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Making the Connection Patients today respond to digital marketing.

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November/December . 2018

Editor’s Note

Finding their Voice.............................................................................. 4

Addressing Workplace Bullying

Bullying in the dental office can take an emotional and financial toll on the practice......................................... 6

Be the Leader They Want..............................................10 Making the Connection

Patients today respond to digital marketing......................................14

Periodontal Disease

Understanding the risks of periodontal disease can motivate patients to adhere to a good oral homecare routine............24

Endodontics

Cutting-edge technology has facilitated more accurate diagnosis and treatment.............................................26

The Dental/Medical Clinic

As the two disciplines draw closer together, is the dental/medical clinic far behind?.............................................30

Needlestick and Sharps Injuries

One Message, Many Audiences

Maintaining a consistent brand across a large organization isn’t easy, particularly when the target audience is so diverse.............17

Dentistry may not be as dangerous as skyscraper construction or racecar driving, but it has its share of risks...............42

A Tale of Two Brands ......................................................20

OSAP Dental Infection Control Boot Camp™....................................................50 Industry News......................................................................54

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

EDITORIAL BOARD

Jack Allen, national purchasing director, Great Expressions Dental Centers. DeAnn McClain, vice president of operations, Heartland Dental. Lorie Streeter, FAADOM, CTC, chief operating officer, American Association of Dental Office Managers.

EDITOR Laura Thill • lthill@sharemovingmedia.com

ADVERTISING SALES Diana Craig dcraig@sharemovingmedia.com

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

ADVERTISING SALES Jamie Falasz, RDH jfalasz@sharemovingmedia.com

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

Efficiency In Group Practice is published six times a year by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2018 by Share Moving Media All rights reserved. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publishers. Publishers cannot accept responsibility for the correctness of an opinion expressed by contributing authors.

ISSUE 6 • 2018 : DentalGroupPractice.com

Editor’s Note

Finding their Voice

Laura Thill

Dental group practices today have more options than ever before for reaching out to current and prospective patients. Yet, knowing the best way to communicate with widely varying groups of people – and then conveying an image that resonates with such a diverse audience – can be challenging. In this issue, Efficiency in Group Practice explores how dental group practices can successfully accomplish both.

Particularly as more and more American households have come to revolve around smartphones, tablets and computers, digital marketing has become a widely acceptable tool for dental group practices to reach out to current patients, as well as introduce themselves to new ones. In fact, practices that don’t take advantage of digital marketing are missing out on an opportunity, according to Xavier Dao, senior director of marketing, Pacific Dental Services® (PDS®). That said, the array of digital marketing channels available to dental practice owners can be overwhelming, he points out. From websites and search engines, to social A strong brand will resonate media, email, SMS, content marketing and digital display advertising, with a variety of audiences, “digital marketing is not only one of the best ways to reach new and Ramsey notes. And while existing patients, it’s also one of the most complex ways,” he says. “Refinaudience segments is an art requiring both creative and analytic proeach audience may require ing cesses.” a different message, each At the same time, dental practices must be ever mindful of the image message conveys who the – or brand – they convey to patients. This can be challenging for a large organization is and group practice or DSO that targets a diverse audience. “Our brand is why that should matter, one of the most valuable and important assets of our organization,” says Ramsey explains. Jacque Ramsey, director of marketing, Mortenson Dental Partners. “We teach and empower all of our team members that they are brand ambassadors who shape our brand in a more influential way than signage or a TV commercial ever could.” A strong brand will resonate with a variety of audiences, Ramsey notes. And while each audience may require a different message, each message conveys who the organization is and why that should matter, Ramsey explains. Most importantly, an organization’s brand must help build trust with the consumer. “The ability to deliver cutting edge, quality service, while building trust with the target audience, will be the key to branding moving forward,” Ramsey says.

Efficiency In Group Practice : ISSUE 6 • 2018

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Practice Points

Addressing Workplace Bullying in the dental office can take an emotional and financial toll on the practice. Workplace bullying is destructive not only to targets but also to the organizations within which it occurs. Leaders in the organization should address and prevent it promptly. Researchers and practitioners encourage many strategies, including: • The development of zero tolerance policies on workplace bullying. • Leadership development workshops and positive culture programs. • Systems designed to effectively manage and intervene workplace conduct and civility. • Specialized executive coaching designed to reduce abrasive work styles of both leaders and team members. • Conflict resolution training for all workers. By Kristine Berry, RDH, MSEC, Executive Coach Kristine Berry has worked as a clinician, dental board examiner, dental operations consultant, executive coach, educational manager for a global Fortune 500 company and an operational manager overseeing $23 million of revenue for dental service organizations in New Hampshire and North Carolina. She specializes in coaching and speaking on abrasive styles in the workplace and creating profitable and positive practices. To inquire about her availability, she invites you to contact her via www.kristineberry.com or kristine@kristineberry.com.

Defining bullying What exactly is workplace bullying? The academic literature on workplace mistreatment is fragmented and ranges from low-level workplace incivilities to more aggressive behaviors where intent to harm is clear. Examples of abrasive behavior include, but are not limited to: • Rudeness. • Excessive reassurance-seeking. • Downgrading or demeaning • Singling out. another’s capabilities. • Ignoring. • Public ridicule and disrespect. • Constant targeted criticism or gossip. • Swearing and shouting or • Violating confidentiality. other verbal abuse. • Work interference that • Failing to control bodily functions. sabotages outcome. • Chronic complaining. There is no U.S. business standard for workplace bullying; different organizational cultures embrace differing standards of acceptable behavior. For the purposes of this article, the definition of bullying is “Actions and practices that a ‘reasonable person’ would find abusive, occur repeatedly or persistently, and result in adverse economic, psychological, or physical outcomes to the target and/or a hostile work environment.” 1 This definition distinguishes bullying from an erratic rude remark made by a manager or owner having a stressful day or an employee that may, from time to time, be a little tough on his/her colleagues. Although such incivilities are inappropriate and are not to be condoned, they are not bullying. Bullying is repeated and persistent abuse that results in harm.

Efficiency In Group Practice : ISSUE 6 • 2018

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Practice Points

The cost of bullying Abrasive behavior has the potential to destroy individual wellbeing and organizational effectiveness. The costs can first be calculated in terms of work disruption. Abrasive behavior can impact productivity to the point of paralysis. Employees who face bullying in the workplace may experience several issues, including stress, depression, illness, insomnia and even suicidal behavior. Costs of organizational disruption include: • Attrition of valued employees. •D ecreased morale and motivation, resulting in lower productivity. • Higher incidence of stress-related illness and substance abuse. • Higher turnover rates. • Maximum use of well/sick days and mental health leave. • Increased legal actions based on hostile environments. • Retaliatory responses, such as sabotage (word of mouth and social media platforms).

Intervention Specialized coaching for abrasive leaders and/or valued team members is an efficient strategy because it tackles the underlying causes of workplace abrasiveness. Intervention starts when the abrasive leader’s supervisor and/or owner of the organization sits down with the abrasive personality to address his/her conduct. They should first voice the value of that person to the organization/practice (Don’t bother intervening if the abrasive personality offers no value!). Explain that you believe you owe it to him or her to make them aware of the growing problem. Emphasize that he/she is not the problem; rather, negative perceptions about his/her interactions with others are. “I had a choice whether or not to talk to you about this, and I feel a responsibility to let you know about these negative perceptions.” Then, set limits and explain consequences. Steps on managing conduct and civility are as follows: • Determine conduct expectations. • Evaluate conduct and civility. • If conduct is acceptable, recognize and reward it. • If conduct is not acceptable, intervene. • Present negative perceptions of conduct. 1

• Set limits and consequences for continued unacceptable conduct. • Offer help, such as training, specialized coaching or additional resources. • Monitor for improvement.

Outcomes Keep in mind that the specific goals of coaching for abrasive leaders or team members or aggressors of bullying may vary depending on the coachee in question. Although the elimination of bullying behavior may be a common goal, results include factors related to the coachee, team and/or organization, namely: • Co-workers’ suffering ends and employees are heartened that the formerly abrasive cared enough to change. • Co-workers regard the HR, manager and/or owner positively for intervening and requiring respectful conduct. • The former abrasive is grateful for the company’s willingness to invest in him/her and offer a second chance through coaching. • The organization reduces the potential for litigation, attrition and anti-management/owner sentiment or community backlash, while retaining the abrasive’s technical expertise. It may also be that the coaching is ineffective in reducing coachee’s bullying. In these cases, the abrasive leader or abrasive may be terminated; then, coaching can still be beneficial because the bullying behavior will be stopped and the organization is hailed for walking its talk and creating a work climate and culture that truly does not tolerate mistreatment. Leaders and colleagues who resort to bullying exact a toll on the health and profitability functioning of an organization. If the problem of abrasive leadership, clinical providers and/or management goes unaddressed, the toll will be heavier. Early intervention through policies, systems and/or a confidential process that respects the concerns of both the abrasive and the co-workers can solve this problem before it escalates into disruptive investigations, antagonistic relationships and loss of production.

Crawshaw, L. (2007). Taming the abrasive manager: How to end necessary roughness in the workplace. San Francisco: Jossey-Bass.

Efficiency In Group Practice : ISSUE 6 • 2018

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Leadership

Be the Leader They Want By Lisa Earle McLeod

A recent Forbes article revealed that 65 percent of people would rather have a different boss than a raise. Take that in for a moment: People would trade money for a better boss

He explained, “Next to your spouse, your boss has the power to make your life wonderful or miserable.” At the time, his comment petrified me. At the ripe old age of 25, half my team was twice my age. I was scared to death because I knew my father was right.

Words of leadership wisdom When I was 25 years old, my father shared something with me that forever altered my perspective on leadership. I had just been promoted to my first manager position at Procter & Gamble. I called my father to give him the good news. “Congratulations,” he said, “You’ve just become the second most important person in the life of your employees.” “What do you mean?” I asked. 10

Efficiency In Group Practice : ISSUE 6 • 2018

Your leadership makes an impact Think about your bosses and the impact they’ve had on you. Your boss is a presence at the family dinner table, in conversations with your friends, with your parents. When I was a kid we talked about my Dad’s boss, Mr. Keck, almost every night. I knew when he was in a good mood or bad mood. I knew about his family.

“Small violations can have

big consequences.

What could I be missing?”

STAYING COMPLIANT

IS MORE CRITICAL THAN EVER. Managing infection prevention standards and guidelines at multiple offices is no easy task. The number of standards and guidelines outlined by organizations like the CDC, state dental boards and OSHA can be overwhelming, and every office is held to a high level of accountability. To have an effective infection prevention program, staff members must be thoroughly trained and committed to following the right steps every time. Because there is no “good enough” — only compliant or noncompliant. Change the way your offices look at infection prevention with the GreenLight Dental Compliance Center by Hu-Friedy. This exclusive, one-of-a-kind resource keeps all of your infection prevention guidelines and regulations conveniently housed in one portal. With GreenLight, you can easily assess, improve, and maintain compliance at your offices. Get started on the path to increased compliance by visiting GreenLightComplianceCenter.com

Leadership

My mother was a schoolteacher. I knew about her principals – the good and the bad. I even knew about the time one of them had a breakdown when she was getting divorced. If you’re the boss, you’re a looming presence in the lives of your people, whether you like it or not. You have the power to create happiness, or misery.

How to be a great leader

People want a boss who cares and who isn’t shy about showing it. Great leaders don’t shy away from emotion. They love their job, they love their customers, and they love their team. And they’re not afraid to let everyone know it.

After working with thousands of employees and leaders, I can tell you, the one mantra that will make you a better boss: Be all in. People want a boss who cares and who isn’t shy about showing it. Great leaders don’t shy away from emotion. They love their job, they love their customers, and they love their team. And they’re not afraid to let everyone know it. For them, business is personal. They don’t shy away from difficult conversations. They care enough to address the tough stuff, head on. They give direct feedback. Great leaders are attuned to the emotional undercurrents of their organization. They’re not perfect, but their team knows their passion comes from their belief in a cause bigger than themselves. 12

Efficiency In Group Practice : ISSUE 6 • 2018

As a leader, you’re the one who tells your people whether this is just a job, or if their work actually matters. For great leaders, work is more than just a transaction – it’s a chance to make a difference in the lives of other people. They build a tribe of True Believers because they’re all in.

What will your team say about you?

I wrote Leading with Noble Purpose to help leaders emotionally engage with their people. It’s a call for today’s managers to become the kind of leaders a team wants to follow. As the late Maya Angelou said, “I’ve learned that people will forget what you said. People will forget what you did. But people will never forget the way you made them feel.” Your team is going to talk about you at their dinner tables whether you like it or not. You can be the leader whose team experienced their work as just a grind. Or you can be the leader whose people say, “She really cares.” The choice is yours. What steps do you have to take to be the kind of leader your people want?

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Making the Connection Patients today respond to digital marketing. By Laura Thill

Today, few households in America do not revolve around smartphones, iPads and desktop/laptop computers. Indeed, dental patients – from pediatric to the elderly – are likely spending a good amount of time accessing their world through some type of digital device. Dental practices that don’t take advantage of digital marketing are missing out on an opportunity to introduce themselves to new patients and stay in touch with current ones, according to Xavier Dao, senior director of marketing, Pacific Dental Services® (PDS®). 14

Efficiency In Group Practice : ISSUE 6 • 2018

“Over the past 20 years, more and more people have come to depend on their desktop/laptop computer, smartphone and tablet to gain access to content,” says Dao. The growth in popularity of these devices has driven dental professionals to rely on digital marketing to target new and existing patients, he points out. “Digital marketing encompasses any form of marketing that utilizes electronic devices or the Internet,”

Marketing & Branding

Dao continues. But, while electronic devices can be narrowed down to smartphones, tablets or other types of computer devices, the array of digital marketing channels available to dental practice owners can be overwhelming, he notes. “Digital marketing channels include websites, search engines (both paid and organic), social media, email, SMS (text messages), content marketing and digital display advertising.” And this is only the tip of the iceberg. “There are many other channels as well, each with additional layers,” he says. “Digital marketing is not only one of the best ways to reach new and existing patients, it’s also one of the most complex ways.”

visit a dental practice’s website, respond to a comment on the practice’s Facebook page or simply respond to emails. “As an example, Pacific Dental Services® has refined its PRIVATE PRACTICE +® model, a supported means of autonomy that allows dental professionals to concentrate on clinical excellence and the highest levels of cost-effective comprehensive patient care, while PDS provides the support structure for the business functions. Our owner dentist model allows us to support thousands of clinicians across the country, so that they can focus on their patients while we take care of running the business. We support both local dental office brands and national brands through the industry-leading strategic development of cross-channel marketing “ At PDS, we help our supported clinicians target campaigns, tools and guidance.” patient groups who have expressed an interest in oral That said, PDS is careful to healthcare. Patient groups can express their interest in focus on the dental practice as an several ways: They may conduct a Google search, visit a entity, Dao adds. Whether the dental practice’s website, respond to a comment on the dental practice owner, an office manager or the regional operations practice’s Facebook page or simply respond to emails.” manager communicates a need for – Xavier Dao, senior director of marketing, Pacific Dental Services® support, PDS responds quickly and efficiently. “PDS offers a subset of “Refining audience segments is tools for the entire dental team,” an art requiring both creative and Dao says. “For instance, we may analytic processes,” Dao explains. help them update their website and “The continual optimization process make it more usable. Or, the dental is never-ending, especially today, practice may reach out to help them when new mechanisms within each make better use of Facebook. Our channel are continually introduced.” DSO model is as follows: to act as a support system for the whole dental Tools at their disposal practice. Our goal is to help them The good news for dental profestake full advantage of the tools they sionals is that more and more have at their disposal.” patients use the Internet to actively Dao is confident that digital marseek providers. At the same time, keting will continue to evolve as peodental service organizations like PDS ple spend more time engaging with Xavier Dao have developed tools to help their electronic devices. “Moving forward, supported clinicians target specific patient groups. As dental practices will take advantage of mobile payments to long as people have access to an electronic device or are facilitate the payment process,” he points out. “Voice prodconnected to the Internet, digital marketing can be very ucts will help them reach and interact with patients.” And effective, notes Dao. the growth of artificial intelligence will make it easier and “At PDS, we help our supported clinicians target more efficient to target patient populations, he adds. “As patient groups who have expressed an interest in oral digital marketing continues to evolve, the dental industry healthcare,” he says. “Patient groups can express their interwill have to embrace new technology and new channels to est in several ways: They may conduct a Google search, deliver the services patients will come to expect.” 16

Efficiency In Group Practice : ISSUE 6 • 2018

One Message, Many Audiences Maintaining a consistent brand across a large organization isn’t easy, particularly when the target audience is so diverse. By Laura Thill

At the heart of every organization is its brand, a “Our main objective with regard to branding is to powerful image that comes to mind whenever the orgacommunicate a trusting and professional image,” she connization is mentioned. When viewed as a cohesive effort tinues. “We want patients to feel they can count on us to within the organization to build a trusting relationship service their dental needs in a comfortable environment, to with current and potential clients, branding can unite its educate them on the care prescribed and to deliver desirmembers and motivate them to conable outcomes.” And they know their vey a winning message to the public. branding efforts have been successful “At Mortenson Dental Partners, when a patient hears the DSO’s mesour brand is who we are in the minds sage via social media or a personalof our patients, and future patients,” ized text, connects with a Mortenson says Jacque Ramsey, Mortenson’s practice and has an exceptional expedirector of marketing. “It is one of rience, she adds. the most valuable and important When a brand is strong, it assets of our organization. We teach reaches across a variety of audiences, and empower all of our team memRamsey points out. “We focus on bers that they are brand ambassadors building a brand that resonates with who shape our brand in a more influpotential patients, existing patients, – Jacque Ramsey, ential way than signage or a TV comfuture team members, current team director of marketing, mercial ever could. members and audiences within the Mortenson Dental Partners

“At Mortenson Dental Partners, our brand is who we are in the minds of our patients, and future patients.”

ISSUE 6 • 2018 : DentalGroupPractice.com 17

Marketing & Branding

dental industry.” Each of these audiences may require a different message, but each message conveys who Mortenson is as an organization and why that should matter, she explains.

Consistent but diverse A large dental service organization may find it challenging to maintain brand consistency throughout the organization, according to Ramsey. For instance, people don’t always understand the impact of minor tweaks on the integrity of the brand over time, she points out. “It is important that

“ We work hard to educate our team members that they – not a billboard – are the face of our brand. Their actions matter; the way they present themselves and treat others is a direct reflection of our brand.”

each market we operate,” says Ramsey. “This allows us to tailor our message to a specific community, while maintaining the consistency of our brand. We also consider generational differences in our approach, looking not only for the best messaging to resonate with different generations, but the best media as well.” Carrying multiple brands isn’t easy, she notes. “But, the ability to customize our message, voice, tone, look and feel helps us reduce our risk if there is a brand-damaging event,” she explains. So, for example, Mortenson’s pediatric brand enables the DSO to address parents much differently than it would reach out to the same group of adults regarding their own dental care, she adds.

An evolving industry

Dentistry is not immune to change, and as the industry evolves, so too must a DSO’s brand. “When Mortenson Dental Partners was originally created, we were a group of like-minded partner practices,” says Ramsey. “In the last 10 years, we have repositioned our busi– Jacque Ramsey, director of marketing, Mortenson Dental Partners ness strategy to be that of a cohesive company rather than a variety we always use the same font, tone, colors, language, etc.,” of partnerships. This shift has led us to redefine our she says. “When people try to create a message on behalf of mission and values to better reflect our history and set the brand that is not in alignment with all of the brand stanthe stage for our future.” This, in turn, has provided a dards, the value of the brand begins to decline.” solid foundation for the DSO’s branding efforts, she The more people representing the brand, the more notes. “Today, Mortenson’s brand communicates that we difficult it can be to maintain consistency, Ramsey conCare for Everyone, Share Abundantly, Build Relationships, tinues. “We work hard to educate our team members that Express Gratitude and work every day to Improve the Lives they – not a billboard – are the face of our brand. Their of Others by Living Our Values Every day.” If this message actions matter; the way they present themselves and treat isn’t getting across to the target audience, “we need to others is a direct reflection of our brand.” rethink what we are trying to say and how.” At the same time, a large DSO must ensure its brand Mortenson’s approach to branding will likely conappeals to a diverse group of people. Typically, an auditinue to evolve as dental care becomes more innovative, ence identifies with others who share the same region, says Ramsey, who anticipates consumers will increasingly culture, age and more. “We typically have one brand in regard dental professionals as service providers. And, a 18

Efficiency In Group Practice : ISSUE 6 • 2018

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“In the future, it will be imperative for DSOs to support their marketing decisions with actual data.”

new mindset means new expectaand be more intentional in the way tions. Patients will expect faster serwe connect to patients.” vice, but not at the expense of qualTechnological advances in artiity, she points out. They will want ficial intelligence will also impact the transparency when it comes to diagway DSOs reach out to patients, Ramnoses and solutions, and they will sey points out. “We’ll have to consider rely on a network of peers to validate whether we are set up to allow Alexa choices, she notes. “And they will or Siri to schedule an appointment,” not tolerate mistakes if there is not she says. “Can we connect with a strong relationship with the brand health-based apps to talk to patients to begin with,” she says. about overall systemic health? Do we In the future, it will be imperaembrace the Internet and fully under– Jacque Ramsey, director of markettive for DSOs to support their marstand what it means for our business? ing, Mortenson Dental Partners keting decisions with actual data, “I think DSOs will need to use says Ramsey. “By doing so, we will branding to support these themes be able to communicate specific messages to specific audiin their messaging, without compromising an opportuences. Understanding our patients better will not only nity to build trust with the consumer,” she continues. allow us to market to them better, but to also deliver cusThe ability to deliver cutting edge, quality service, while tom patient experiences that wow the patient and build building trust with the target audience, will be the key to patient loyalty. This approach will help us eliminate waste branding moving forward, she adds. ISSUE 6 • 2018 : DentalGroupPractice.com 19

Marketing & Branding

A Tale of Two Brands Tech-savvy dental professionals today have plenty of products at their disposal, most of which will deliver great results. So, what makes a practice choose one product solution over another – and then stick with it? In a word: the brand. Creating

A better experience Villa Radiology Systems builds its brand by “always striving to give our clients a better experience,” according to company COO Paul Blocchi. That means maintaining a close relationship with dental clients, he notes. “Whether a product is sold through a distributor partner or directly, it’s very important that our clients contact us directly with any questions or concerns,” he explains. That said, Villa Radiology Systems doesn’t hesitate to involve its distributor partners when it’s in the best interest of their clients, he adds. “Our branding campaigns combine timeless values with leading-edge technology to consistently give both our clients and partners the best possible training and support experience throughout the product lifecycle.” Villa Radiology System’s mission to deliver a value-added client experience has remained intact through the years. At the same time, the company has refined its approach to stay current in a changing industry. Particularly as the price of 20

Efficiency In Group Practice : ISSUE 6 • 2018

a brand that customers identify with and trust can be a tricky business, however. Efficiency in Group Practice asked a couple of experts what branding means to their company, and how they build their customers’ trust.

large equipment has dropped in recent years, it has become increasingly important for manufacturers to give clinicians the value they expect, and to do so more efficiently, notes Blocchi. “At Villa Radiology Systems, we’ve addressed this through mass commoditization,” he says. “For example, some dental imaging equipment is selling at a market price of 67 percent lower than just eight years ago,” he says. “We must provide a better client experience throughout the entire product lifecycle, and work very cost effectively to build our brand position in the Americas.” Villa Radiology has streamlined its operations in recent years, creating an open wall policy that enables it to share “the right knowledge at the right time with the right partners,” he adds. This trend will continue in years to come, says Blocchi. “In spite of having fewer resources, dental manufacturers will have to provide a better experience to both the dental professionals and distribution partners in order to effectively build or maintain their brand position in the marketplace.”

Marketing & Branding

A strong identity Air Techniques believes it’s important to provide customers with a strong product identity – a strategy that’s largely tied to the company’s mission to educate and build trust among the public. “Branding encompasses every identifier we create, from our company logo to literature, packaging, signage, ads, trade show displays and more,” says Laura Walsh, marketing manager. “As a dental manufacturer, it’s important that we provide

be our Mojave LT vacuum system, which includes a compact footprint for dental offices with limited space.”

Digital marketing

As dental professionals have come to depend on social media to help them stay current on new products and technologies, companies like Air Techniques have expanded their branding strategies to remain industry leaders. “Digital marketing has definitely impacted our branding strategy over the last five years,” says Walsh. “Dental professionals are using social media more than ever to share ideas and successes, as well as to learn about new products or to earn continuing education credits.” As some clinicians have come to rely more on social media sites, they have felt less need to attend traditional – Laura Walsh, marketing manager, Air Techniques trade shows, she adds. In turn, Air dental professionals with the products they need to create Techniques has significantly increased its digital commuthe most efficient and effective patient workflow; At the nications to dental professionals, including posts via same time, we must provide them with educational semisocial media, blogs, email campaigns and website links. nars and webinars to ensure they stay up-to-date on the There’s no doubt that Air Techniques’ digital marever-changing technology.” keting efforts have impacted the company’s branding That said, Air Techniques appreciates the varied campaigns, according to Walsh. “Our digital marketing needs and interests of its customer base from one area campaigns today outnumber our traditional print marto the next. So, whereas water consumption is an issue keting campaigns, two to one,” she points out, noting on the West Coast, for other customers, the larger issue that the growth of larger group practices and DSOs likely may be designing an office within a small space. “Some will further impact this trend in the next several years. of our customers depend on our eco-friendly Mojave dry “We have initiated new branding efforts that target large vacuum system, which is designed to reduce water usage,” group practices via specialty trade shows and digital marWalsh points out. “For other customers, the solution may keting campaigns,” she says.

“ Branding encompasses every identifier we create, from our company logo to literature, packaging, signage, ads, trade show displays and more.”

Efficiency In Group Practice : ISSUE 6 • 2018

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Periodontal Disease

Periodontal Disease Understanding the risks of periodontal disease can motivate patients to adhere to a good oral homecare routine.

Periodontal disease begins with gingivitis – a mild form that causes the gums to become red, swollen and prone to bleeding. The good news is that, with professional treatment and good oral homecare, the disease is reversible. Left untreated, however, gingivitis can advance to periodontitis. Plaque can spread and grow below the gum line over time, and toxins produced by the bacteria in plaque irritate the gums. The toxins stimulate a chronic inflammatory response, causing the tissues and bone that support the teeth to break down. In turn, the gums separate from the teeth, forming pockets, which can become infected. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Eventually, teeth can become loose and may need to be removed. The most common forms of periodontitis include: • Aggressive periodontitis. Aggressive periodontitis occurs in patients who are otherwise clinically healthy. Common features include rapid attachment loss and bone destruction, and familial aggregation.

• Chronic periodontitis. Chronic periodontitis results in inflammation within the supporting tissues of the teeth, progressive attachment and bone loss. This is the most frequently occurring form of periodontitis and is characterized by pocket formation and/or recession of the gingiva. It is prevalent in adults, but can occur at any age. Progression of attachment loss usually occurs slowly, but periods of rapid progression can occur. • Periodontitis as a manifestation of systemic diseases. This often begins at a young age. Systemic conditions, such as heart disease, respiratory disease and diabetes, are associated with this form of periodontitis. • Necrotizing periodontal disease. Necrotizing periodontal disease is an infection characterized by necrosis of gingival tissues, periodontal ligament and alveolar bone. These lesions are most commonly observed in individuals with systemic conditions such, as HIV infection, malnutrition and immunosuppression.

Source: The American Academy of Periodontology. For more information visit https://www.perio.org/consumer/ types-gum-disease.html. 24

Efficiency In Group Practice : ISSUE 6 • 2018

Sponsored: SDI

A novel solution

SDI’s Riva Star is a two-step process silver diamine fluoride (SDF) and potassium iodide (KI) desensitizer. Periodontal disease affects over 50 percent of adults 30 years and older, according to research by the Centers for Disease Control and Prevention. Because genetics often play a role in periodontal disease, however, some patients mistakenly believe there is little they can do to control it. But, that’s not so, notes Amy Miller, RDH, business development manager, SDI (North America), Inc. Flossing, brushing with a sonic or electric toothbrush, the use of a water flosser and improved nutrition all can help slow down or reverse the disease. “Patients have many options for addressing periodontal disease,” she points out. “It’s important that they work with the entire dental team, from the periodontist to the hygienist and general dentist, to explore the oral antibiotics and mechanical tools available to them. In turn, the dental team should conduct a thorough risk assessment.”

Riva Star: A patented two-step process Scaling and Root planning – or the process whereby bacteria and calculus are removed from the tooth surfaces and beneath the gums – are common means for limiting periodontal disease. At the same time, periodontal disease can exacerbate tooth sensitivity, making the process more difficult for both the hygienist and the patient. “When the hygienist removes bacteria from the tooth surface, the surrounding tissue shrinks, exposing new and potentially sensitive dentin,” Miller explains. Dentin is sensitive to hot, cold and pressure, and in some cases, patients require anesthesia or nitrous oxide to help them make it through the cleaning process, she says. SDI’s Riva Star, a next-generation, two-step silver diamine fluoride desensitizer is FDA-approved for use in the

“Riva Star is cost-effective, non-invasive and addresses sensitivity with other antibacterial properties.” – Amy Miller, RDH, business development manager, SDI (North America), Inc.

United States with the same indication as fluoride varnish, giving patients a novel solution to address their tooth sensitivity with immediate relief and over two years of desensitizing results. Riva Star’s key ingredients include silver fluoride (a silver capsule), which has known antibacterial properties, and potassium iodide (a green capsule), designed to bind silver ions and help avoid darkening around active cavities or decalcification. Both properties treat sensitive areas for up to five teeth. “Not only is Riva Star indicated for post-operative periodontial surgery and hygiene appointments, it’s also great for pre-hygiene for all sensitive and exposed root surfaces,” says Miller. “It is a great insurance policy to be applied by dentists after surgery, before the patient’s anesthesia has worn off.” Riva Star is a game-changer for all dental practices, including pediatric practices, Miller continues. “Clinicians should consider how many times each day they see patients with exposed root surfaces and sensitivity, preventing them from providing adequate treatment,” she says. “Riva Star is cost-effective, non-invasive and addresses sensitivity with other antibacterial properties. And when used according to the manufacturer’s directions, and the second step (potassium iodide) is applied, any darkening around an active cavity or de-calcification will be mitigated.” For more information, visit sdi.com.au. ISSUE 6 • 2018 : DentalGroupPractice.com 25

Endodontics

Cutting-edge technology has facilitated more accurate diagnosis and treatment. By Laura Thill

Advancements in technology have made it easier for dental professionals to deliver successful endodontic treatment. But the fact remains, endodontics is a specialty that’s best handled by trained experts. “It is appropriate for a general dentist to perform endodontic treatment on a patient when he or she is properly trained to perform the said procedure, has the appropriate equipment and the treatment is within the skill set of that individual clinician,” says Gary Glassman, DDS, FRCD(C) and a consultant for Kerr Endodontics. If there’s any doubt the clinician can perform the procedure to the same standard of practice 26

Efficiency In Group Practice : ISSUE 6 • 2018

as an endodontic specialist, however, the case should be referred out, he points out. The American Association of Endodontists (www.aae.org) offers its Case Difficulty Assessment Form and Guidelines to help dentists with case selection, he adds. “If a dentist has just graduated from dental school and has only performed a handful of cases, it would be silly to think that he or she is ready to perform molar endodontics,” says Joe Chikvashvili, DDS, director of endodontics at Newark Beth Israel Hospital, a dental practice owner in West Orange, N.J. and a key

opinion leader for Roydent Dental Products. “Molars have much more variablility in anatomy than anteriors and premolars. So, the ability to perform anterior root canals does not necessarily enable one to perform molar root canal therapy.”

A higher standard of care

can give clinicians “a false security that they can attempt any root canal and treat any tooth.” As with any specialty, endodontics has its share of challenges, he notes. “Endodontists face the inherent pressure of saving teeth that others cannot, whether those started by general dentists or even other endodontists,” says Chikvashvili. These cases can be inherently difficult to treat due to difficult anatomy or tooth location, patient anxiety or the patient’s inability to sufficiently open his or her mouth, he notes. In addition, losing an abutment can significantly increase the cost and time needed to repair a patient’s occlusion. “Most patients that come to the endodontist have already had prior bad experiences, so trust must be built between the specialist and the patient in a short time,” he explains. “That’s not always easy to do.”

As dental equipment becomes increasingly sophisticated, dental professionals can – and do – deliver a higher standard of endodontic care, according to Glassman. • Dental operating microscopes enable clinicians to better visualize the anatomy of the pulp chamber. As such, the procedure is less invasive and it’s easier to maintain the structural integrity of the tooth. In addition, clinicians can position themselves more ergonomically, reducing stress on their back and neck. • The ultrasonic with specially designed endodontic tips allows clinicians to uncover calcified canals, remove pulp stones, refine access preparations, remove post and cores, and it aids in the debridement of the root canal system during irrigation protocols in a controlled and predictably safe manner. • The accuracy and acuity of – Joe Chikvashvili, DDS, director of endodontics at Newark Beth cone beam computerized Israel Hospital, a dental practice owner in West Orange, NJ and a key opinion leader for Roydent Dental Products tomography (CBCT) has facilitated safer treatment for patients. CBCT provides a Glassman points to several challenges facing endodonroad map of the tooth anatomy, enabling clinitists, including: cians to visualize the tooth in three dimensions. In • The diagnosis of endodontic versus nonaddition, the resolution of CBCT is higher than endodontic issues. traditional radiography, allowing the detection • Anaesthetizing endodontically treated teeth, espeof peri-radicular pathology, which otherwise may cially those that exhibit irreversible pulpitis with or go undetected. The type, location and extent of without apical periodontitis. internal/external resorption can now be defini• Preparing the access cavity while avoiding procetively diagnosed, and the relationship of normal dural accidents, such as perforations, gouging or anatomic structures can be assessed with ease. the removal of unnecessary tooth structure. Challenges persist • The location of root canal orifices, particularly the Technology can be a double-edged sword, however, and MB2 canal of the maxillary molar, lingual canals Chikvashvili warns that access to more efficient equipment of mandibular incisors and premolars. With the

“ Endodontists face the inherent pressure of saving teeth that others cannot. Most patients that come to the endodontist have already had prior bad experiences, so trust must be built between the specialist and the patient in a short time. That’s not always easy to do.”

ISSUE 6 • 2018 : DentalGroupPractice.com 27

Endodontics

“It is appropriate for a general dentist to perform endodontic treatment on a patient when he or she is properly trained to perform the said procedure, has the appropriate equipment and the treatment is within the skill set of that individual clinician.” – Gary Glassman, DDS, FRCD(C) and a consultant for Kerr Endodontics

appropriate equipment, clinicians can better locate canals and treat teeth appropriately. • Negotiating blockages and ledges, and avoiding apical transportation and separated instruments within the canal confines. • Obturation challenges, specifically well-condensed homogeneous fills, underfills, overfills and impingement on normal anatomic structures, such as the maxillary sinus and mandibular canal. • Restorative challenges to prevent coronal leakage into a root-canal-treated tooth.

Communication a must When it comes to challenging endodontic procedures, nothing is more important than communication among the entire dental team, as well as between the clinicians and their patients, according to Chikvashvili. “When a patient is referred by his or her dentist, everyone must be on the same page,” he says. “I often call the general practitioner to discuss findings and treatment options prior to beginning any work. Because root canal pain is visceral, 28

Efficiency In Group Practice : ISSUE 6 • 2018

Endodontists: Get the facts • Endo is Greek for inside, and odont is Greek for tooth. By definition, endodontists treat the inside of the tooth. • While all endodontists are dentists, less than 3 percent of dentists are endodontists. • Endodontists typically have two or three years of additional education in an advanced specialty program in endodontics following their four years of dental school. • By limiting their practice to endodontics, endodontists focus exclusively on treatment of the dental pulp, performing an average of 25 root canal treatments each week compared to the one or two performed by general dentists Source: The American Association of Endodontics (https://www.aae.org).

more than 10 percent of the time, patients themselves don’t know which tooth is to blame. So, I must ensure that everyone understands what the problem is, as well as the benefits and risks of each procedure required to solve that particular problem. Excellent communication is as important as exceptional treatment.” Working in a large dental practice or dental service organization has its advantages, Chikvashvili continues. For one, clinicians may have a higher patient load, which can provide a bigger frame of reference, he points out. And, sharing ideas and questions with one’s colleagues can be helpful, he notes. Additionally, clinicians can have someone take over for them when they feel they are out of their league. When clinicians involve their patients and the dental team from the start, they can help avoid many concerns, says Chikvashvili. But, the importance of experience can’t be overstated. “Knowing when it is better to retreat versus extract usually comes with time and years of experience,” he says. “The sooner clinicians can learn what works and what doesn’t, the better off they – and their patients – will be.”

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Trends

The Dental/Medical Clinic As the two disciplines draw closer together, is the dental/medical clinic far behind?

Mason visits the Kaiser Permanente Northwest Cedar Hills Dental and Medical Office in Portland, Oregon, for a routine exam. Checking his medical records, his pediatric dentist sees that he is due for some vaccinations. An onsite licensed practical nurse administers the vaccinations then and there. Ronald, an adult patient, comes into the clinic with a tooth that is bothering him. The dentist recommends dental surgery, but after taking Ronald’s blood pressure, decides the numbers are too high to proceed with the surgery. So the dental assistant takes Ronald down the hallway to see the primary care physician, who checks the patient’s medical records, reviews his blood pressure history, and talks with him about how he is managing his medications. They come up with a plan to control the hypertension, which will allow them to proceed with the dental surgery once his numbers have stabilized. Julie, another adult dental patient comes in, and the Kaiser Permanente dental team notices that a medication she is taking could affect her jaw. Her dentist 30

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knows to look for certain things during the exam based on this information.

Paths converging After a century and a half, the pathways of medicine and oral health appear to be converging, driven by a growing awareness of the connection between oral health and overall, systemic health. The Cedar Hills Dental and Medical Office – where these real-life scenarios took place – is one example. Whether they are physically co-located or virtually connected, this coming together of oral health and medicine is likely to have an impact on the dental industry. “The importance of oral health as part of overall health has been in literature, research and on the minds of prominent health professionals and health executives for decades,” says Steve Kess, vice president, global professional relations, Henry Schein. “For almost 20 years, Henry Schein has closely followed the growing recognition and innovative healthcare model, especially in the

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Trends

community health care sector, where physicians and dentists have collaborated on improving patient care and outcomes across the country. “We have supported interprofessional education among the health professions, including the Harvard School of Dental Medicine Initiative to Integrate Oral Health and Medicine and The Santa Fe Group, which reports on the importance of good oral health – especially good periodontal health – as a way to improve health outcomes, reduce cost and improve quality of life for patients with non-communicable diseases. “We also continue to champion the important role electronic health records will play to enhance health care professionals’ awareness of patients’ total health as reported by physicians to dentists and dentists to physicians,” says Kess. “We are optimistic that this increasing trend of interprofessional care – coupled with cost-saving solutions – will advance over – Kenneth Wright, the next few years in both the DMD, MPH public and private sectors.”

“Maybe some of the kids aren’t too happy. But it does save mom and dad time.”

No longer a pilot Kaiser Permanente opened its integrated dental-medical clinic as a pilot in January 2017. At the time, Kenneth R. Wright, DMD, MPH, vice president of dental services for Kaiser Foundation Health Plan of the Northwest, called it an “innovation site where we will pilot new ways to combine dental and medical care that maximize convenience for our members and ensure their visits address their total health.” One and a half years later, the clinic is well past the pilot stage. “It’s been an incredible journey, a transformation,” says Wright. Since opening, the clinic has added four dental operatories and now has five general dentists, one pediatric dentist, four dental hygienists, 11 dental assistants, three front-office staff, a family practice physician, a physician assistant and three LPNs. 32

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“Because we have integrated health records [using the Epic system], we consult the member’s record in advance of the visit and identify opportunities to close the care gap,” says Wright. A patient who comes in for a routine dental cleaning, for example, might need an A1c test or a well-child exam. Wright estimates that 15 percent to 35 percent of the clinic’s dental patients receive some medical attention as well. Wright believes that integrating the two disciplines “is truly the essence of care.” Patients welcome it, he adds. “Once they have a chance to meet the staff, they say, ‘Why haven’t we done this before?’ “It’s unique and a pleasant surprise,” he continues. “Maybe some of the kids aren’t too happy” to get treated by a doctor and a dentist during the same visit. “But it does save mom and dad time. They don’t have to miss so much work, and ultimately, it’s beneficial to the member and his or her family.”

Precision medicine The Columbia University College of Dental Medicine is pointing its students toward a future in integrated care. In December, the College dedicated its Center for Precision Dental Medicine, comprising 48 new dental operatories outfitted with technology to help the students learn how to deliver truly personalized care. Electronic dental records will be tied in to medical records to enable dentists and other providers to treat patients based on comprehensive health information rather than just oral disease, according to the College. Using Epic electronic health records, dental and medical information will be shared with clinicians at Columbia University Medical Center, New York-Presbyterian and Weill Cornell Medicine. “The College of Dental Medicine was founded 100 years ago with the disruptive idea that dentistry should be taught and practiced within the context of the whole body,” Christian S. Stohler, DMD, DrMedDent, dean of the College of Dental Medicine and senior vice president for Columbia University Irving Medical Center, said at the time of the center’s opening. “The Center for Precision Dental Medicine gives us the capacity to realize this founding vision in the information age.” The time is right, he believes. Since 1990, Americans’ average lifespan has increased, but quality of life – particularly in the later years – has

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Trends

not, he says. In fact, increased lifespan often means more years of ill health, not well-being. “If this continues, and as the numbers of the elderly keep growing, the burden of disease – particularly, chronic disease – may not be sustainable,” either from a quality-of-life perspective or an economic one. Incorporating oral health and medicine may provide at least part of the solution. That’s because many of chronic diseases affecting the elderly today share an underlying physiological mechanism – inflammation, says Stohler. Dentistry is a key factor in identifying and addressing inflammation, he adds. “In dentistry, for the past 150 years, we have focused on cutting out the ‘piece’ that is bad and replacing it with something that will hold for a number of years before

“Many people receive dental insurance through their employer,” notes Jane Barrow, MS, associate dean for global and community health, and executive director of the Initiative to Integrate Oral Health and Medicine at the Harvard School of Dental Medicine. Then, when they turn 65, they lose access to dental insurance, unless they purchase it separately. “Generally, this comes as a surprise to many people, and it happens at a time when they need more dental services than they ever did before.” The Initiative convenes academics and leaders in the healthcare community to develop innovative ideas around the integration of oral health and primary care. Activities undertaken include research, policy statements, conferences and seminars. Electronic health records present another barrier – as well as opportunity. Connecting patients’ medical and dental electronic records is a sine qua non for true integration of oral health and medicine, according to some experts. “If a person visits his or her primary care physician, then is referred – Steve Kess to a specialist in surgery or medicine, there’s communication back and forth, often using the same EHR,” says Barrow. “But if that patient is referred to a dentist, there’s no communication because, generally, those information systems don’t talk to each other. The Initiative is working on technology that will facilitate bidirectional communication.” Integrating oral and medical records systems will facilitate care not only in clinics where dentists and MDs are co-located, but in virtual arrangements as well, notes Stohler. Columbia’s Center for Precision Medicine, for example, will share records not only with Columbia University Medical Center, but New York-Presbyterian (with which it is affiliated) and Weill Cornell Medicine. “The marching order has been given, and work groups are already working on it,” he says. “With the patient’s permission, anyone who treats you will be able to access your integrated health record,” he says. Patients will have access to their records as well.

“ We are optimistic that this increasing trend of interprofessional care – coupled with cost-saving solutions – will advance over the next few years in both the public and private sectors.” requiring replacement,” he says. It is time for dentists to do more, e.g., examining a patient for oral disease and treating its underlying cause rather than removing diseased tissue. “We can’t see inside a person’s intestinal system as easily we can inside his or her mouth, to determine whether an inflammatory component is present,” he says. “We should take advantage of it. “In the future, you will need to manage diabetes and periodontal disease as a package, psoriasis and dental disease as a package, rheumatoid arthritis and dental disease as a package. That’s why the linkage [between oral health and medicine] is crucial.

Some barriers The wall between oral health and systemic health is longstanding, and it will not crumble easily or quickly. The traditional, siloed manner in which insurers cover dental and medical care is one barrier to overcome. 34

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Trends

“We are in an age of shared responsibility. Patients have access to what science is telling us today. We are entering an environment where the physician is their guide through the information jungle.”

Human element Technology issues – while formidable – aren’t the only hurdles to oral/medical integration. “One of the challenges is change management, that is, getting people to implement a new system,” says Wright. The learning curve comes with a predictable – but temporary – drop in productivity. “We saw some of that the

first year, but by the end of the year, we were operating at peak efficiency. It’s like learning to drive a new car. “It has been incredible to see the tremendous transformation that has taken place among our team this past year. When two different groups of people come together, there’s some apprehension, some doubts about compatibility.” An open mind erases most of that, he says. “Even though we had never worked like this before, our team embraced the mission. They collaborated in mind and spirit. They have huddles throughout the day; they are in active discussion about improving workflow and processes. Whatever silos existed before have been completely obliterated.

The Insurance Angle

Will we see combined Dental/medical policies? Dental and medical professionals understand the connection between oral health and systemic health. How about insurers? “The plan for the future is to manage risk, and that means managing the heavy costs associated with comorbid conditions,” says Christian S. Stohler, DMD, DrMedDent, dean of the Columbia University College of Dental Medicine. “The only way American insurance will survive is to keep people healthy, as much as possible – managing their health appropriately, then measuring the risk. Dentistry needs to fit into that picture.” Some in the insurance industry agree. Empowered consumers “There’s plenty of research to indicate the connection between medicine and dentistry,” says Quinn Dufurrena, DDS, JD, chief dental officer, United Concordia Dental. “Bundling of medical and dental insurance makes sense, and I think we will see it.” Dufurrena has a broad perspective on the topic – as a dentist, as an advisory board member of the Harvard School of Dental Medicine Initiative to Integrate Oral Health and Medicine, and as an executive of United Concordia, a subsidiary of health insurer Highmark Inc. Barriers to the integration of the two disciplines exist, he concedes. For example, it’s difficult to

Efficiency In Group Practice : ISSUE 6 • 2018

quantify the impact of improved oral health on systemic health (though few would dispute that the two are closely associated). The fact that dental professionals – unlike those in medicine – seldom use diagnostic codes for recordkeeping makes such studies that much more difficult. “And one of the biggest barriers is the fact that we use different

“ Bundling of medical and dental insurance makes sense, and I think we will see it.” – Quinn Dufurrena, DDS, JD

practice management systems,” says Dufurrena. “It’s difficult for medicine and dentistry to communicate with each other. Such barriers will be overcome, he predicts. Empowered consumers will come to insist on the convenience of co-located dental/medical clinics, as well as the improved health outcomes co-location can bring. Combined dental and medical insurance may follow.

“I see a great deal of passion here. They are changing the world, transforming healthcare. There’s a certain amount of kinetic energy here. They realize this place is special.”

“We can’t see inside a person’s intestinal system as easily we can inside his or her mouth, to determine whether an inflammatory component is present.”

ments that will train primary care providers to deliver high quality, cost-effective, patient-centered care that promotes oral health, addresses oral health disparities and meets the unique needs of all communities. Tomorrow’s practitioners Demonstration practice sites are up Working side by side may come more and running. naturally to tomorrow’s dental health Dental students and medical and medical professionals than it students at Columbia share their does to their older counterparts. first 18 months of education, says The Boston-based Center for Stohler. “We have fertile ground on Integration of Primary Care and which to build that foundation. And Oral Health (CIPCOH) serves as if you have that foundation, you a national resource for research on should take advantage of it. oral health integration into primary “Our students appreciate the – Christian Stohler, DMD, DrMedDent care training. Established in 2016 significance of genomics in driving through a cooperative agreement personalized medicine. They know with the U.S. Department of Health and Human Services they may be practicing for 40 years. The world will Health Resources and Services Administration (HRSA), change, and personalized medicine cannot be practiced the Center places special emphasis on training enhancewithout dentistry.” ISSUE 6 • 2018 : DentalGroupPractice.com 37

HOW

UNCERTAIN ARE YOU?

In today’s era of dentistry, thinking your infection control protocols are compliant isn’t enough. You need to know. Conversations about infection control can happen any time, any place. Imagine yourself at your next industry event; it’s not hard to see the following scenario unfold. “Hey, did you hear what happened out west?” You’re just settling into one of the last available seats in Conference Hall B, jammed in the back row between a dentist on the left who is encroaching maybe a bit too far into your zone and on your right, a chatty younger dentist, clearly eager to make the most of this year’s

conference by networking with every dental professional who crosses her path. It’s a little early for you to contribute coherently to a conversation. You came in late last night, jetting across three time zones after a full day of patients. The latte you grabbed on the way to the seminar this morning (the reason you were too late for the choice seats) is only just now starting to kick in. But you remember, not too long ago, you were in this young dentist’s lab coat, searching for sage advice to jumpstart your career. You bite. “That depends,” you say, mentally willing the bleariness out of your voice. “A lot of things happen every day. What are you referring to?” And then, realizing your rudeness, you introduce yourself. The young dentist shakes your hand, apparently thrilled to have found a willing conversant. “A dental practice wasn’t using any internal indicators during their sterilization process,” she says. “They also only performed monthly biological monitoring of their sterilizers and didn’t record the results. At some point, their sterilizer started malfunctioning and they didn’t have any records showing when it was last working properly.” The young dentist lowers her voice conspiratorially.

“They had to recall…,” she says, pausing for effect, “ALL the patients for testing of diseases such as hepatitis and HIV. It was a fiasco — and an expensive one at that!” Dramatic chords strike in your head, like an old-timey radio show — dun, dun, DUHNNN! You have to suppress a smile. Of course you know about that incident. You make it a habit, and a matter of professional interest, to stay on top of the infection control news. And this one was a big story. But in kindness to the earnest young dentist, you offer, “Is that so?” “Oh, yeah,” she says. “That’s why I’m here. This infection control stuff is serious. I don’t want to end up like that practice. One mistake, and my practice could be investigated. Patients could leave. I could be closed down!” Infection control — the topic of this morning’s seminar — is why you’re here, too. Like most of the dentists in the room, you’ve been making an annual pilgrimage to this conference to learn about the latest infection risks, updated guidelines from organizations like the CDC and OSHA, and modern tools and practices to fight

the spread of infection in your dental office. But unlike most of the dentists in the room, this year, the seminar is really just a refresher course for you. You’ve been learning everything you need to know to keep your practice compliant and safe through a single online portal. Just as the seminar is about to begin, you decide to have mercy on the young dentist to your right. “Let’s grab a coffee after this” — you know you’re going to need another jolt of caffeine soon — “I’ll fill you in on GreenLight Dental Compliance Center™ by Hu-Friedy. It’s why things like this,” you whisper, gesturing around the conference room, “don’t freak me out that much.”

Why We Created GreenLight Compliance is Misunderstood We surveyed more than 300 dental professionals* and asked, “How effective are your infection control practices?” Over 90 percent rated their infection control practices “very effective” or “extremely effective.” That’s a lot of confidence — enough to make you think most American dental practices are doing exactly what they need to do to keep their staff and patients safe from infection and to comply with regulations.

…in reality, they’re failing to implement all the protocols the guidelines call for. But when we asked more specific questions, the results were revealing. A large percentage of dental practices may think they’re complying with infection control guidelines, but in reality, they’re failing to implement all the protocols the guidelines and regulations call for. Our survey’s surprising results included these bombshells: Nearly 30 percent of respondents are still hand-scrubbing their instruments. 33 percent are not using internal chemical indicators in each package to be sterilized. Over 20 percent are not performing weekly biologically monitoring on each sterilizer. “Loose on a tray” is the most common method of transporting contaminated instruments.

Guidelines are Confusing We also found that most dental practices look to OSHA for their infection control standards. This is a good idea, especially since OSHA can audit your practice and fine you for non-compliance. But OSHA’s focus is on workplace safety. It doesn’t have * Hu-Friedy engaged The Key Group, an independent third-party market research company, to survey dental professionals on their infection control practices.

GreenLightComplianceCenter.com

much to say about infection control and protections for patients. That’s where the Centers for Disease Control and Prevention guidelines come in. Wherever your practice is located, the CDC guidelines are the standard of care, and they are the guidelines to which you will be held accountable if a breach occurs. Every state also has its own infection control rules. Some states follow the CDC guidelines — effectively making them law — while other states take things a step further. However, hunting down the infection control regulations in your state can be cumbersome and confusing. And many dentists are simply too busy, focused on treating patients and growing their businesses. As a result, infection control responsibilities can fall to dental assistants, who may have been trained with outdated or spotty information, kept in well-worn binders passed down from one generation of assistants to the next. And yet, as dental practices see more and more patients, the risk of infection increases, and with it, the risk of costly fines and embarrassing incidents.

How GreenLight Helps We created GreenLight because infection control is serious. GreenLight provides everything needed to manage, maintain, and improve infection prevention compliance — all in a convenient online

portal. If your practice is in Kansas, GreenLight will tell you how to comply in Kansas. If you’re in Connecticut, you’ll learn the rules of the Nutmeg State. GreenLight isn’t just about learning the regulations, either. It can help your practice master them, with features that allow you to: Set up personalized protocols quickly and easily, based on your answers to questions about your current procedures. Self-assess your compliance through an easy-to-use audit system. Access training resources like videos, product information and safety data sheets, and insights on the infection control/prevention coordinator role.

…hunting down the infection control regulations in your state can be cumbersome and confusing. Each new GreenLight member also receives a free consultation with Hu-Friedy’s team of experts, who will answer any questions that may arise as you create and implement your new infection control protocols.

That never occurred to me!” exclaims the young dentist, nearly launching a mouthful of scalding coffee in your direction. “I think you just saved my practice.” The two of you are sitting in a buzzing coffee shop just across the street from the convention center. You just told the rookie dentist about the CDC standard for colony forming units (CFUs) in dental unit water, one of the many infection control practices you discovered through GreenLight.

What Are You Missing? Many dentists think their practices are compliant with infection control standards, but most are not. Here are some of the most frequent culprits:

 IMPROPERLY TRANSPORTING INSTRUMENTS.

If you move instruments from the operatory to the sterilization area, they should be placed in a puncture resistant container that is appropriately labeled or color-coded and leakproof on the sides and bottom.

 INADEQUATE STERILIZATION MONITORING. The

CDC states that each package to be sterilized has an internal chemical indicator and that biological monitoring be performed on each sterilizer once a week with the test results recorded.

 LACK OF A WATERLINE MAINTENANCE PROGRAM. Dental unit waterlines can become breeding grounds for infectious bacteria. You should perform daily maintenance to prevent organic deposits and scale, regular cleaning to remove bacterial biofilms microbial contamination and testing your water to ensure you meet the guidelines for safe water.

 NO BREACH PREPAREDNESS PLAN. Patients are

learning more about what dentists should be doing to prevent infection; they’re noticing deficiencies and asking questions. If a breach does occur, it’s critical you have a plan to let staff and patients know how you will address its cause and ensure the breach doesn’t happen again. Even if a breach doesn’t occur in your office. It helps to be prepared when patients ask you questions.

“And that’s not all,” you say. “Research shows if left untreated, a new waterline’s microbial count can reach 200,000 CFUs/mL after just five days.” You watch the realization dawn across the face of the young dentist. “What else am I missing?” You glance at your watch. You didn’t expect to be leading an impromptu one-on-one infection control workshop of your own at this conference. You’re reaching the bottom of your second latte of the day, and a keynote session is starting soon. You’d really love to have a decent seat this time.

 NO INFECTION CONTROL COORDINATOR. The CDC

“Actually, I can’t tell you for sure because it depends on your state,” you explain, eager to be on your way. “If you register for GreenLight, your compliance portal will have that for you. You can test your current procedures against your protocols and learn how to make up the difference in any area in which you fall short.” “Wow, this really sounds like the kind of thing I’ve been looking for since I started practicing,” the young dentist says. “I’m going to check out that GreenLight website as soon as I get a chance. You’re getting another latte to go? This one’s on me.” You gratefully take her up on her offer. It seems like you made a friend for life — and maybe saved a few patients and dental staff members from infections.

Hu-Friedy Mfg. Co., LLC: 3232 N. Rockwell St. | Chicago, IL 60618 | USA Telephone: 1-800-Hu-Friedy (1-773-975-6100) | Website: GreenLightComplianceCenter.com ©2018 Hu-Friedy Mfg. Co., LLC. All rights reserved. [954] GL-009/1018

says every office should have a dedicated infection control coordinator. But often whoever is assigned this role lacks the time and resources to do it properly.

By putting all the information and tools you need in one place, GreenLight will help you and your entire dental team — new and veteran staff, alike — understand and maintain your compliance. To learn more about how to join the program and to get started on a better path to compliance, visit us at

GreenLightComplianceCenter.com

Infection Control

Needlestick and Sharps Injuries Dentistry may not be as dangerous as skyscraper construction or racecar driving, but it has its share of risks.

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.

Dental professionals face a constant risk of sharps injuries and exposure to bloodborne pathogens, especially during the delivery of patient care. They are at particular risk for hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV). According to the Centers for Disease Control and Prevention (CDC) studies of healthcare personnel who have sustained injuries from needles contaminated with blood containing HBV, there is a 22 to 31 percent risk of developing clinical hepatitis in cases where the blood is both hepatitis B surface antigen (HBsAg) and HBeAg positive, and a 37 to 62 percent risk of developing serologic evidence of HBV infection. The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV-positive source is 1.8 percent. And, the average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated at approximately 0.3 percent.1 Even a risk that small is too great. Indeed, the Occupational Safety and Health Administration (OSHA) estimates 5.6 million workers in the healthcare industry and related occupations are at risk for occupational exposure to bloodborne pathogens each year, and the approximately 385,000 needlestick and other sharps-related injuries are sustained by hospital healthcare workers alone. Similar injuries are sustained in other healthcare settings such as dental facilities, nursing homes, emergency centers and clinics.2,3 When accounting for both hospitals and other health care settings, studies have estimated that between 600,000 and 800,000 needlestick and other percutaneous injuries occur annually to healthcare workers.4 That said, other studies completed in medical facilities demonstrate that there is considerable underreporting of these injuries.5

Sharps safety protocols Dental practices – especially large groups and DSOs – are very busy places with tight patient schedules, and many of the instruments and devices that are used are considered “sharps.” Sharps is a term for devices with sharp points or edges that can puncture or cut skin or other tissue; dental examples include syringe needles, ortho bands/wires, instruments (i.e. scalers), scalpel blades, burs, files, suture needles and broken glass.3

Efficiency In Group Practice : ISSUE 6 • 2018

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Infection Control

What steps should be followed when a dental healthcare team member sustains an occupational exposure sharps injury? The procedure and protocol for this demonstrate a perfect example of the interconnection between OSHA, a regulatory agency, the U.S. Public Health Service (USPHS) and the Centers for Disease Control and Prevention (CDC). First aid and reporting Dental team members who sustain a needlestick or other sharps injury may think that they should wait until the patient procedure is completed to manage and report these injuries, but that is not the case. When a sharps injury occurs, the first priority should be the team member with the injury. According to the CDC, “first aid should be administered immediately and as necessary after an occupational injury. Puncture wounds from sharps and other injuries to the skin should be washed with soap and water and no evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, use of antiseptics is not contraindicated. Also, the application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended. Exposed dental team members should immediately report the exposure to the infection-control coordinator or other designated person, who should initiate referral to the qualified healthcare professional and complete necessary reports.”6 According to OSHA, “exposure incidents should be reported immediately to the employer since they can lead to infection with HBV, HCV, HIV or other bloodborne pathogens. When a worker reports an exposure incident right away, the report permits the employer to arrange for immediate medical evaluation of the worker. Early reporting is crucial for beginning immediate intervention to address possible infection of the worker and can also help the worker avoid spreading bloodborne infections to others.”7 Thus, it is crucial to manage and report these injuries without hesitation or worry about workplace repercussions; accidental injuries can happen. Medical evaluation and follow-up OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) requires employers to make immediate 44

Efficiency In Group Practice : ISSUE 6 • 2018

confidential medical evaluation and follow-up available for workers who have an exposure incident, such as a needlestick. The standard states this evaluation and follow-up must be: • Made available at no cost to the worker and at a reasonable time and place. • Performed by or under the supervision of a licensed physician or other licensed healthcare professional. • Provided according to the recommendations of the USPHS current at the time the procedures take place. In addition, laboratory tests must be conducted by an accredited laboratory at no cost to the worker.7,8 The CDC defines and outlines specific information to be included in the exposure incident report, which is recorded in the exposed dental team member’s confidential medical record and provided to the qualified healthcare professional for medical evaluation and follow-up. This includes: • Date and time of exposure. • Details of the procedure being performed. • The type of device used, and how and when it was being used, when the exposure occurred. • Details of the exposure, including the type and amount of fluid or material and the severity of the exposure.6 Additional information should be included in the report as well, including: • Whether the source material was known to contain HIV or other bloodborne pathogens and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy and viral load, if known. • The exposed person’s hepatitis B vaccination and vaccine-response status. • Details regarding counseling, post-exposure management and follow-up.6 The report, along with the job description of the exposed dental team member, must be taken to the medical provider that performs any serological tests. Records of all employees with occupational exposure must be maintained for 30 years after the employee terminates employment.8

Serological testing According to OSHA, a worker who participates in post-exposure evaluation and follow-up may consent to have his or her blood drawn for determination of a baseline infection status of HBV and HIV, but has the option to withhold consent for HIV testing at that time. In this instance, the employer must ensure that the worker’s blood sample is preserved for at least 90 days, in case the worker changes his or her mind about HIV testing.3,7 Although testing is an option for the exposed and injured dental healthcare worker, it may help to preserve peace of mind during the entire post-exposure process. As an example, although HIV infection following an occupational exposure occurs infrequently, the emotional effect of an exposure often is substantial; therefore, giving an exposed person access to persons who are knowledgeable about occupational HIV transmission and who can deal with the many concerns an HIV exposure might generate is an important element of post-exposure management.6 It is a good practice to seek a health clinic or medical provider who specializes in occupational health as the clinic or provider of choice for any post-exposure follow-ups.

Counseling When dental team members sustain a sharps injury and have possible exposure, OSHA requires that post-exposure follow-up include counseling the worker about the possible implications of the exposure and his or her infection status, including the results and interpretation of all tests and how to protect personal contacts. In addition, post-exposure prophylaxis for HIV, HBV and HCV, when medically indicated, must be offered to the exposed worker according to the current recommendations of the U.S. Public Health Service.7

Although testing is an option for the exposed and injured dental healthcare worker, it may help to preserve peace of mind during the entire post-exposure process.

The source individual The source individual is any patient whose body fluid is involved in the exposure incident.3 According to the CDC, if the HBV, HCV and/or HIV infection status of the source is unknown, the source person should be informed of the incident and tested for serologic evidence of bloodborne virus infection as soon as possible. Procedures should be followed for testing source persons, including obtaining informed consent in accordance with applicable state and local laws. Any persons determined to be infected with HBV, HCV, or HIV should be referred for appropriate counseling and treatment. Confidentiality of the source person should be maintained at all times.6

The written opinion Once the medical healthcare provider has evaluated the employee and source patient’s test results, a written opinion is generated. According to OSHA’s standard, the employer must obtain and provide the injured employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of completion of the evaluation. The written opinion should only include whether hepatitis B vaccination was recommended for the exposed worker; whether or not the worker received the vaccination; and that the healthcare provider informed the worker of the results of the evaluation and any medical conditions resulting from exposure to blood or OPIM, which require further evaluation or treatment. Any findings other than these are not to be included in the written report.7 All other medical information must remain confidential per HIPAA laws. ISSUE 6 • 2018 : DentalGroupPractice.com 45

Infection Control

Source: American Dental Association References:

Although the process may seem cumbersome, if policies and protocols are in place, managing a sharps injury should be a streamlined and seamless process. Again, in large group practices and DSOs the infrastructure for a standard operating procedure or protocol should be in place. The flow-chart to the left illustrates the process for post-exposure evaluation and follow-up in a straightforward manner.9 This can be used as an initial resource for practices that are working to establish a protocol. Dental team members and practice management teams should not take the risk of sharps injuries lightly. In the provision of dental care, risk is present and any needed follow-up from an occupational exposure sharps injury must be completed in a timely and efficient manner. The CDC recommends that all dental practices establish written, comprehensive programs that include hepatitis B vaccination and post-exposure management protocols.1,10 The safety and health of the dental team members must be a priority in all practice settings.

1. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. MMWR Morbid Mortal weekly Rep 2001;50(RR-11). Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm. Accessed September 17, 2018. 2. US Department of Labor â&#x20AC;&#x201C; Occupational Safety and Health Administration. Healthcare Wide Hazards- Needlestick/Sharps Injuries. Available at https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html. Accessed September 13, 2018. 3. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 5th ed. St. Louis: Mosby Elsevier; 2013;198. 4. American Nurses Association. Fact Sheet. Available at https://www.nursingworld.org/~48de3c/globalassets/docs/ana/snsl-fact-sheet_ final110110.pdf. Accessed September 14, 2018. 5. John Hopkins Medicine. Medical Students Regularly Stuck by Needles, Often Fail to Report Injuries. Available at https://www.hopkinsmedicine.org/news/media/releases/medical_students_regularly_stuck_by_needles_often_fail_to_report_injuries_. Accessed September 14, 2018. 6. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. MMWR Morbid Mortal Weekly Report 2001;50(RR-11). Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm. Accessed September 17, 2018. 7. Occupational Safety and Health Administration. Fact sheet: Bloodborne Pathogens Exposure Incidents, 2011. Available at https://www.osha. gov/OshDoc/data_BloodborneFacts/bbfact04.pdf. Accessed September 17, 2018. 8. US Department of Labor. Occupational Safety and Health Administration. Bloodborne Pathogens Standard; 1910:1030. Available at https:// www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030#1910.1030(b). Accessed September 14, 2018. 9. American Dental Association. Employer Obligations After Exposure Incidents OSHA. Available at https://www.ada.org/en/science-research/ osha-standard-of-occupational-exposure-to-bloodbor#Flow. Accessed September 18, 2018. 10. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. MMWR 2003;52(No. RR-17);13.

Efficiency In Group Practice : ISSUE 6 â&#x20AC;˘ 2018

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