for parents who wish

for immediate results for their children, and clinicians who are always in a position to deliver. “Dental caries is still the most prevalent

“It is important that we meet each child to determine his or her needs for behavioral management, and put together a treatment plan that best suits that child.” – Kim Hansford, DMD, a pediatric dentist at Middletown, Kentucky-based Kid’s Dentistree

childhood disease we see, even in our affluent society,” says Hansford. Most people’s diet includes processed foods, with lots of refined carbohydrates, she points out. “Even crackers break down on the teeth into simple sugars, which can cause decay. “Parents become frustrated,” she continues. They feel they are doing everything they can to protect their child’s teeth, but to no avail, she notes. While good nutrition helps children avoid tooth decay, there often are overlooked culprits that impact oral health. Medications are a prime example, she points out. “A liquid allergy medicine taken every night by a child has sugar in it,” she says. “Gummy vitamins are made with sugar and stick to the teeth. “Grazing or snacking – and not letting the mouth have time in between snacks or drinks to normalize – can place children at high risk, due to repeated exposure. It is my job to provide parents with the tools they need to avoid these easy ISSUE 4 • 2019 : DentalGroupPractice.com 21

Pedodontists

traps, and teach them to care for their child’s teeth at home.

Exceptional technology “Unfortunately, there is no magic bullet for treating children,” says Hansford, noting she makes a point to put herself in these parents’ shoes and be sensitive to their expectations. That said, pedodontists today have some exceptional technology at their disposal for treating patients, she adds. For many years, nitrous oxide has proved itself invaluable in many dental settings, but particularly in pediatric practices. “Nitrous oxide sedation continues to be the safest and most

predictable way to provide an easier experience for most children,” says Hansford. “We use it for patients of all ages; it can make or break a child’s experience under the right circumstances.” She advises dental professionals against using the term sedation too freely. There are a number of options for pediatric patients, and the pedodontist can determine the best method for each patient. “Some children may do great in a pediatric dental setting without any additional medications,” she points out. Equipment such as digital imaging/radiographs are another musthave for pedodontists. “Developments

“ General public awareness of the importance of early evaluation is key in helping children get established in a dental home and hopefully lowering their risks of oral health issues.” – Kim Hansford, DMD, a pediatric dentist at Middletown, Kentucky-based Kid’s Dentistree.

Efficiency In Group Practice : ISSUE 4 • 2019

in digital imaging greatly reduce children’s exposure to radiation while delivering excellent clinical X-rays,” she explains. “We make a commitment to image gently in our office.” Without radiographs, pedodontists cannot determine an exact number of cavities, she adds. “Hidden interproximal decay can be a big surprise to parents!” Hands-free dental vacuum suction and isolation systems have “totally changed the way I practice pediatric dentistry,” says Hansford. “In the past 20 years, this technology has allowed pedodontists to provide treatment on one whole side of the mouth safely and comfortably, with less local anesthetic than in the past when we relied more on rubber dam isolation. “Dental materials have also come far, allowing pedodontists to provide more esthetic options, in more instances than in the past. Glass ionomer restorations in children provide fluoride release, good esthetics and are more tolerant in moist environments, where perfect isolation may not be achieved. “General public awareness of the importance of early evaluation is key in helping children get established in a dental home and hopefully lowering their risks of oral health issues,” Hansford continues. Children may always have caries, she adds. But, with new treatments like silver diamine fluoride as an adjunct therapy to delay treatment, or decrease need in times where it may not be practical due to the patient’s medical status or very young age, pediatric dental practices should have greater opportunity to take a preventive stance to oral healthcare.

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Pedodontics

Kid-Friendly Dentistry Treating young children requires a unique skill set. A few generations back, the general consensus was that children should be seen but not heard. Fortunately, by today’s standards, not only should children be seen and heard, they should be afforded the best possible healthcare, including oral care. Indeed, the recent drive to educate families on the importance of early oral care and the need to make treatment more accessible has paid off, both for pediatric patients and the pedodontists treating them. Overall, this is great news for dental professionals. At the same time, many dental owners are challenged with making their waiting rooms more child-friendly, investing in newer technology and providing their teams with more and better training.

Outreach and education Rolando Mia, vice president of customer success at Zyris, has seen a definite rise in pediatric dental visits among the company’s pedodontist customers. “We believe the increasing population of children in the United States is helping fuel growth among our pediatric customers, many who are expanding – adding operatories, personnel and even offices,” he says. “We also hear that more families are realizing the importance of bringing their children to the dentists’ office; This is reinforced by our pediatric and community health center customers via additional and ongoing educational programs, as well as dental education outreach in their local communities. For instance, many dentists today offer on-site visits to schools and provide free dental packs (e.g., toothbrushes, toothpaste, floss, etc.) for the children. “It appears that more children and their families are taking advantage of insurance coverage, as well 24

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as special pediatric-focused dental outreach programs for preventative dental care, (e.g., the American Dental Foundation’s Give Kids a Smile, America’s Tooth Fairy, etc.),” he continues. “It’s been especially helpful as dental associations have come together to develop a successful ad council awareness campaign promoting the importance of managing children’s oral hygiene (e.g., 2 Min – 2X/Day, which involves brushing one’s teeth for 2 minutes, twice daily). As a result, more chil-

dren are receiving higher quality oral healthcare today.”

Addressing the need As more and more children are scheduled for dental visits, pedodontists and general dentists who perform basic pediatric care (e.g., checkups and cleaning, preventive care, caries treatment, sealants, education, etc.) are tasked with adopting new technology, remodeling their waiting rooms and offering reward programs to motivate their younger patients. “We’ve observed that many of our customers recognize the need to make their offices an inviting, fun and safe place for children to visit,” Mia points out, noting it’s common for dentists to rely on themes to make their offices less intimidating. So, for instance, the office may feature a beach theme or a tropical, jungle, ocean or zoo theme. It’s also becoming more common to have digital or board games available in the waiting room, children’s programming playing on a television and interactive iPads available in waiting rooms, operatories and recovery rooms. Some practices have begun sponsoring special events, such as field trips to the dental office to give children the opportunity to use the instruments, see the operatories and learn about dentistry, he adds. “We also see different engagement and reward systems for children who are successfully performing preventative oral care, such as the Brush

DJ app, a no-cavity club or movie passes, awards or toys,” says Mia. Not surprisingly, with an increase in patient visits comes a handful of administrative responsibilities, including recruiting qualified doctors and staff, managing the business and working with parents and caregivers – some who can be overbearing! “Pediatric dentists must be effective in consistently managing issues related to profitability, staffing, expense control, maintaining a high quality of care and managing the team,” says Mia. And, it’s not always easy to secure qualified or experienced dentists, he adds. Many dental school graduates are opting to join DSOs over solo practices. “In addition, we’ve learned from working with our pediatric customers there is a special patience and focus required to work with children,” he points out. “There is a level of communication and patience required to be effective with children, and not all doctors and clinicians have the capacity or talent to do so. “Children are especially difficult to treat due to their decreased understanding of the procedure, short attention span and smaller mouth,” he continues. “Pediatric dentists have a small window of opportunity to treat a child before the patient becomes tired, distracted or simply upset during the procedure.” Sometimes, it’s a matter of working with a difficult parent or caregiver, he notes. “We continually hear that parents can make or break a dental procedure visit. When parents do not cooperate, or they feel compelled to question everything a

clinician is doing, we’ve been told this can upset the child and compromise the clinician’s ability to effectively treat the patient. In addition, children key off their parents/caregivers during a procedure. If a parent is nervous, impatient, fearful, etc., the effect on the child can be negative. “As technology and materials continue to improve, procedures are easier and quicker to perform,” says Mia. That said, incorporating and using new technology, equipment and materials can be challenging, he adds. “We’ve been told the proliferation of computer and digital systems is especially daunting. The challenge is to find clinicians, hygienists and dental assistants with the skills and ability to operate and use these systems once they are trained.” Examples of newer pediatric technology includes silver diamine fluoride (SDF) for caries prevention and treatment, digital X-rays, digital and laser cavity detection devices and aids, hard and soft tissue laser designed to painlessly treat cavities and decay, CAD/ CAM impression technology, painless injection systems and improved isolation and retraction devices, such as the Isolite System. At the same time, pediatric dentists today must be comfortable with sedation dentistry, which is now used more routinely. “We’ve heard a number of concerns from our dental customers regarding these newer technologies,” says Mia. For one, there’s an ongoing cost involved in adopting new technology, some of which may quickly become obsolete as next generation systems become available. “Our customers

also tell us that new technology can be disruptive to clinicians,” he says. Naturally, there’s a learning curve involved and it takes time for clinicians to become comfortable using new technology. The dental team must also keep up with software updates and on-going training and support. “It requires a dedicated effort, and when technology is set aside and forgotten, it’s a wasted investment.”

Training and education Even as dental care becomes more accessible to many children, some community health clinics continue to face a huge patient backlog, notes Mia. “According to one community health clinic we work with, some pediatric patients have wait times of one to two years to be seen by a clinician,” he says. “The majority of recent dental school graduates are trained to perform procedures primarily on adults,” he explains. “They often have limited education or expertise when it comes to working with younger children. “Pedodontists must participate in a graduate education program that is focused specifically on treating and managing younger children,” says Mia, noting this requires a much different skill set from working with adult patients. “When a child is experiencing more complex oral health issues or severe conditions, it is imperative that he or she is treated by a specialist – one that is specifically educated and experienced in treating young children and special needs patients.”

https://www.childstats.gov/americaschildren/tables/pop1.asp https://www.childtrends.org/indicators/number-of-children ISSUE 4 • 2019 : DentalGroupPractice.com 25

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Specialty Focus

Implantology Improvements in implant technology are making them increasingly attractive to doctors and patients. Twenty years ago, patients who were missing one or more teeth did not have many options when it came to replacing them; often, they had to go to a specialist for treatment. That is not the case today. Dental implants have become increasingly popular among patients, not only because they offer a number of advantages over traditional bridges, but because they have become much more routine to place. In fact, in most parts of the world, typically it is the general dentist who now places the implant, according to Madhu Mahadevan, DDS, clinical director for Tru Family Dental. Indeed, improvements in implant technology are making them increasingly attractive to doctors and patients alike, notes Mahadevan. “Implant manufacturers have improved surface 28

Efficiency In Group Practice : ISSUE 4 • 2019

treatment, exterior design and connection type, all which have led to better implant integration and reduced bone loss,” he says. Now, too, dentists have access to a great variety of implant sizes, enabling them to customize the implant to fit the amount of bone available in the patient’s mouth. “As more adjunct services become available – including cone beam computed tomography (CBCT) X-rays, surgical stents for guided surgeries, bone grafting, sinus augmentation and platelet-rich fibrin (PRF) membrane placement – implant surgeries are much

more successful,” says Mahadevan. “Advances in CBCT imaging have allowed implant surgeons to view bone levels and density in a 3D radiographic rendering. Vital structures, such as nerves and vessels, can be seen on the CBCT, which may not be clear on a traditional panoramic radiograph. And advances in bone grafting, sinus augmentation and PRF membrane placement have led to more customizable options for implant placement, better healing and faster recovery times for patients.”

The pros and the cons All that said, placing an implant is still considered a surgical procedure and, as such, dentists should discuss their patients’ options with

them. On the plus side, placing an implant does not require the adjacent teeth to be altered in any way. By comparison, bridgework necessitates the two teeth adjacent to the missing space be irreversibly altered, which can sometimes lead to further issues, notes Mahadevan. In fact, implants can be placed even when the adjacent teeth are unhealthy, whereas a bridge cannot. Also, with an implant, patients can floss more easily than with a bridge. Implants help maintain healthy bone levels, are more functionable and typically look nicer than bridges. On the other hand, implants take more time to place than a bridge, according to Mahadevan. “Implants can take as long as a year to complete, whereas a bridge can sometimes be completed in two weeks,” he points out. Common risks include fracture or overloading of the implant, infection or peri-implantitis, damage to the surrounding nerves, blood vessels or teeth, poor positioning of the dental implant, poor bone quality and more.

And, unlike bridges, implants aren’t always fully covered by insurance plans. Nor is every patient a candidate, he adds. “Heavy smokers, unstable diabetics and patients who take bisphosphonates typically are not good candidates for implant therapy.

when restoring the implant and thoroughly educating the patient about proper oral hygiene,” he continues. Implantologists who work in a large group setting are at an advantage, he points out. “The implantologist at a large group practice or dental service

“ Implant manufacturers have improved surface treatment, exterior design and connection type, all which have led to better implant integration and reduced bone loss.” – Madhu Mahadevan, DDS, clinical director for Tru Family Dental

“Much of the risk associated with placing dental implants can be avoided with proper patient selection or by taking a detailed medical history, reviewing a CBCT of the patient’s jaw before planning the surgery, understanding proper occlusion

organization typically has a restoring dentist on hand at the time of surgery,” he explains. “The restoring dentist can provide feedback regarding the placement of the implant, which most certainly will lead to a better end result for the patient.”

Endosteal vs. subperiosteal Dentists can select from two types of implants: endosteal, which are placed in the patient’s bone, and subperiosteal, which are placed between the patient’s gum tissue and bone. “Endosteal implants are most commonly used,” says Madhu Mahadevan, DDS, clinical director for Tru Family Dental. “Given the recent advances in bone augmentation, implant design and zygomatic implant techniques, subperiosteal implants tend not to be a dentist’s first choice. “Subperiosteal implants should be placed when the patient’s bone in the maxilla or

mandible is atrophied and limited,” he continues. “Using a subperiosteal implant for these patients helps them avoid bone grafting.” And, since the implant sits on top of the bone rather than within it, the healing process tends to be faster, he notes. Whenever possible, however, Mahadevan recommends the use of an endosteal implant. “The advantage of the endosteal implant is that it is much more stable and has a very low failure rate compared to subperiosteal implants,” he says.

ISSUE 4 • 2019 : DentalGroupPractice.com 29

Trends

All the Right Moves For Eric Shirley, the best solutions lie beyond the obvious answers. By Laura Thill

care, enabling the practice to adopt new technologies and products, and designing oral healthcare environments that do all of this more effectively and comfortably.” “Distributors and manufacturers both have a role to play in that. If we each do our jobs really well, we’re going to increase the value of oral healthcare and help patients receive better care. Ultimately, we’re going to help the practices become more successful.”

From manufacturing to distribution

Eric Shirley

When Eric Shirley joined Patterson Dental as president of the dental business unit earlier this year, he brought with him years of industry experience and perspective, as well as a fresh vision for the company and its business partners. “Patterson has two critical and unique assets: our customers and our teammates,” says Shirley. “With that wonderful foundation, I am not here to solve huge problems. My role is to ask the right questions and challenge ourselves to think in ways 30

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that enable our teams to make our customers more successful.” Both distributors and manufacturers are tasked with increasing the value of oral healthcare, he points out. “It’s about empowering the clinical team to provide better and more efficient

Shirley’s career took root in dental manufacturing when he joined Kavo Kerr (currently part of Danaher) in 1991 as the Southern California territory manager, as well as a product and marketing manager. He remained with the company for seven years, after which he joined Dentsply as the director of marketing for preventive care. For the next six years, he assumed various sales and marketing roles at Dentsply. In 2004, he joined Midmark Corp. as vice president of sales and marketing for the company’s dental business, later transitioning to general manager of both the dental and animal health divisions. Afterward, he was appointed Midmark’s chief commercial officer and directed the customer-facing efforts for all three of the company’s businesses: Medical, Dental and Animal Health.

â&#x20AC;&#x153;Midmark utilized the Toyota Production System in all of its manufacturing facilities and office environments â&#x20AC;&#x201C; an experience that was very educational and eye-opening,â&#x20AC;? says Shirley. â&#x20AC;&#x153;Working on the manufacturing side taught me a great deal about process, operations and product development. I learned to look beyond answers to the questions and to really search for new ways to solve problems that the customer or clinical team couldnâ&#x20AC;&#x2122;t necessarily articulate. The discovery of unmet needs is critical on the manufacturing side, as is the ability to utilize real, established

processes within those business units to achieve goals.â&#x20AC;? Itâ&#x20AC;&#x2122;s precisely this experience, he adds, that he hopes to offer Patterson.

Meeting the need For Shirley, the reasons for joining Patterson were clear. â&#x20AC;&#x153;Patterson has always impressed me as an organization that truly understands the dynamics of the dental practice, including how to bring real value-added expertise to help the practice team achieve its goals,â&#x20AC;? he explains. â&#x20AC;&#x153;I worked with Patterson as a supplier partner for many years and have gotten to know

the organizationâ&#x20AC;&#x2122;s values very well. Iâ&#x20AC;&#x2122;ve long been fascinated with how deeply Patterson knows the practice mechanics of its customers.â&#x20AC;? As newly appointed president of Patterson Dental, Shirley embraces the opportunity to bring new insight to dental practices, including practice owners and the clinical team, ultimately improving the care patients receive. Itâ&#x20AC;&#x2122;s becoming increasingly important to provide dental practices with the data and insights necessary to achieve their goals, he points out. â&#x20AC;&#x153;Whether we offer new services, integrate technology, design dental

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Trends

practices, facilitate transitions, or use our data to find new sources of revenue for the practice, I think it’s critical for us to understand how we can evolve and change as a partner to help our customers achieve these goals,” he says. “It’s important to understand what our dental customers need from a distribution partner, and to realize that these needs are changing – needs that are unique to each customer,” he continues. “Our customers’ needs are not the same as they were 10 or 15 years ago, and they will continue to change over the next 10 or 15 years. Our goal at Patterson is to understand our customers’ needs and position ourselves as the one company that can address those needs.”

Shirley couldn’t have joined Patterson at a more opportune time. Today more than ever, the company works to understand its dental customers’ needs and address

“Our customers’ needs are not the same as they were 10 or 15 years ago, and they will continue to change over the next 10 or 15 years. Our goal at Patterson is to understand our customers’ needs and position ourselves as the one company that can address those needs.”

A history of philanthropy Eric Shirley, newly appointed president of Patterson Dental’s dental business unit, has long been involved in a number of philanthropic efforts, including TeamSmile and the Dental Lifeline Network. So, it’s no surprise he feels at home at Patterson Dental. “Since 2004, the Patterson Foundation has given $3.2 million in scholarships to 415 students from Patterson families and $7.6 million in grants to 140 nonprofit organizations,” he points out. “So, I know how strongly the Patterson team feels about the mission and the work of the Foundation, and they’ve already encouraged me to continue the philanthropic work that I do. “The TeamSmile work is what I’m most proud of because I’ve seen how the organization has grown in the years I’ve been a part of the Board of Directors,” Shirley continues. “The passion of Dr. Bill Busch and the many people who work with TeamSmile to provide free dental care to children all over the country – including partnering with professional sports teams – has been so inspiring. I’m really proud of what they do. We began 13 years ago with a single event with the Kansas City Chiefs; today, the program has mushroomed into 40 annual events with 40 professional sports teams!”

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the unique goals and objectives of each practice. “We are focusing on what makes the Patterson difference impactful to a dental practice,” he says. “It’s about the data and insights we bring to this conversation and getting to know what each practice really wants to accomplish.” This can vary widely from practice to practice, depending on whether it’s a large dental service organization, a regional group practice or a smaller solo practice, he adds. Sometimes dental practices are looking to design better operatories or acquire other practices, Shirley continues. In some cases, their goal may be to add new services, procedures and technologies. What sets Patterson apart is “its ability to have those kinds of deep, one-on-one conversations with practices,” he points out. “We are becoming a stronger partner to dental practices, bringing business and clinical solutions to help each practice accomplish their individual goals.” In turn, Patterson’s dental customers are placing greater trust in the distributor by installing its software, equipment and technology offerings, helping to fuel its leadership position in the dental industry.

A look to the future In Shirley’s experience, not only will the needs of dental professionals continue to change in years to come, so, too, will the industry landscape. In fact, he expects the industry to expand, making room for both large and small players. “We will continue to see the role of Dental Service Organizations (DSOs) grow and new models emerge,” he says, adding that these organizations will

look very different in three or five years. “We’ll see new models emerge in size and scope,” he says. “We’ll also see new and changing ownership models. For instance, we may see more medium-sized regional service organizations that are made up of practices with the same consistent values and core concepts.” At the same time, Shirley anticipates the re-emergence of the small practice environment. “I’m really encouraged by what I see with the sole practice model,” he says. “Solo practices want to be more relevant and provide better care and a different patient experience. They are clearly asking themselves some tough questions about how they can compete in

the new world; I’m encouraged by what I see in all areas.” In addition, he has great confidence in today’s millennial dental graduates, who as a group appear eager to begin their careers and give back to their community. “I have the pleasure of working with a lot of dental school graduates, [many] who are eager to own several practices,” he points out. “I also see dental school graduates who are interested in public dentistry and giving back to the community, and I think that’s great too. I’m encouraged by what I see in the graduating classes of dental schools; I think it’s going to be exciting for the future.

“I’ve fallen into an industry that is really [fantastic] to be a part of,” says Shirley. “Everybody wants to do the right thing and improve the oral healthcare of the patients that we all serve.” That said, he credits the people in his life – family, friends and colleagues - who have inspired him to try to make the world a better place. “I’m lucky to have a very supportive family and so many wonderful friends and colleagues in this industry who have helped me so much,” he says. “My parents and grandparents have been an inspiration to me, and I feel like I’m trying to bring their legacy forward. They have worked so hard over the years, and I am grateful for their example of work ethic and love.”

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Practice Points

The Dash to the 2019 Finish Line 4 steps to implementable success

Where are you regarding reaching your year-end goals? I invite you to pause and take stock of your successes from the last two quarters. This article focuses on the support you need in planning for the months ahead.

By Kristine Berry, RDH, MSEC Kristine Berry is an international speaker and executive coach, specializing in enhancing group practices. If you are looking for a speaker or coach, she invites you to email her at kristine@kristineberry.com or visit her website www.kristineberry.com.

Looking backwards to the first two quarters of the year: • What successes did your team have? • What major accomplishments did your team have? • What were the key lessons learned? • What habits or practices helped you? • What role did you play in planning? • What systems and practices supported your focus and planning? • What got in the way? • What do you NOT want to carry forward into the coming seasons?

Efficiency In Group Practice : ISSUE 4 • 2019

What’s this you say? You have yet to lay out your goals for this year? If a poll was taken of most people, it would reveal that the life they lead is a result of happenstance and not planning. The same goes for business. It’s my belief – and the belief of many business and professional coaches – that the business solvency of the companies we lead is more often a result of lack of planning, rather than over-planning or having the wrong plan. Perhaps you dread making or tracking key metrics, or you never planned

what your income will be, or you never decided how many patients you want to have. Perhaps you are at a point where you wish your team would just listen to you, so that you only have to say things once and it’s done! Or you are feeling like you’ve been on a treadmill the first half of the year and are ready to bust through the brick wall of running your business so that you can grow. Or perhaps you feel the people around you just don’t care. Or maybe you don’t care anymore! Effectiveness in business requires a focus on both results and relationships. One without the other is not enough. This article offers tools and a roadmap to make your dash to the 2019 finish line more focused, effective and without carnage. In order to establish and achieve your goals, you must follow these 4 steps: • Discover your direction. • Identify your gaps. • Pack your practice with meaningful purpose. • Create sustainable results.

Discover your direction This is where the rubber meets the road. “Where is the road?” you ask. My answer: “Where do you want it to be?” Whether or not you set goals for your practice in January, yesterday or you commit to doing it after reading this article, Step 1 is to create space. You must clarify and specify the future you want for your business, where you want to go or what you want to have. Some people do not even know what's possible for their businesses; you may need someone to help you get a clear vision of how

you want your office to be. At dental practice management firm Next Level Practice, our community sets goals considering the following divisions: leadership, management, administration, marketing, case acceptance, finance and quality assurance. With these divisions in mind, you can begin to create specific destinations for your business. For example, one of my clients took the quality assurance division and set monthly calibrations with the clinical teams to ensure everyone was working to their highest standard of care. In the leadership department,

implement a system to interrupt that pattern. She realized it started with her leadership and that she needed to develop this first.

Identify your gaps Once you have identified where you want to go, the next step is to identify the gaps between what you want for your business and where you are now. For example, if you want to work three days a week and take four weeks off a year, and you are currently working five days a week with two weeks of vacation, those gaps begin the process of awareness.

Dr. Marshall Goldsmith, preeminent executive coach and author of “What Got You Here Won’t Get You There,” believes that leaders need “guidelines to help eliminate dysfunctions and move to where you want to go.” He adds, “Often our own success delusion stands in our way and causes us to resist change.” In order to reach your goals, you may need to move out of your comfort zone. a doctor who owned multiple locations shared that she kept encountering the same obstacle: Her team did not want to implement anything 100 percent. During one of our coaching sessions, she was willing to explore why this kept happening. She discovered that her team did not trust her to keep and honor her word about the changes, or to hold anyone accountable; she was known for not following through. Her team was playing the waiting game – always waiting for her to go on to the next idea. So, the doctor’s end game was to

People do not particularly like gaps. Once identified, we instinctively want to close them. Some of this is the result of cognitive dissonance. People in general want to be consistent in their attitudes, beliefs, values and actions/behaviors. They want to act in accordance with their attitudes, beliefs, values and goals. When their actions contradict them, they experience dissonance. This dissonance is uncomfortable, and people naturally want to reduce it. The dissonance gap creates a vacuum in which the solution starts to unfold. This strategy is one ISSUE 4 • 2019 : DentalGroupPractice.com 35

Practice Points

competency that I implement with my client teams. We discover what the owner/doctor/CEO/team leader, etc., wants to create with regard to time and dollars, and then we walk them through a process called reverse engineering. Reverse engineering is a proven implementation strategy or process for goals, systems and engaging teams. Leaders with effective communication structures, team leaders, morning huddles and other key practice success methodologies will not find themselves in the position of being a hall monitor and policing or micromanaging people. Rather, they can do what they love to do: Practice dentistry and monitor outcomes.

Pack your practice with meaningful purpose Perhaps some readers of this article are members of the drill-and-fill PPO club. Your culture and standards crank out transactional dentistry and experience the daily challenge of outrunning the expenses of your practices. That’s not good, bad, right or wrong; it just is. On the other side of the spectrum, there are practices that deliver complete health dentistry that have a high value proposition and embrace the triple win. The triple win is a culture that embodies agreements and systems to ensure the patient, team and practice all win. These triple-win practices are playing a different game; they

understand whole-body health and the mouth’s role in preventing chronic inflammatory and brain disorders. Doctors and teams go to work every day with an abundance mindset. They believe there are more than enough patients who value health, and they love to serve them. You may find you are somewhere in the middle. It’s important to identify where you are on the purpose spectrum. No position is good or bad. And, if you want to finish every year strong, you cannot get there alone. Your team wants meaningful careers and workplaces. In order for you to achieve your goals, your team must align their values and passions with your vision, philosophy and/or guiding principles.

Create sustainable results To create happy teams that implement sustainable results, you as a leader must locate your authentic leadership style. If you are not breaking even and/or have not consistently hit your financial goals, I invite you to take a deep dive into your leadership style. At Next Level Practice, we have worked with 6,000 practices and researched the personas of thousands of doctors. Communicating solely from your dominant persona often results in your team not understanding you; their personas cannot yet hear yours. The following are four personalities we identify within doctors and teams: methodical, humorist, competitive and spontaneous. Seventy-five percent of dentists we researched fall into the category of introvert methodical, meaning they know the steps, but they might find it challenging to 36

Efficiency In Group Practice : ISSUE 4 • 2019

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Practice Points

articulate their ideas. As you read the descriptors below, which one resonates with you? •M ethodical. Paralysis analysis, likes step-by-steps, might not consider relationships while focusing on the finish line. • Competitive. Needs it done yesterday; get to the bottom line; you are not moving fast enough. • Humanistic. People pleaser, listens to how any strategy will influence relationships, acquiesces decisions. • Spontaneous. Likes to have fun and, if it is too much work, they won’t do it!

adds, “Often our own success delusion stands in our way and causes us to resist change.” In order to reach your goals, you may need to move out of your comfort zone. The doctor’s persona overlays the practice’s communication system. Think about what can happen when a competitive doctor/owner wants to talk to his 80 percent humanistic team about numbers. The team is most likely going to view any metrics-and-measurements conversation as the doctor being obsessed with production. They may suspect he only cares about the money. Unless the owner knows how to set the context for his or her

Once you have identified where you want to go, the next step is to identify the gaps between what you want for your business and where you are now. Identify which category best describes you. In order to achieve the goals you set and the freedom you deserve, you may need to disrupt your current modus operandi. You can do so by becoming aware of the way you see yourself and the manner you customarily use to relate to everyone around you. Dr. Marshall Goldsmith, preeminent executive coach and author of “What Got You Here Won’t Get You There,” believes that leaders need “guidelines to help eliminate dysfunctions and move to where you want to go.” He 38

Efficiency In Group Practice : ISSUE 4 • 2019

humanist team, and understands that KPIs are a way of tracking how they are living their standard of care or helping their community become healthier, the team will disengage. It only takes one person to derail the team. Leaders must be aware of whether or not their automatic leadership (and hence communication style) is alienating team members. The truth is, a team’s perception is their reality! Another way to determine whether some team members aren’t engaged in your mission, and to better understand your style, is to look

at team meeting agendas for 2009 and 2019. If the same items are on both agendas, you need to be open to leadership development. Think about hiring a coach to support your expansion as a leader. Once clear leadership and effective communication style are in place, you are in a better position to lead a happy team that gets consistent results. Now turn to the remainder of the year’s planning and set your group practice up to finish strong: • What are your goals for quarters three and four? • Narrowing it down, what are your top three to five priorities? • What time is earmarked for planning? • What time is earmarked for team training and development? • What new habits and practices do you want to put in place? • What relationships do you want to focus on? • What is the one thing you can do on a daily basis to move your goals forward? • What needs clearing up? • Where can you get accountability, support and mentorship? Successful practices require dedication and strategy. Consider the four strategic steps to implementing effective results and relationships in your practice. Think about which of these areas is the weakest in your practice, and start there. Coaching can be a powerful ally in moving forward to a healthy, thriving practice. Be in touch if I can assist you in making a dash to the 2019 finish line!

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buildup, post cementation and as a dentin-replacement material. Core-Flo DC’s compressive and flexural strength offers clinicians reliability and durability when fabricating direct restorations. The material provides a void-free flow when cementing the post, and the core provides a homogenous bond to substrates. In a simplified technique, clinicians can cement the post and build up the core with a single application. Core-Flo DC is radiopaque and available in two esthetic shades: natural/A1 and opaque white, designed to meet all direct and indirect restorative requirements. • Core-Flo DC Lite. A dual-cured, fluoride-containing core material dispensed with an auto-mix dual-syringe, Core-Flo DC Lite’s optimal self-leveling viscosity allows for excellent adaption, resulting in gap-free margins when replacing natural dentition with a direct core build-up. Additionally, the clinician can cement the post and build up the core. Core-Flo DC Lite is available in natural/A1 and opaque white shades. Whether dental clinicians are looking for the optimal primer, adhesive, liner or cement, BISCO products are designed to guide them through any clinical curveball with fewer steps and more confidence.

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References 1.

Glossary of dental clinical and administrative terms. American Dental Association. https:/www.ada.org/ en/publications/cdt/glossary-of-dental-clinical-andadministrative-ter#d. 2. Gandolfi MG, Siboni F., Taddei P., Modena E., Prati C. Apatite-forming ability of TheraCal pulp-capping material [abstract 2520]. J Dent Res. 2011;90(Spec Issue A). 3. Okabe T., Sakamoto M., Takeuchi H., Matsushime K. Effects of pH on mineralization ability of human dental pulp cells. J Endo. 2006;32(3):198-201. 4. Gleave CM., Chen L., Suh BL. Calcium & fluoride recharge of resin cements. Dent Mater. 2016;32(1):e26. 5. Chen L., Gleave C., Suh B. New self-adhesive resin cement with alkaline pH [abstract 286]. J Dent Res. 2017;96(A).

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ADA definitions for direct and indirect pulp capping at http://www.ada.org/en/publications/cdt/glossary-of-dental-clinical-and-administrative-ter 2 Apatite-forming Ability of TheraCal Pulp-Capping Material, M.G. GANDOLFI, F. SIBONI, P. TADDEI, E. MODENA, and C. PRATI J Dent Res 90 (Spec Iss A):abstract number 2520, 2011 (www.dentalresearch.org) 3 Selcuk SAVAS, Murat S. BOTSALI, Ebru KUCUKYILMAZ, Tugrul SARI. Evaluation of temperature changes in the pulp chamber during polymerization of light-cured pulp-capping materials by using a VALO LED light curing unit at different curing distances. Dent Mater J. 2014;33(6):764-9. 1

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Infection Control

Engineering and Work Practice Controls Key elements of Bloodborne Pathogens Standard are often overlooked.

By Katherine Schrubbe, RDH, BS, M.Ed, PhD Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent compliance consultant with expertise in OSHA, dental infection control, quality assurance and risk management. She is an invited speaker for continuing education and training programs for local and national dental organizations, schools of dentistry and private dental groups. She has held positions in corporate as well as academic dentistry and continues to contribute to the scientific literature. Dr. Schrubbe can be reached at kathy@ schrubbecompliance.com.

For all dental practice settings, OSHA’s Bloodborne Pathogens (BBP) Standard (29 CFR 1910.1030) provides the fundamentals for a safe workplace, prescribing safeguards to protect workers against health hazards caused by bloodborne pathogens. The Standard places requirements on employers whose workers can be reasonably anticipated to contact blood or other potentially infectious materials (OPIM), such as unfixed human tissues and certain body fluids.1 All of the elements of the BBP Standard are important and work together to provide a comprehensive plan for dental healthcare worker safety. Most dental team members are familiar with several points, such as requirements for an exposure control plan and personal protective equipment (PPE), the opportunity to obtain a hepatitis B vaccination and the implementation of universal precautions.2,3 Some elements of the BBP Standard, however, are often overlooked. Based on personal anecdotal and field observation, the concepts of engineering controls and

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work practice controls are not always assigned the importance – or the attention – they deserve. Dental healthcare workers not only are exposed to human bloodborne pathogens, but also to toxic chemicals in the workplace. But OSHA makes it clear: Engineering controls, as well as work practice controls, are vital to overall safety.2,4 OSHA’s longstanding policy is that engineering and work practice controls must be the primary means used to reduce employee exposure. Wherever possible, elimination or substitution of a hazard is

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Infection Control

most desirable, followed by engineering controls. Administrative or work practice controls may be appropriate in some cases where engineering controls cannot be implemented, or when different procedures are needed after the implementation of the new engineering controls. Personal protection equipment is the least desirable, but may still be effective.5 The pyramid chart below illustrates least effective to most effective methods for reducing occupational exposure.

In other words, it’s product versus process. Engineering controls are products or devices that have been made or manufactured to help reduce the risk of injury; work practice controls are strategies or processes that dental team members should implement to reduce the risk of injury and practice as safely as possible.

Engineering controls According to C.H. Miller, engineering controls isolate or remove the hazard from the workplace. In dentistry, this

Controlling Exposure pyramid5

With regard to all healthcare, including dentistry, engineering controls refer to controls (e.g., sharps disposal containers, self-sheathing needles and safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace, according to OSHA. Work practice controls refer to controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).3 44

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means the use of devices that eliminate or reduce chances of exposure to blood and saliva. These include sharps containers, needle safety devices, red-bags, rubber dams, high-volume evacuation, instrument cassettes and mechanical instrument cleaners. The controls used must be examined and maintained or replaced on a scheduled basis.4,6 Although the requirement to utilize engineering controls has been in effect since the 1992 BBP standard, because occupational exposure to

bloodborne pathogens from accidental sharps injuries in healthcare and other occupational settings continued to be a serious problem, Congress required modification of the BBP standard. As such, the Needlestick Safety and Prevention Act was signed into law on November 6, 2000, to ensure that OSHA’s BBP standard set forth in greater detail OSHA’s requirement for employers to identify, evaluate and implement safer medical devices, such as needleless systems and sharps with engineered sharps protections.1,7 The Needlestick Safety and Prevention Act took effect on April 18, 2001, and mandated additional requirements for maintaining a sharps injury log and for involving non-managerial healthcare workers in identifying, evaluating and choosing effective engineering and work practice controls.1,7 In dental practice settings, this is a sound strategy to promote safety and team involvement. As new sharps safety devices become available in the dental marketplace, team members should bring them into their practice and test them out. They should trial the new device for a period of time, ask for feedback from one another, document the safety trial and determine if the device is something that could be implemented to promote a safer workplace.

Work practice controls Miller points out that work practices can be used to reduce the likelihood of exposure by altering the manner in which a task is performed; all procedures must be performed in such a manner as to minimize the spraying and spattering of oral fluids.4,6 Also,

work practice controls assist in carrying out tasks in a safe manner to reduce the possibility of a sharps injury. Miller provides the following list of work practice controls, although it is not all-inclusive: • Flush mucous membranes as soon as feasible if contaminated with infectious materials. • Recap dental needles by a mechanical means, such as forceps or another cap-holding device, or by using a onehanded “scoop” technique. • Prohibit the cutting, bending or breaking of contaminated needles prior to disposal. • Discard contaminated needles and other disposable sharps in proper sharps containers. • Prohibit the overfilling of sharps containers. • Place contaminated reusable sharp instruments in containers that are puncture-resistant, leak-proof, colored red or labeled with the biohazard symbol, until properly processed. • Eliminate hand-to-hand passing of contaminated sharp instruments. • Prohibit eating, drinking, smoking, applying cosmetics and handling contact lenses in areas where there is occupational

Worker deaths in America are down on average, from about 38 worker deaths a day in 1970 to 14 a day in 2017; and worker injuries and illnesses are down – from 10.9 incidents per 100 workers in 1972 to 2.8 per 100 in 2017.9 exposure, such as the dental operatory or instrument processing areas. liminate the storage of food •E and drink in refrigerators and cabinets, on shelves or on countertops where blood or saliva may be present. • Store, transport or ship blood and saliva, as well as items contaminated with blood or saliva (extracted teeth, tissue, impressions that have not been decontaminated), in containers that are closed, prevent leakage, colored red or labeled with a biohazard symbol.3,4 OSHA’s mission is to assure safe and healthful working conditions for all working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.8 When OSHA standards are followed, job-related

injuries, illnesses and fatalities decrease dramatically. At times, dental team members may complain that doing so is cumbersome, overwhelming and challenging, but OSHA has made a significant difference in a positive way. Worker deaths in America are down on average, from about 38 worker deaths a day in 1970 to 14 a day in 2017; and worker injuries and illnesses are down – from 10.9 incidents per 100 workers in 1972 to 2.8 per 100 in 2017.9 It is important for all dental healthcare workers to comply with all of the elements of the OSHA standards, and it is imperative that practice owners and management teams are committed to implementing all aspects of the OSHA standards. This is the only way to ensure that dental team members can carry out their duties safely in the practice and that the dental facility is a safe place to work and care for patients.

References 1.

.S. Department of Labor. Occupational Safety and Health Administration. Quick Reference Guide to the Bloodborne Pathogens Standard. U Available at https://www.osha.gov/SLTC/bloodbornepathogens/bloodborne_quickref.html. Accessed May 19, 2019. U.S. Department of Labor. Occupational Safety and Health Administration. OSHA Bloodborne Pathogens fact sheet. Available at https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf. Accessed May 19, 2019. 3. U.S. Department of Labor. Occupational Safety and Health Administration. OSHA Bloodborne Pathogens Standard. Available at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Accessed May 19, 2019. 4. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 5th ed. St. Louis: Mosby Elsevier; 2013; 247. 5. U.S. Department of Labor. Occupational Safety and Health Administration. Chemical Hazards and Toxic Substances. Available at https://www.osha.gov/SLTC/hazardoustoxicsubstances/control.html. Accessed May 20, 2019. 6. Miller CH. RDH. Isolate or remove bloodborne pathogen hazards. Available at https://www.rdhmag.com/infection-control/sterilization/article/16405576/ isolate-or-remove-bloodborne-pathogen-hazards. Accessed May 20, 2019. 7. U.S. Department of Labor. Occupational Safety and Health Administration. Frequently asked questions. Available at https://www.osha.gov/needlesticks/needlefaq.html. Accessed May 20, 2019. 8. U.S. Department of Labor. Occupational Safety and Health Administration. About OSHA. Available at https://www.osha.gov/about.html. Accessed May 21, 2019. 9. U.S. Department of Labor. Occupational Safety and Health Administration. Commonly used statistics. Available at https://www.osha.gov/oshstats/commonstats.html. Accessed May 21, 2019. 2.

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Waterline Treatment

Safe Water, Safe Patients Growing attention to the hazards of contaminated dental unit water has led more and more dental clinicians to take the necessary steps to protect their patients. There are no shortcuts to obtaining compliant dental water. Without the right products and protocols, however, dental practices will not be able to meet the acceptable standard for water delivered to patients during non-surgical procedures. What’s more, even though compliance with water safety standards in the United States has not been required by law, that is changing. “A dental practice simply will not achieve compliance without effective, EPA-validated products used in accordance with the correct protocols,” says Jerod Mendolia, marketing assistant, Sterisil, Inc. “At Sterisil, our philosophy is embod46

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ied in the acronym, PPC: Products + protocols = compliance. We have applied this methodology with great success in various settings, from mid-sized five-chair clinics to Ivy League dental schools.” New technology is important, he adds. But unless clinicians are educated on the appropriate protocols and develop a conscientious attitude, “we are setting them up for failure.”

A serious business Because dental water is used as an irrigant solution in conjunction with high-speed rotary handpieces, potentially contaminated aerosols and spatter can carry waterborne pathogens through the air, increasing the potential for infections. Unwanted health implications associated with contaminated dental unit coolants range from the exacerbation of existing asthma symptoms due to endotoxin exposure to complex bacterial infections, such as Legionnaires' disease, according to the Organization for Safety and

Asepsis Prevention (OSAP). In recent years, two high-profile cases have linked dental unit water to serious infections, notes Mendolia. The first incident occurred at Dentistry for Children in Jonesboro, Georgia. A second incident occurred at Children’s Dental Group in Anaheim, California. In both cases, Mycobacterium were isolated as the cause of infections in pediatric patients who received a pulpotomy procedure with contaminated dental unit water, he points out. Although the Centers for Disease Control and Prevention (CDC) has recommended that water delivered to patients during non-surgical dental procedures meet Environmental

Protection Agency (EPA) standards for drinking water (<500CFU), some question whether this is sufficient in a clinical environment. “In 1995, the American Dental Association challenged dental unit manufacturers to develop the equipment necessary to deliver effluent handpiece water with <200CFU,” says Mendolia. That standard has since been raised to the <500CFU/ ml drinking water standard. “Currently, there are many products on the market validated to deliver levels of disinfection well below 200CFU. I don’t think it is unreasonable to expect dental professionals to meet this higher standard considering the number of products and protocols

available with advertised effectiveness claims at ≤10CFU.”

The right solution For many dental professionals, the importance of delivering safe water during patient treatment is clear. Navigating their options, however, can sometimes be tricky. There are several methods available for treating water, notes Mendolia, and clinicians must stay informed in order to best serve their patients. There are advantages and disadvantages to each. There are many filter options capable of removing some level of microbial contaminants, but without the presence of a residual disinfectant,

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ISSUE 4 • 2019 : DentalGroupPractice.com 47

Waterline Treatment

filtration alone is insufficient to consistently maintain and prevent microbial growth downstream from the filter, according to Mendolia. For best results, filtration should be paired with an ion exchange-based product for shock and residual disinfection. “Clinicians should steer clear of filtration methods that require water storage in a tank,” he says. “Unless the practice has something like a UV light after the tank, water storage can lead to incubation of existing bacteria in the tank to >500CFU. Most waterline treatment products will have some sort of disclaimer stating for use with potable water. So, contaminated storage tank water would be unsuitable for use with many chemical treatments based on this alone.

do so with caution. Municipal contaminants like chlorine and copper can interfere with the efficacy of some chemical treatments. The best regimens will always feature both shock and maintenance treatments that are compatible with one another. Whenever possible, clinicians should use distilled water in their bottle reservoirs for the best results.” In theory, in-office distillers are a viable solution, notes Mendolia. However, they are often associated with water test failures. “The machinery of distilling demands regular cleaning and disinfection to ensure the water purity and microbial viability,” he explains. “Once water has been heated into a gas and con-

Unwanted health implications associated with contaminated dental unit coolants range from the exacerbation of existing asthma symptoms due to endotoxin exposure to complex bacterial infections, such as Legionnaires’ disease, according to the Organization for Safety and Asepsis Prevention (OSAP). “Since the introduction of the independent bottle reservoir, chemical treatments have become a viable and convenient method for reducing effluent dental water microbes,” he continues. “When dental clinicians follow the instructions for use (IFUs), they can expect good results. However, when using municipal tap water, they must 48

Efficiency In Group Practice : ISSUE 4 • 2019

densed back into liquid, it no doubt will be above room temperature. This increases the likelihood you are incubating bacteria as it’s stored. Without a residual disinfectant or some sort of shock treatment prior to introduction to the chair, it’s unlikely the 500CFU drinking water standard will be met, and the practice risks violating the manufacturer’s labeling.

“Don’t get me wrong,” he says, “distilled water is much better than municipal tap water in just about every way. But physically distilling water is not the most effective method. Deionized water is essentially the same thing, and the process by which it is created does not increase the bacterial content. It is for this reason, all Sterisil systems employ this technology as the final purification step. Now you have a very pure base water to which a residual disinfectant can be introduced, with minimal interference from microbes or chemical contaminates.” Pre-sterilized water is clean enough for any dental procedure, says Mendolia. “However, once it is introduced into a dental chair, it is unlikely to meet the <500CFU standard,” he points out. “Unless the dentist intends to irrigate with single-use pipettes or purchase a very expensive sterile water generator, this will not be a viable option.” And, the cost of purchasing sterile water makes this an unaffordable option for many dental practices, he adds. Mendolia recommends that dental practices use their bottle reservoirs for their intended purpose. “The independent bottle reservoir was designed to isolate the dental unit from municipal tap water and provide a conduit through which antimicrobial treatments could be introduced,” he says. “Tap water is not suitable for the dental setting for many reasons, but particularly due to the infinite variability in water chemistry. If clinicians are using residual disinfectants to control microbes in a dental chair, these details matter. Distilled water will

always save the dental practice a lot of headaches in the end, trust me. “Dental practices should always consult with their dental unit manufacturers and their waterline treatment providers about water testing,” Mendolia continues. “Minimum standards for water testing should be followed whenever possible, even though they are recommendations rather than requirements. If the dental practice’s protocols are in line with these standards, it is off to great start.” A passing water test verifies the absence of bacteria and validates the dental practice’s disinfection efforts, he points out. “According to OSAP, dental practices should be testing within 30 days of introducing a new product or new protocols, and then every 30 days thereafter,” he says. “The initial test validates the product and protocol’s efficacy, and subsequent tests validate the protocol execution throughout the product’s lifespan (assuming the product did not expire prematurely). If both tests pass, the practice can begin testing every six months. If there is a test failure, the clinician should shock immediately and retest per the waterline treatment manufacturer’s IFU. I personally recommend testing through a third-party lab that specializes in dental water microbes, like Agenics. They offer HPC counts and many other water chemistry metrics that help diagnose problems should they arise.”

Legal precedent Compliance with water safety standards in the United States has not been required by law. But, that’s quickly changing. “Water compliance may not have been the law in

2016, when 73 pediatric patients contracted Mycobacterium infections from contaminated dental water at Children’s Dental Group in Orange County, California,” says Mendolia. However, in 2019, it will become a law in California, he points out, noting that eventually much of the country will likely follow suit.

products, relative to their overall need for water,” says Mendolia. “If a large practice intends to confront this problem head on, it would serve them well to go with the option that has the lowest cost per liter. That’s not always the lowest initial cost, but the purchase will pay for itself with time. Sometimes dental practices just want to get their toes wet, so to

“ Dental practices should always consult with their dental unit manufacturers and their waterline treatment providers about water testing. Minimum standards for water testing should be followed whenever possible, even though they are recommendations rather than requirements. If the dental practice’s protocols are in line with these standards, it is off to great start.” – Jerod Mendolia, marketing assistant, Sterisil

“What I try to impress on people is that this issue isn’t going away,” he says. “Now that there are legal precedents associated with patient vs. clinicians, and manufacturers vs. clinicians, with regard to this topic, it will be difficult for dental clinicians to prove in court that they are not responsible for any infections related to dental water in their practice, even if they weren’t legally required to take action.” That said, for some dental professionals, cost will always be an obstacle. “We must focus on the relative cost per liter differences among the various

speak. “Low cost options like Citrisil tablets are a good place to start, with the same great treatment you get from the higher end products,” he says. But, they’re not as convenient as a long-term solution. “The lowcost options in this category always leave something to be desired when it comes to efficiency and cost per liter.” As more practitioners are on board with the need for waterline treatment, they are looking for solutions that provide enhanced efficiency and require less staff involvement, notes Mendolia. “We are here to help,” he adds. ISSUE 4 • 2019 : DentalGroupPractice.com 49

Waterline Treatment

Instructions for Use: They’re Meant to be Read! Assumption of knowledge is a dangerous thing. By Laura Thill

If you don’t read the instructions that accompany your new iPhone, chances are you – or your teenage son or daughter – will figure it out. When it comes to dental equipment, however, assuming you know how to use a new product can lead to detrimental – even life threatening – consequences for your staff, your patients and your practice. Particularly in the case of waterline treatment, noncompliance can lead to serious infection outbreaks, according to Leann Keefer, RDH, MSM, director, clinical services and education, Crosstex, a Cantel Medical Company. Nevertheless, dental professionals commonly refer to manufacturer instructions for 50

Efficiency In Group Practice : ISSUE 4 • 2019

use (IFUs) only on a need-to-know basis, they point out. “In order to get the most effective and efficient use of any product, compliance with IFUs is critical,” says Keefer. “With regard to documentation and training, everyone in the office needs to be on the same page with the technology, not

just the person who does the ordering. Procedures and policies of water management are an integral part of the office’s infection control manual, and the IFUs are critical to use in protocol development.” Unfortunately, many dental offices set aside the IFUs, referring to them when they have a specific question. In fact, after adopting new technology, some dental teams assume they can transfer knowledge from previous clinical experiences, she adds. But, they do so “without necessarily being aware of the differences and

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nuances in science, procedure or technique. Assumption of knowledge is a dangerous thing.”

Vigilance and caution When adopting new waterline treatment technology, dental professionals are tasked with being extra cautious. For instance, it’s not unheard of for a manufacturer of a validated water treatment system to omit providing a monitoring protocol in their IFU, notes Keefer. In this case, the dental practice should reach out to the manufac-

hypochlorite solution as an intermediate shock for bacterial reduction in the dental waterlines. However, use of this chlorine-based product may conflict with best practices for other automated dental waterline products that may be in use. “OSAP issued a white paper in September 2018 specific to waterlines that speaks to the importance of contacting dental chair manufacturers and waterline treatment manufacturers for specific guidance and instructions on methods to improve and maintain the quality of dental

water quality. The water management plan should include specific testing locations and frequencies, and actions to take (e.g., remediation, retesting at shorter intervals) based on test results. [Practitioners] should follow the manufacturer’s instructions for cleaning and disinfecting the dental unit at recommended intervals. They should contact the manufacturer of the dental unit to obtain the most up-to-date instructions or direction for reprocessing of the dental unit.”

Risks and realities

“ In order to get the most effective and efficient use of any product, compliance with IFUs is critical. With regard to documentation and training, everyone in the office needs to be on the same page with the technology, not just the person who does the ordering.” – Leann Keefer, RDH, MSM, director, clinical services and education, Crosstex, a Cantel Medical Company

turer for a best-practice recommendation, she points out. In addition, the dental team must be aware of discrepancies in directions for use from one manufacturer to the next. “Dental offices need to be aware of the differences in instructions for use from both dental chair manufacturers and waterline treatment manufacturers and reach out to these manufacturers when IFUs provide conflicting information,” she says. “For example, a dental chair manufacturer may recommend the use of a 52

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procedure water,” says Keefer. “Per FDA [guidelines], dental practitioners should consult with the dental unit manufacturer’s instructions for the recommended maintenance schedule of the dental unit waterlines,” she continues. “Dental practitioners should adopt appropriate infection control procedures for dental unit water lines (DUWLs) based on the manufacturer’s instruction for use. This should include infection control measures such as (but not limited to) monitoring

It can’t be said enough: When dental practitioners ignore DUWL treatment protocols, it places the staff, patients and, ultimately, the practice at risk. “Whether using a DUWL treatment like Crosstex DentaPure™ Cartridges or Liquid Ultra™ Solution, or a different DUWL treatment method, it is imperative that dental offices follow the instructions for use to ensure the chosen waterline treatment meets the product-approved claims for CFU/mL reduction to meet EPA standards of <500 CFU/mL,” says Keefer. “We frequently overlook the risk of the staff ’s constant exposure to contaminated bioaerosol. Clinicians work between 14-16 inches from a patient’s mouth, and aerosol can carry over three feet. Studies have shown that occupational asthma is triggered due to endotoxins contained in aerosols.” (https://cdn.ymaws.com/www.osap. org/resource/resmgr/Docs/2_SADJFebruary_2009_REVIEWOc.pdf.) In a few widely publicized cases, it was the patients who suffered the most. In In 2015, contaminated

dental treatment water at a Georgia Pediatric dental clinic led to at least 23 children becoming infected after pulpotomies. Their ages ranged from 3 to 11, according to the Centers for Disease Control and Prevention. They had all been infected with Mycobacterium abscessus, a rapidly-growing bacterium known to contaminate waterlines in dental offices. (https://www.ajc.com/news/ local/georgia-didn-sanction-dental-chain-accused-infecting-children/5501Ebv2D27LyuerW1ywdI/.) In 2016, an Anaheim, California, pediatric dental clinic’s water system became infected with Mycobacterium, causing over 70 children to be hospitalized following pulpotomies. In early 2011, an 82-year-old woman in Italy contracted Legionnaires' disease, which was traced to equipment in a dental surgery she attended shortly before being hospitalized. Despite treatment and antibiotics administered at the hospital, she developed rapid and irreversible septic shock and died two days after being admitted. (https://www. eurekalert.org/pub_releases/201202/l-dow021412.php) “At Crosstex, we provide a selection of literature that includes procedural guidance for following our DWUL IFUs after purchase, while addressing the evidence-based science behind why treatment is so important,” says Ilene Russo, Crosstex waterline product manager. “We also provide live CE programs, as well as on-demand webinars covering the science, treatment choices and implementation (www. crosstexlearning.com).” In addition, Crosstex sales representatives refer dental offices to the CDC Summary

of Infection Prevention Practices in Dental Settings: Basic expectations for self-care (https://www.cdc.gov/ oralhealth/infectioncontrol/pdf/ safe-care2.pdf ). “Following IFUs is not a standalone issue for waterlines,” says Keefer. “It’s a standalone mindset for how we approach overall infection prevention and control in the

dental setting. This becomes both an ethical and a clinical choice when patient safety is in question. It should not take tragic headlines to ensure compliance. However, if reminding clinicians of the risks and realities associated with noncompliance shifts the paradigm, Crosstex will continue to keep these preventable incidents top-of-mind.” ISSUE 4 • 2019 : DentalGroupPractice.com 53

Hygiene

Your DSO Accelerator How to maximize the tremendous value your hygiene team brings to the group practice

Did you realize that 83% of the patient experience is with the hygienist? Or that 74% of the doctor’s revenue is treatment planned in the hygiene chair? By Heidi Arndt Heidi graduated from the University of Minnesota with a Bachelor of Science in Dental Hygiene. In 2002, Heidi started working for a large dental group in Minneapolis as a clinical hygienist and a hygiene mentor before she was promoted to the National Director of Dental Hygiene. In 2011, Heidi started Enhanced Hygiene. In January 2019, Heidi sold Enhanced Hygiene to Ascension Dental. Ascension Dental administers dental membership plans for dental groups and practice across the country. She is currently serving as their Chief Operating Officer.

Did you know that the average annual revenue of a full-time hygienist is $250,000/year? Although, the hygiene team is responsible for 30% of the DSO’s revenue, they provide tremendous value beyond the 30% revenue you have been monitoring for years. With training, development and support, your dental hygiene team provides your biggest growth opportunity, and can accelerate same-store growth immediately in your practices. There are many dental practices and dental groups that do not take the time to invest in the training and development of their hygiene teams as they still see hygiene as a loss leader, or have had limited success in the past with hygiene-focused initiatives. After years of training, coaching and mentoring dental hygiene teams, I can attest that this can be a hard needle to move. However, with focused and dedicated

Efficiency In Group Practice : ISSUE 4 • 2019

attention, you can experience huge – and sustainable – gains. Where are groups achieving these gains? Here are two big opportunities that exist in almost every dental group I have analyzed in the past 5 years.

Focus on same-day treatment One of the most frequent questions I hear in the industry is: “How do you deal with schedule fall out?” With the average schedule utilization running between 70% to 75%, each practice has an opportunity to create same-day treatment opportunities for their patients. By creating same-day treatment opportunities you’re turning down time into productive time, and your patients appreciate the convenience. Same-day treatment has brought amazing results to several DSOs. In hygiene only, I’ve seen a group increase their same-day hygiene revenue by 1331%.

Yes, you read that correctly. This sameday treatment fueled a 72% increase in their product per visit, and a 92% increase in hygiene revenue. In order for same-day treatment to work in your group, the team must agree to be flexible, strong communicators and team focused throughout the day. They must also embrace the phrase, “we can start today."

they can move the patient toward ideal treatment when they understand and support their doctor’s treatment philosophy. Remember, your

The hygienist as true treatment advocates

Your hygienist spends more time with the patient than any other person in your practice. The hygienist has an incredible influence on the patient.

When you realize that 74% of the doctor’s treatment revenue is developed in the hygiene chair, you’ll see why it’s imperative to have your hygiene team focused on comprehensive treatment planning skills. Yes, the dental hygienist cannot diagnose or treatment plan but

hygienist spends more time with the patient than any other person in your practice. The hygienist has an incredible influence on the patient. The doctor exam in the hygiene room usually takes 5 to 8 minutes.

If the hygienist is not teeing up treatment for the doctor, it will be a very difficult for the doctor to adequately diagnose, provide a treatment plan and “sell” the patient on the treatment. The doctor and hygienist must work as a team to support the patient, and to optimize the practice. Don’t allow your hygiene team to work in a silo. The partnership between the hygiene and doctor team is crucial to the success of your group, and supports quality patient care. It is time to expand your group’s horizons by looking beyond the 30% your hygiene team brings to your group revenue. Their value can be recognized in every level of your group; but only when you take the time to invest in them.

ISSUE 4 • 2019 : DentalGroupPractice.com 55

INDUSTRY NEWS Ivoclar Vivadent CEO Robert Ganley receives lifetime achievement award

Ivoclar Vivadent (Amherst, NY) announced that its CEO Robert Ganley was recently awarded the Lifetime Achievement Evy Award by the American Academy of Cosmetic Dentistry (AACD) (Madison, WI). Ganley was presented with his award during the 35th Annual AACD Annual Scientific Session’s Celebration of Excellence. The AACD honors its most accomplished and dedicated professionals with Celebration of Excellence awards (or “Evy awards”). The Lifetime Achievement Award is given to an individual who has demonstrated significant achievement in the cosmetic dentistry or restorative dentistry fields both personally and professionally. Ganley, who has been with the company for 39 years, will retire in July but remain active as a member of the company’s Supervisory Board. 56

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GEDC dentist receives public service award from Michigan Dental Association Great Expressions Dental Centers (Southfield, MI) announced that Dr. Michael Vilag was recently recognized with the public service award from the Michigan Dental Health Association (MDA) for “his exceptional and noteworthy contributions to the dental profession as well as his community service efforts.” Reaching beyond the office and into the community, Dr. Vilag also co-founded a student-run clinic in 2011 where nearly 20 doctors and students provided dental services to residents in Detroit at St. Vincent de Paul who were experiencing homelessness and physical abuse. The clinic ran for over six years and raised awareness for the imminent need of quality dental health services and care for people with limited access to such resources. Currently, Dr. Vilag runs a similar service clinic through the Malta Free Dental Clinic at St. Leo’s church.

Touro Dental Health to cut opioid prescriptions by 80% Touro Dental Health (Hawthorne, NY), an 81-chair clinic, plans to cut opioid prescriptions by 80%. The dental clinic will allow opioid prescriptions under certain circumstances, including allergies to alternate treatments, failed prior attempts to control pain with non-narcotic pills (like Tylenol and Advil), or significant oral surgery. Even then, the clinic will use a strict review of the patient’s history and limit the

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opioid script to three days, a shift from historic trends in dentistry that sent many patients home with at least six days’ worth of pills. Under the new policy, patients getting opioids at the dental clinic must also sign a contract as part of an educational consultation about addiction risks and identifying drug-seeking behavior. Touro, whose clinic handles about 40,000 patient visits per year, plans to promote the policy to other dental schools and students as well as practicing dentists. The decision to change the policy comes after insurance giant UnitedHealthcare imposed sweeping limitations on dental coverage linked to opioid pain medication, citing the heightened opioid addiction risk for teens. The study found that of the patients give opioids, 7% went on to get another opioid prescription. There was also a 5.4% increase in future opioid use disorders among the at-risk group of teens getting their first script tied to wisdom-teeth extraction, the study found. As a result, the health insurer this year capped all first-time opioid scripts written by dental health professionals for age 19 and under at three days and fewer than 50 morphine milligram equivalents per day.

MouthWatch names James Martorelli as director of sales MouthWatch, LLC, recently appointed James “Jay” Martorelli to the position of Director of Sales. In this position, Martorelli will be responsible for developing key public health and private sector accounts as well as Jame Martorelli forging strategic alliances with DSOs and group practices throughout the United States. Other responsibilities include the following: Development and management of sales plans, forecasts and budgets; Conducting competitive analysis of other intraoral camera and teledentistry companies; Hiring, training and managing the MouthWatch sales team; Representing MouthWatch during dental meetings 58

Efficiency In Group Practice : ISSUE 4 • 2019

and conventions; Providing input and needs assessment regarding MouthWatch marketing efforts.

Results of largest endodontic study released Results of a comparative study that included 59 subjects and was conducted in Chile was presented during the General Session of the International Association for Dental Research (IADR) in Vancouver, Canada. EndoSequence® BC, (Brasseler), ProRoot® MTA (Dentsply Sirona), and Biodentine® (Septodont) were compared in terms of extent of healing. Supported with funds from the Septodont company, it is the largest endodontic study of its kind to date. The study team was formed with faculty from the Chilean Navy, the University of Valparaiso, and the Finis Terrae University in Santiago. The principal investigator on the project was endodontist Stephen Cohen, MA, DDS, of San Francisco, California, who is the eponymous author of Pathways of the Pulp. Statistical analysis was conducted by Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD, at the University of Illinois; Alicia Caro, DDS, MS, headed up the team in Valparaiso; Veeratrishul Allareddy, BDS, MS, at the University of Iowa, performed the radiological evaluation; and Gustavo Mahn, DDS, previously on faculty at Finis Terrae University, served as project coordinator. Dr. Mahn will present the findings in Vancouver in next month (June 2019). While the study revealed no statistical difference among the three products used to enhance remineralization after endodontic surgery, Dr. Cohen said, “We are pleased to learn that dentists and endodontists can be assured that the product they select should not impact patient outcomes, and that they may base their clinical decisions on other factors.” “This study represents a first in the endodontic field in terms of the scope and numbers of patients recruited for a single study. As clinical dentistry moves toward rigorous evidence-based practice, more studies engaging large sample sizes must become the norm,“ Dr. Cohen said.

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