ARTICULATOR MDDS
Connections for Metro Denver’s Dental Profession
Spring 2014 Volume 18, Issue 4
New HIPAA Laws: What They Mean for Dental Practices and Our Patients 11 Abutment Emergence Modification for Immediate Implant Provisional Restorations 12 Employee Health Insurance...Should You Offer it to Your Employees? 16 Global Reserve Currency the U.S. Dollar 27 Online Reputation Marketing – is it Building Your Practice or Costing You a Fortune? 28
DENTIST TAX LAW CHANGES FOR 2014 pg. 8 PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT 2882
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ARTICULATOR MDDS
Connections for Metro Denver’s Dental Profession
Volume 18, Issue 4
MDDS Articulator
mddsdentist.com
Spring 2014
Inside This Issue:
Editor Carrie Seabury, DDS Director of Marketing and Communications Jason Mauterer Creative Manager & Managing Editor Chris Nelson Communications Committee Brandon Hall, DDS, Chair Maria Juliana DiPasquale, DMD Jonathan Boynton, DMD Karen Franz, DDS Kelly Freeman, DDS Anil Idiculla, DMD Jeremy Kott, DDS Nicholas Poulos, DDS Maureen Roach, DMD Jennifer Thompson, DDS MDDS Executive Committee President Mitchell Friedman, DDS President-Elect Larry Weddle, DMD Treasurer Ian Paisley, DDS Secretary Sheldon Newman, DDS Executive Director Elizabeth Price, MBA, CDE, CAE Printing Dilley Printing The Articulator is published bi-monthly by the Metropolitan Denver Dental Society and distributed to MDDS members as a direct benefit of membership. Editorial Policy All statements of opinion and of supposed fact are published under the authority of the authors, including editorials, letters and book reviews. They are not to be accepted as the views and/or opinions of the MDDS. The Articulator encourages letters to the editor, but reserves the right to edit and publish under the discretion of the editor. Advertising Policy MDDS reserves the right, in its sole discretion, to accept or reject advertising in its publications for any reasons including, but not limited to, materials which are offensive, defamatory or contrary to the best interests of MDDS. Advertiser represents and warrants the advertising is original; it does not infringe the copyright, trademark, service mark or proprietary rights of any other person; it does not invade the privacy rights of any person; and it is free from any libel, libelous or defamatory material. Advertiser agrees to indemnify and hold MDDS harmless from and against any breach of this warranty as well as any damages, expenses or costs (including attorney’s fees) arising from any claims of third parties. Inquiries may be addressed to: Metropolitan Denver Dental Society 925 Lincoln Street, Unit B Denver, CO 80203 Phone: (303) 488-9700 Fax: (303) 488-0177 mddsdentist.com ©2011 Metropolitan Denver Dental Society Member Publication
A Letter From Our President ............4
Employee Health Insurance...Should You Offer it to Your Employees? ................16
Member Matters ..............................5 Feed the Foundation's First Annual Event All I really Need to Know I've Learned
Rocks Parallel Seventeen! ...................... 19
From Legos .....................................6 Pathway to Predictability ..................22 Dentist Tax Law Changes for 2014 ..........8 Event Calendar ...............................24 New HIPAA Laws: What They Mean for Dental Practices and Our Patients .... 11
Global Reserve Currency the U.S. Dollar ..27
Abutment Emergence Modification
Online Reputation Marketing – is it
for Immediate Implant Provisional
Building Your Practice or Costing You a
Restorations. ................................. 12
Fortune? .........................................28
Get To Know Your MDDS Staff Erica Carvin - Membership & Events Manager
This month we would like to introduce Erica Carvin. Erica joined MDDS in March of this year as the Membership & Events Manager. Though originally from Madison, Wisconsin, she grew up all over the country with a father in the hotel industry. Erica and her family have called Colorado their home for the past year. She received her Bachelor of Science degree from the University of Wisconsin-Madison. Her two young boys keep her very busy and sleep deprived. In her free time she enjoys skiing, tennis, traveling, cooking and getting together with friends and family. Every year she and her husband try and do something they wouldn’t normally do, like sky diving, white water rafting, scuba diving or running a half marathon. Erica has spent the last six years in the event planning industry working for Marriott and Hilton properties. During her last three years as the Regional Sales & Catering Manager for four hotels, she managed everything from corporate conferences, weddings and board retreats, to her company’s annual meeting for their 30 hotel properties. She has also coordinated the volunteer efforts for Ford Ironman Wisconsin and supported operations for other major events like Madison Marathon and Taste of Madison. As Membership & Events Manager, she is responsible for the Society’s Member Services Committee, member recruitment and retention programs, and planning and executing membership events. Erica is also responsible for managing attendee registration for the RMDC and all other continuing education courses and events, among other things. She is incredibly excited to work for MDDS in this position because customer service is in her blood and serving MDDS members is her top priority. You can reach Erica Carvin at (303)-488-9700 ext. 3269, or membership@mddsdentist.com.
A LETTER FROM OUR PRESIDENT And What a Year It Has Been… By Mitch Friedman, DDS
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s your president this past year, I have had the opportunity to be involved in a significant milestone at MDDS - the purchase and construction of our new facility. Your Board of Directors, MDDS committee members and executive director, along with MDDS staff, worked tirelessly to create a new headquarters for MDDS and a world class learning facility, the Mountain West Dental Institute (MWDI). The MWDI was a huge success during the Rocky Mountain Dental Convention with an array of fully attended hands-on courses. And now, as we step up our fundraising effort, I want to personally thank Dr. Weddle, Dr. Paisley and Dr. Chiovitti for their amazing efforts in securing significant donations including many to the 5280 Club level. If you haven’t donated yet, please help us provide you a facility that we can all be proud of. On another note, last November I had the once-ina-lifetime opportunity to travel to Kathmandu, Nepal with the Himalayan Dental Relief Group. We saw over 700 children and provided much needed dental care to a population that has no access to medical or dental treatment. MDDS member dentist, Dr. Neal Jepsen and I, and our wives, worked extremely hard. At the end of the week, I had a blister on my thumb from giving
so many injections. It was truly an amazing experience providing dental care to so many children in need and making such a huge difference in such a poor country. If anyone is interested in going on a trip like this, please call me and I can fill you in on the details and provide you with contact information. It is very rewarding to be able to use your dental skills in this way.
"The MWDI was a huge success during the Rocky Mountain Dental Convention with an array of fully attended handson courses. " After working in the clinic for six days, my wife Debbie and I flew to Lukla to begin our guided trek on the Everest trail. We climbed to about 14,000 feet, staying in local tea lodges along the way. The views of Mount Everest were astounding and we found ourselves transported into another world, inhabited by different sights, sounds and people. The trek was challenging and it turned out to be the most amazing hiking experience we ever dreamed of. Even the small mountains were 22,000 feet high. After a week of
trekking we flew back to Kathmandu for our 30 hour journey back to Colorado. Medical missions provide dentists with the opportunity to help others. There are many volunteer opportunities out there all over the world and it is my hope that more of our members embark upon volunteer dental missions as a means to reach out and make a difference in the lives of those less fortunate. So now, as my term nears its end, I want to thank the staff at MDDS for being such awesome people to work with. As we all know, our staff members are a well-trained, professional group of people who make MDDS what it is today. They all work tirelessly to make MDDS the best dental society in the country. I also want to thank my Board of Directors. I could not have asked for a better group of doctors to work with. It’s hard to believe that they are all volunteers because they work so hard to make MDDS the successful organization it is today. I appreciate the time and expertise you have all provided this past year and your commitment to organized dentistry. It has been a busy year and a very rewarding one. I am grateful to have had the opportunity to work with each and every one of you. Mitch Friedman, DDS President, MDDS
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Articulator
Spring 2014
MEMBER MATTERS
11th Annual Give Kids a Smile Day
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ince the American Dental Association began the Give Kids a Smile program in 2003, it has gone from a one-day event, to local and national events year-round. Dentists and dental professionals volunteer time and services to treat and educate children throughout the United States. Each year approximately 450,000 children benefit nationwide from GKAS. MDDS would like to thank all of you that volunteer your valuable time.
Dr. Maureen Roach giving a kid a smile
Dr. Darren Bennett working on a little patient
OHCO, Colorado State Capitol Building, Denver – Feb. 7, 2014
New Members, Welcome!
On February 7, 2014, the same Friday as GKAS Day, Oral Health Colorado (OHCO) and supporting partners like MDDS and CDA gathered in the state capital with oral health advocates from around the state to celebrate National Children’s Dental Health Month and focus on winning Colorado’s oral health battle. Governor Hickenlooper proclaimed in 2013 that oral health is one of Colorado’s priority “Winnable Battles.”
Congratulations,
Dr. Christopher Hahn Dr. Hahn has been the owner of Mile High Endondontics for 20 years. He has also served as a Dental Officer for the US Navy in Bosnia, and taught at the Faculty Emergency Clinic at the Nebraska Medical Center College of Dentistry. Dr. Hahn is one of the first endodontists in Colorado to offer dental laser surgery, has recently been named a 5280 Top Dentist and continues to grow his practice at
mddsdentist.com
Dr. Stephanie D. Barnett Dr. Megan E. Bright Dr. Tina Christiansen Dr. Kaushal K. Dhawan Dr. Gary D. Dixon Dr. Krista Duran Dr. Ardavan Fateh Dr. Patricio Ernesto Gonzalez Dr. Erin E. Gutierrez Dr. Samer Hejlawy Dr. Edward Y. Lee
Dr. Linda C. Ludin Dr. Walter H. Meinzer II Dr. Mark A. Moynier Dr. Steven H. Nadel Dr. Randall J. Russell Dr. Mayank Saxena Dr. Lindsey L. Schroepfer Dr. Joseph Stoll Dr. Nazeli Tarjan Dr. Carly M. Topley Dr. Arthur M. Yagudayev
ሺ͵Ͳ͵ሻ ͵ǦͲͻͺͳ ̷ Ǥ
his new office located at 7555 E Hampden Avenue, Suite 305, Denver, CO 80231. His 1,064 square foot office designed by Ware Malcomb includes an office, two exam rooms, sterilization, reception, waiting area, and equipment and break room. The office was built on a quick, 5 week schedule and features custom pendent lighting, custom cabinetry, thin brick accents and faux wood flooring.
Articulator
Spring 2014
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REFLECTIONS All I Really Need to Know I’ve Learned From Legos By Carrie Seabury, DDS
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t the RMDC opening session this year, we heard an inspirational speech by Mr. David Weber named “Overcoming Life’s Goliaths.” As Mr. Weber spun the story of David and Goliath, he weaved in many of the problems (the “Goliaths”) we face in our dental careers. He motivated us, opened our hearts, and had us laughing until we were crying, (or maybe that was just me drying my eyes in the front row). On my desk I still have the symbolic “David’s stone” given out after the course. I grab a hold of the tiny stone when encountering a new (or even an old familiar) Goliath. My metaphors tend to be a little less polished and a little more juvenile than Mr. Weber’s. I think of my dental career and my life as ninja training and consider any problems that I encounter as the enemy. Sometimes my enemy can be a physical person, however my enemy is more often a task, a barrier or a self limiting idea. I could turn to the great philosophers and leaders of the world for the secrets of defeating my enemies, but I prefer my life lessons to be in cartoon form. The only logical resource that can teach me ways to defeat my enemies is Lego Ninjago: Masters of Spinjitzu. Obvious choice you say. So in episode 8, the question posed to the ninjas by Sensei Wu is this: “What is the most effective way to defeat your enemy?” (Spoiler Alert! If you have an eight year old at home, he will already know the answer! Send him thither with the vague promise of Minecraft and he will give you time to think). Of course my mind starts spinning with all of the Lego options I know of when Sensei Wu asks this. I have many Lego options to choose from when developing my plan to defeat my enemies. I can strengthen my nunchacku skills to overpower my enemy, spin my Lego head around between Good Cop and Bad Cop to psychologize my enemy, or build an invisible jet from spare Lego bricks laying around and escape from my enemy. The problems with these three
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approaches is that they often allow my enemy to grow stronger. Overpowering my enemies can certainly solve the problem for me. I come out on top: my enemy rolls over and exposes his weak spot. My Lego training teaches me that I can either finish my enemy or keep him in this docile state. The problem is, once defeating an enemy in this fashion, I have stripped him of his self esteem and self worth. This is precisely how super villains are born. I’ve seen it happen in Spiderman, The Incredibles, My Little Pony...you name it. Using a good cop/bad cop approach can be very effective to defeat an enemy - I have seen it work many times with desirable end results. In theory, the pros and cons of a position can be expressed by the good
"my enemy is more often a task, a barrier or a self limiting idea." cop and bad cop. You could almost say its a balanced approach. The problem is that it leaves our enemy loving the good cop and fearing the bad cop. It leaves the enemy more imbalanced and unstable than before. Lastly, comes the invisible jet. I use this technique all too often. I tend to live in a world of lollipops and rainbows. I have deep faith that everything always works out. The problem with my invisible jet is that my enemies can just wait until my invisible jet lands. Granted, it takes them a while to realize it has actually landed but that is beside the point. Once I get back from petting the bunnies and riding the unicorns, my enemy has just gained more momentum and strength. So if none of my Lego training can help me, I have no choice but to turn to my personal motto. Since I can’t control the world outside of me, I will focus on my reaction to the world including my reaction to my enemies. I kept my motto simple in case I started panicking. I adopted this motto back in dental school while visiting a classmate for a study session.
On her wall read a sign that said only three words: “Because Nice Matters.” I kept staring at that sign. I told my classmate I needed to re-create that sign and hang it on the wall of my office. It is so simple and yet so complete. It carries a message more profound than any Spinjitzu master can teach me. The idea behind my motto was originally instilled in me through the actions of my favorite dai sensei master. He is no longer able to spar with me, but he continues to teach me to this day. He is my Grandfather. He was a surgeon by profession and a patriarch by passion. I recently had a long visit with my 98-year-old Grandmother who told me that my Grandpa went to great lengths for his patients when he practiced. She told me that the efforts he made to ensure his patients were well cared for surpassed the norm even back in his time. He made post-op home visits to his patients and brought them their medications from the pharmacy. He knew his patients and their family very well and protected them to the best of his ability. My Grandma told me that she still, to this day, is stopped by patients to thank her for all that Dr. Savage did for them while they were under his care. Being nice mattered to him and he changed lives by living those words. So how do I face my Goliath? How do I face my enemy? I have learned through Sensei Wu that “The best way to defeat my enemy is to make him my friend.” Whether it is a person, an idea, a barrier or a task, embracing my enemy helps me to defeat it. Once I befriend my enemy, I understand him. Once I understand him I can live by my motto and diminish the problem. I encourage you to grab your stones of David, bend like the reed, embrace your enemies, and let your spring be about growth and renewal this year. You have made it over some enormous personal hurdles and have cared for your patients in a very meaningful way. Dental professionals are some of the kindest and most supportive people I know. We all entered the field of dentistry in order to help people - and why do we do it every day? We do it Because Nice Matters.
Articulator
Spring 2014
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Articulator
Spring 2014
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DENTIST TAX LAW CHANGES FOR 2014 By Scott H. Kippur, CPA, MT
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his past fall, a number of doctors asked me to review their anticipated year-end numbers and tax projections for 2013 and 2014. Many of these doctors had similar concerns that you might have – primarily – what are the key tax law changes going into 2013 and 2014; and what else can I do to reduce my liability? The purpose of this article is to review the key tax law changes, and recommend ways to cut tax costs and increase tax deductions.
KEY TAX LAW CHANGES Many doctors are ‘bracing’ themselves for the sweeping number of tax law changes which come into effect in 2013 and 2014. No pun intended for all of you orthodontists reading this article! In fact, there were two major tax ‘Acts’ passed by Congress over the past three years, which impacts virtually everyone in the medical community from a tax standpoint. The American Taxpayer Relief Act of 2012 (ARTA) was signed by President Obama on January 2, 2013, to avoid the ‘fiscal cliff,’ and balance the U.S. budget with additional debt. The following is a brief summary of key tax law changes resulting from this Act:
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Income Tax Rate Increase for the Wealthy – A new 39.6% income tax rate applies for married filing joint households with taxable incomes greater than $450,000 ($400,000 for singles). Personal Exemptions Phase Out – A taxpayer is entitled to a ‘personal exemption’, or deduction, for everyone living in his/her household, which amounts to $3,950 per person. Thus, a family of four would normally be entitled to an exemption deduction of $15,800 on the joint return. Beginning in 2013, these exemptions will phase out for households with incomes greater than $300,000 Married Filing Joint ($250,000 for singles). Significant Reduction of Section 179 Accelerated Depreciation – Congress said they would ‘never’ take this business deduction away, yet, it has been significantly reduced to a point where is virtually non-existent. Beginning in 2014, the new law substantially reduces the Section 179 accelerated depreciation limits from $500,000 per year, down to $25,000 for immediate write-offs of newly acquired fixed asset purchases. Some tax commentators believe this could change, but currently, this is the Section 179 limit based on present day tax law. This
is arguably one of the most favorable tax deductions for medical practices. The second and more controversial ‘Act’ has disastrous tax ramifications starting in 2013. This Act is called the 2010 Health Care Act, or often referred to as ‘Obama Care’ in many social and political circles. This Act is made up of numerous health care and insurance provisions and requirements, but also contains a handful of costly carve-out provisions with respect to individual income taxes. The most notable changes are as follows: Medicare Tax Increase on Wages and Self Employment Income – Married households with wages greater than $250,000 will be subject to an additional tax of 0.9% on wages exceeding such amounts (The threshold is $200,000 for single filers). Medicare Tax on Net Investment Income – Individuals earning interest, dividends, royalties, annuities, capital gains, passive income and rents outside of the ordinary course of business will be subject to a 3.8% tax to the extent such married households have income exceeding $250,000
Articulator
Spring 2014
FINANCE MANAGEMENT Adjusted Gross Income ($200,000 for singles). Tax Penalties for Individual Taxpayers not Carrying Health Insurance – Individuals electing not to carry health insurance will be subject to tax penalties on personal tax returns. Tax on Medical Devices – This Act calls for a 2.3% excise tax on medical devices and was put in place effective January 1, 2013. In light of the above tax law changes, you may wish to consider the following recommendations to help reduce your liabilities. Of course, you may want to discuss these items with your tax advisor if they are not being currently considered by your practice: Consider Establishing a Retirement Plan for your Practice – A 401(k) Plan is an effective way for you and your employees to defer a portion of your salary tax free (up to $17,500) and not subject it to federal income taxes. This may even put you in a lower tax bracket. The funds grow tax free during your working years, and you would likely be able to pick from a basket of mutual funds, assuming it’s managed correctly. You may also be able to ‘stack’ a profit sharing plan and/or matching contributions on top of the 401(k) Plan, by which, the practice makes a contribution for you and your employees via the plan. Consider Keeping Your Salary below $250,000 ($200,000 if single) you want to avoid being subject to the 0.9% Medicare tax on wages above such thresholds by maintaining a lower, reasonable salary. This will reduce other additional payroll taxes too. Consider Implementing the Home Office Deduction - Many doctors work from home in the evening and weekends. This may include
mddsdentist.com
reviewing charts, talking to patients over the phone or by email and dealing with administrative duties. The home office deduction would allow you to depreciate your home, and deduct a portion of your maintenance, cleaning, insurance and other home costs aside from taxes and interest. Consider Putting Together (and Following) a Budget for Your Practice – Given the rising costs of taxes, staff wages and dental supplies, it makes sense to set goals and budget your income and expenses for the practice at the beginning of the year, and monitor your progress on a monthly basis. This is an effective way for you and your accountant to assess the growth of your practice, and address problematic areas with respect to costs. Review Your Entity Formation (LLC vs. S Corp) With your Advisor – Due to the rising costs of FICA and Medicare Taxes, your entity ‘formation’ could cost you or save you money, if not carefully considered. Consider Leasing Assets vs. Purchasing – Given the significant cutback of immediate depreciation under Section 179, it may be wise to consider leasing equipment versus purchasing it once you hit the $25,000 limit. Again, you may want to consult your tax advisor about these items, and others, to help reduce your taxes and/or increase deductions for your practice. Scott H. Kippur, CPA, MT, practices in the Denver Metropolitan area and specializes in assisting dentists with their tax planning, preparation, budgeting and general accounting needs. If you would like to meet with him for a free, one-on-one consultation, please contact his office at (303) 758-1796.
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New HIPAA Laws: What They Mean for Dental Practices and Our Patients By Brandon Hall, DDS
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his past September 24th, new HIPAA regulations came into effect that change how we interact with our patients and their protected health information as well as the businesses we work with that have access to this data.
risk present but now the burden is on the office to show that there is a low probability of harm based on a ‘risk assessment.’
Before we get into what the new laws are, let’s quickly review what HIPAA is and what it’s intended for. In 1996, President Clinton signed into law the Health Insurance Portability and Accountability Act (HIPAA). It was signed into law to reflect the new electronic interchange of health information between providers, patients and insurance companies. In essence, it was designed to protect the privacy of individuals and their information while making things more efficient.
The types of identifiers linking health information to individuals, such as names, medical record numbers or geographic information
There have been several changes since 1996 but none as drastic as what went into effect on September 24, 2013. While this article is not intended to be all-inclusive, let’s break down the most important changes and what they mean for you and your patients.
Whether or not actual health information was obtained or viewed
New Business Associate Agreement (BAA): It’s now expected that dental offices maintain an agreement with any of its business associates that have access to Protected Health Information (PHI). This now includes any subcontractors that an associate works with now matter how far down the chain things go. For example, if you work with an IT company that has access to your computers via remote log-in or online backup, you must maintain a BAA with them. New Notice of Privacy Practices Due to the advent of social media and the popularity of mobile devices, access to patient’s information has become much more readily available but at the same time more at risk for exposure. Your Privacy Practices need to reflect the new issues that confront our patients’ PHI. And not only that, but they need to address the different identifiers of information, and how they are accessed and for what reasons (i.e. dental insurance). For example, do you have something that addresses Facebook and posting information about patients? What about the use of mobile devices in the office? Breach Notification Rules and Enforcement The new HIPAA regulations also usher in a higher standard for breaches of PHI, along with stiffer enforcement. Before this rule, there was no presumption of a breach unless there was significant
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If there is such a breach of information, the following factors must be addressed and evaluated to determine how serious it is:
If these identifiers would be likely to be used in identification in other information Whether or not the exposure involved unauthorized persons in terms of access or in terms of disclosure to others
Finally, to what extent this disclosure was mitigated. Now, if a breach can be proven as a violation, there is a tiered system of violation categories and penalties that go with them. These are “Unknowing,” “Reasonable Cause,” “Willful Neglect (Corrected)” and “Willful Neglect (Not Corrected”) The latter being the most serious. These violations carry fines from $100 up to $1.5 million per calendar year. It remains to be seen what type of punishment we will see when a practice is found in violation of the new HIPAA regulations or how strictly the new laws are enforced. However, it remains extremely important that practice stay within compliance to avoid having such breaches of PHI and the resulting fallout. It could potentially be catastrophic for a practice from a financial standpoint. So, how do you get information or training on becoming compliant? Start with your dental supply company (Schein, Patterson, etc.). They usually can provide free or very inexpensive HIPAA training for your office staff. You can also purchase the ADA HIPAA compliance kit that has all the regulations explained and forms you’ll need. With the fast-changing landscape of digital media, higher incidences of stolen information and increased access to information, it becomes important we stay on top of our patients’ privacy and their PHI to assure them they won’t be at risk. As a dental provider who is privy to this information, it’s imperative you bring yourself in compliance with the new HIPPA laws.
Articulator
Spring 2014
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CLINICAL
ABUTMENT EMERGENCE MODIFICATION FOR IMMEDIATE IMPLANT PROVISIONAL RESTORATIONS Todd R. Schoenbaum, DDSa, Yi-Yuan Chang, BS, MDCb, Perry R. Klokkevold, DDS, MSc and John S. Snowden, DDSd Abstract: In their stock form, some titanium provisional implant abutments are not ideally designed for use in immediate placement/immediate provisional restoration treatment. This is largely due to the apical flare design which applies excessive pressure to the periimplant soft tissue complex and crestal bone. This appears to have the undesirable effect of increasing periimplant bone resorption and severely impeding the potential for increases in gingival volume. This type of stock titanium abutment will therefore benefit significantly from recontouring. The subgingival portion of the abutment is recontoured from the flared stock shape to a straight or parallel design. This modification minimizes pressure on the surgical site, and provides additional space around the subgingival portion the provisional restoration, within which the gingiva has the potential to remodel and fill. This allows the potential formation of additional periimplant gingival volume, and a coronal maintenance or migration of the soft tissue complex. In order to minimize the “graying effect” of titanium abutments, the retentive portion is opaqued by the technician or clinician. These modifications will improve the potential outcomes for both the periimplant gingiva and the provisional restoration.
Clinical Significance Narrowing the emergence profile of the abutment for immediate implant provisional restorations appears to minimize the loss of peri-implant bone resulting in the development of increased gingival volume. This increases the predictability and potential success of implant treatment in the aesthetic zone.
Introduction:
The use of implant supported provisional restorations has been shown to be a viable and important component of successful implant treatment, particularly in treatments that involve preservation and/or manipulation of the periimplant gingiva in the aesthetic zone.1-5 The immediate provisional restoration replaces natural tooth contours and helps to support the gingival architecture during the immediate and subsequent healing period, thus improving overall predictability of the treatment.6-10 In its initial form, the immediate implant provisional restoration must protect the surgical site and stabilize periimplant graft materials without exerting excessive pressure to the gingiva. For immediate implants in the aesthetic zone, the provisional abutment must perform three functions well: preserve bone and soft tissue, provide adequate strength to the provisional restoration, and support the shade of the provisional. Though “plastic” (generally PMMA, or PEEK) provisional abutments are available, it has been the authors experience that they are significantly more prone to breakage and unreliable for provisionals that frequently need to function for the six to twelve months necessary to achieve an ideal and stable gingival result. Titanium (and zirconia) abutments have been shown to minimize bone and soft tissue loss around the implant,11-12 are less prone to breakage, are approved for use beyond six months, and can be torqued to higher loads. For these reasons, the authors prefer the use of
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a Assistant Clinical Professor, Division of Restorative Dentistry, University of California-Los Angeles School of Dentistry b Staff Research Associate, Division of Restorative Dentistry, University of California-Los Angeles School of Dentistry c Associate Professor, Section of Periodontics, University of California-Los Angeles School of Dentistry d Lecturer, Division of Restorative Dentistry, University of California-Los Angeles School of Dentistry
titanium provisional abutments that allow the creation of a screw-retained provisional restoration. However, with some implant systems the provisional abutment will require some modification to better achieve the goals stated above. This technique is of particular use for implants not designed with a narrow diameter abutment (or “platform switched” interface.)13 Provisional titanium implant abutments from some implant manufacturers significantly benefit from two primary modifications which maximize their effectiveness in the aesthetic zone: recontouring, and opaquing. These abutments have a flare that starts at the abutment/implant interface (Fig. 1a). The flare present on the abutment where it interfaces with the implant creates unnecessary pressure on the soft tissue complex and crestal bone, which may lead to an increase in resorption and recession of the periimplant tissues.14-16 Such changes are most significant at the facial gingival margin and the interdental papillae. In order to minimize apical migration of the crestal bone and accompanying gingival recession, such abutments can be recontoured to a more ideal form. The flare on the abutment can be carefully removed in the laboratory prior to the surgery to create a significant improvement in the subgingival contour of the abutment. This will allow for a straight, smooth transition from the implant to the abutment without changes in contour, thus minimizing unnecessary intrusion of bulk restorative/abutment material into the periimplant space, which should ideally be occupied by gingival tissues.
To maximize the potential height of the soft tissue complex, the most apical portion of the abutment should be modified to be no wider than the implant body at the neck (Fig. 1b). The narrow abutment profile allows for sufficient biologic width around the non-integrated abutment and therefore minimizes remodeling of the peri-implant crestal bone. This
straight emergence profile on the abutment should extend as far coronally as possible (depending on tissue thickness, this is generally 2 to 3mm in the maxilla) before transitioning outward to meet the profile of the crown at the CEJ. The transition from the straight apical area of the abutment to the wider crown area should be smooth and polished with a gentle “S” curve design to promote hygiene and gingival health (Fig. 2). This narrow contour is especially useful in preserving the interproximal crestal bone adjacent to the implant (Fig. 3) Due to their color, titanium abutments can cause a “graying effect” of the provisional restoration. This problem is resolved through the use of a low viscosity opaque composite resin applied to the abutment to neutralize the graying effect commonly associated with titanium.
Figure 1 a Figure 1a: Stock provisional abutments from some implant manufacturers have a flared emergence profile on the subgingival portion. This design occupies valuable periimplant space and may cause apical repositioning of the gingiva, particularly in immediate placement / immediate provisional implant treatment.
Figure 1 b Figure 1b: The flared emergence profile of the provisional abutment has been removed with a heatless stone and polished with rubber polishing wheels to create a subgingival surface of 2 to 3mm that is smooth and parallel with the terminal portion of the implant body.
Technique: 1. Attach stock titanium provisional abutment to a protection analog (Titanium Engaging Temporary Abutment NobelReplace; Nobel Biocare AB, Goteborg, Sweden). (Fig. 1a) 2. Remove the flared portion of the abutment using a heatless stone (No. 6 White Stone Wheel; Shofu Inc, Kyoto, Japan). Do not adjust the portion of the abutment that will interface with the head of the implant body. Ensure that the contour is parallel to the terminal portion of the implant body. (Fig. 1b) (cont. on pg. 14) 3. Polish the adjusted area using coarse Dialite wheel (Dialite Polishing Wheels, Brasseler, Savannah Ga), then with soft cut grade wheel (Shofu), finished with the extra fine Dialite wheel. 4. Apply sticky wax to polished collar area (Kerr Lab Sticky Wax; Sybron Dental Specialties, Orange, Calif). 5. Abrade retentive zone of the abutment with 50 micron aluminum oxide at 2 bar of pressure. 6. Remove the sticky wax, steam clean and dry the abutment.
Figure 2 Figure 2: Buccal view of the completed provisional restoration. Note the straight profile from the implant body to the narrowed abutment collar, and the continuous “S-curve” from the abutment to the full contour of the crown. The implant body is represented by the dotted line.
7. Apply low viscosity composite resin opaquing wash to the retentive zone of the abutment (Tooth-colored UV opaquer; XPdent, Miami, Fla). (Fig. 4) 8. Polymerize the composite opaquing resin using a dental curing light for 60 seconds. 9. Fabricate and deliver provisional restoration and torque to manufacture’s recommended specification. (Figs. 5, 6)
Figure 3 Figure 3: Radiograph of the provisional restoration in position on the day of extraction and immediate implant placement. The narrowed emergence profile of the provisional restoration is evident and will minimize the apical migration of the gingiva due to encroachment of the biologic width.
Figure 4 Figure 4: A low viscosity opaquing composite resin has been applied to the retentive zone to minimize the “graying effect” of the titanium in the coronal portion of the provisional restoration.
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CLINICAL (cont. from pg. 13) 10. Avoid removing or modifying provisional restoration during osseointegration and gingival maturation. Evaluate at three months postoperative. (Fig. 7)
Summary:
Figure 5
Figure 5: The modified, narrow emergence titanium abutment is in position approximately 1 hour after extraction and implant placement. Note the absence of pressure on the gingiva. The abutment has been marked and will be trimmed (extraorally) prior to combining it with the provisional shell.
Immediate implant placement with the fabrication and delivery of a properly designed provisional restoration significantly improves the potential aesthetic and functional outcome of implant treatment. The most significant improvements are gained in the resulting gingival architecture. Though highly durable and biocompatible, some stock titanium provisional implant abutments decrease the aesthetic potential of treatment because they are improperly flared and put undesirable pressure on the surgical site. By recontouring the subgingival portion of the abutment to a parallel design, the pressure on the periimplant gingiva is minimized and the potential for ideal papillae height and gingival contour is significantly increased. Opaquing the retentive portion of the abutment significantly improves the potential for shade matching the provisional restoration to the adjacent dentition. The primary advantage of fabricating a screw retained implant provisional with this modified abutment is the preservation of the soft-tissue complex at its most coronal position. Additionally, the provisional restoration stabilizes the contours of the soft tissue and serves as a guide for the fabrication of the definitive prosthesis/abutment. Following a period of osseointegration and periodontal maturation, the contours of the definitive restoration should replicate those created by the provisional restoration, thus minimizing the potential loss of gingival height.
Figure 6
Figure 6: The provisional restoration in position on the day of extraction and implant placement. Note the open gingival space at the mid-facial, provided by the narrowed neck form of the provisional restoration. It is expected that this space will allow for coronal migration of the gingiva
Disclosure Statement: The authors do not have any financial interest in any of the companies whose products are discussed in this paper.
References: 1. Chee W. Provisional restorations in soft tissue management around dental implants. Periodontol 2000 2001;27:139-47. 2. Gapski R, Wang H, Mascarenhas P, Lang NP. Critical review of immediate implant loading. Clin Oral Implants Res 2003;14:515-27. 3. Lorenzoni M, Pertl C, Zhang K, Wimmer G, Wegscheider W. Immediate loading of single-tooth implants in the anterior maxilla. Preliminary results after one year. Clin Oral Implants Res 2003;14:180-7. 4. Al-Harbi SA, Edgin WA. Preservation of soft tissue contours with immediate screw-retained provisional implant crown. J Prosthet Dent 2007;98:329-32. 5. Harvey BV. Optimizing the esthetic potential of implant restorations through the use of immediate implants with immediate provisionals. J Periodontol 2007;78:770-6. 6. Kan JY, Ringcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants 2003;18:31-39. 7. Barone A, Rispoli L, Vozza I, Quaranta A, Covani U. Immediate Restoration of Single Implants Placed Immediately After Tooth Extraction. J Periodontol 2006;77:1914-20. 8. Han CH, Paik JW, Le e KW, Han DH, Chung MK, Kim S. Impact of immediate and non-immediate provisionalization on the soft tissue esthetics of final restorations on immediately placed implants. J Kor Acad Prosthodont 2008;43:238-244. 9. Lops D, Chiapasco M, Rossi A, Bressan E, Romeo E. Incidence of inter-proximal papilla between a tooth and an adjacent immediate implant placed into a fresh extraction socket: 1-year prospective study. Clin Oral Implants Res 2008;19:1135-40.
Figure 7
10. De Rouck T, Collys K, Wyn I, Cosyn J. Instant provisionalization of immediate single-tooth implants is essential to optimize esthetic treatment outcome. Clin Oral Implants Res 2009; 20:566-70. 11. Abrahamsson I, Berglundh T, Glantz PO, Lindhe J. The mucosal attachment at different abutments. An experimental study in dogs. J Clin Periodontol 1998;25:721-7. 12. Zembic A, Sailer I, Jung RE, Hämmerle CHF. Randomized-controlled clinical trial of customized zirconia and titanium implant abutments for single-tooth implants in canine and posterior regions: 3-year results. Clinical Oral Implants Research. 2009 Aug;20:802–8.
Figure 7: Three month evaluation reveals coronal migration of the periimplant gingiva of approximately 1mm at the mid-facial. The provisional restoration was left in place, and unmodified for the initial three months to minimize damage to the maturing gingiva.
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13. Lazzara RJ, Porter SS. Platform switching: A new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:9-17. 14 . Tarnow DP, Eskow RN. Preservation of implant esthetics: soft tissue and restorative considerations. J Esthet Dent 1996;8:12-9. 15. Pradeep AR, Karthikeyan BV. Peri-implant papilla reconstruction: realities and limitations. J Periodontol 2006;77:534-44. 16. Rompen E, Raepsaet N, Domken O, Touati B, Dooren EV. Soft tissue stability at the facial aspect of gingivally converging abutments in the esthetic zone: a pilot clinical study. J Prosthet Dent 2007;97:S119-25.
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Digital Implant Dentistry: The Next Frontier Dr. Farhad Boltchi, Periodontist Arlington, Texas
“How many teeth do I need?” Restoring August 28, 2014 Dentsply Implants Function and Esthetics with Dental Implants Dr. Mark S. Montana, Prosthodontist Tempe, Arizona
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DENVER IMPLANT STUDY CLUB (D.I.S.C) Location: Mountain West Dental Institute Beauvallon Building: 925 Lincoln Street, Denver, CO 80203 Time: 5:30 PM to 8:30 PM Complimentary light dinner at 5:30 PM. Lecture begins promptly at 6:00 PM. CE credits are available. Fees for 2014 are waived due to corporate sponsorship. Please Note: Capacity is limited. If interested in attending, please R.S.V.P. to reserve your place (see below).
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PRACTICE MANAGEMENT EMPLOYEE HEALTH INSURANCE…SHOULD YOU OFFER IT TO YOUR EMPLOYEES? By Jennifer L. Thompson, DDS
C
olorado small business owners with less than 50 employees are not required to provide health insurance. However, health care coverage, along with time-off benefits, is the most popular benefit to employees. It attracts and helps retain the most qualified employees, as well as helps ensure the wellness of those workers. Employers know that a happy, healthy staff can increase productivity.
Of the more than 8,000 small businesses in Colorado, only 100 had signed up for health insurance on the exchange by the end of December 2013. Business owners cite the high premiums and the inability to qualify for the tax credits as reasons for their failure to participate. They also found it difficult to obtain quotes to compare with their current plans.
Setting up a health plan for your office can be complex and timeconsuming. Working with an insurance broker can ease that process and is the first step. Brokers are paid by the insurance companies directly, But, the cost can be a downside to offering health benefits. Health care so there typically is no “fee” charged to the business for their services. costs have risen enormously in recent years. As a result, not only are costs However, be sure to confirm the financial arrangement prior to engaging draining valuable resources from many small businesses, the uncertainty one of these professionals to eliminate future, difficult conversations. of future increases make financial planning extremely difficult. But, remember to consider an additional benefit to employers who elect to Andrea Levine, RHU, CLTC, with COPIC Financial Service Group, offer health care benefits, and the tax ramifications for their businesses. recommends using a broker to help navigate the options. She specializes Whether you shop in the “Exchange” or “Off the Exchange,” it is definitely in aiding practitioners in deciding what health plans work best for their worthwhile to include your accountant in the final decision. particular needs and budgets. She suggests beginning the process a couple months before your policy’s effective date, providing ample time to find Some criteria to consider when selecting a group health insurance plan the best group policy. It’s also important to ensure a broker is “certified” include: to work on the Exchange to guarantee your office has all options available both on and off the Exchange. Health Benefits: Buy only what is important to you and your employees. It’s not a “one-size fits all” society any more…everyone has different needs. So, if possible, offer your employees “choice.” PROFESSIONAL MARKETING AND APPRAISAL Costs: Which plans fall within your budget when it comes to cost sharing between employer and employees, monthly premiums, deductibles, copay, and coinsurance? For instance, consider a higher deductible plan if your primary requirement is a low monthly premium. Carriers: Are there carriers you prefer, or alternatively, want to avoid? Carriers have different networks for different plans. So, when selecting a plan, be sure your specifically preferred physicians are in the network under consideration. Coverage Add-Ons: Do you want to offer your employees dental or vision coverage? Pediatric Dental is now one of the ten Essential Health Benefits required by the Affordable Care Act. Some health plans already include it while others do not. Employers should consider other alternatives for meeting that requirement when looking at health plans. Voluntary Benefits, another option, is where you (the Employer) do not have to contribute anything. Consider the cost savings to you if you elect to exclude it compared with the cost to include it and the ultimate effects on your staff.
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If you do offer employee healthcare, there are some cost saving strategies. You can consider a Defined Contribution Plan where the employer pays a predetermined amount to an employee’s health plan. You can offer HighDeductible Plans, typically offered by insurers at lower premiums. These plans are paired with employee accounts such as health reimbursement arrangement (HRA) or health savings account (HSA) that help employees use pretax money to pay medical expenses.
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NON PROFIT NEWS
FEED THE FOUNDATION’S FIRST ANNUAL EVENT ROCKS PARALLEL SEVENTEEN! By Amy Boymel, MDDF Executive Director
O
n March 6th, a crowd of more than 50 gathered at Parallel Seventeen to enjoy a five course meal with wine pairings created by chef/ owner, Mary Nguyen, and to raise funds for the Metro Denver Dental Foundation (MDDF). Feed the Foundation, originally created by the MDDS Communications Committee to help promote and support MDDF, put together a small group including committee members Dr. Jeremy Kott and Dr. Maureen Roach, and MDDF Board Members Ms. Andrea
Levine and Dr. Mike Poulos, to plan the event. The group was led by Dr. Nick Poulos, a member of both the MDDF Board and the MDDS Communications Committee, MDDF Executive Director, Amy Boymel, and MDDS Director of Marketing and Communications, Jason Mauterer. Dr. Pat Prendergast, MDDF Board President, and Ms. Elyse Warren, Director of Family Services at Warren Village, shared their thoughts on how MDDF benefits our community and truly changes the lives of those it helps; especially through Smile Again, its hallmark program. Since everyone had such a fantastic time, we’ll need to find a bigger venue for next year’s event!
Guests enjoy the terrific food and great company at Parallel Seventeen.
KIND Comes Home In 1912, a group of dentists from the Denver Dental Society, today known as the Metropolitan Denver Dental Society, recognized the need for dental care amongst the children of low-income miners and railroad workers in Denver. It was their vision to start a clinic where families would be able to bring their children to receive dental care and be able to afford it. Their vision became a reality and Kids In Need of Dentistry (KIND) was formed. This year, KIND has returned home to MDDS. Thanks inpart to a donation from Dr. Inil Idiculla the clinic in the Mountain West Dental Institute is now
KIND’s downtown clinic operating every Monday. MDDS is excited to be able to offer this facility to serve the needs of Denver’s underserved children. All children deserve quality dental care and KIND makes it happen every day. But this wouldn’t have been possible if it weren’t for those caring dentists who 102 years ago believed in the importance of oral health care as well as all of the volunteers, donors and supporters who have supported KIND for over 100 years. To learn more about KIND please check out their website at kindsmiles.org, and to see the Mountain West Dental Institute, visit mwdi.org.
Dr. Avani Khatri and her staff serve the KIND patients in the clinic at the Mountain West Dental Institute.
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Thank You for Making the 2014 RMDC Such a Great Success!
Entrance to the 2014 RMDC Exhibit Hall
Opening session with Mr. David Weber
The Dawson Academy course in the new MWDI Clinic
Attendees participating in a hands-on course at the MWDI
Attendees visiting the Expo Hall Volunteers:
The 2014 Rocky Mountain Dental Convention could not have been such a success without you! We would like to extend a warm “Thank you” to all of our attendees, exhibitors, sponsors and especially our volunteers. We look forward to seeing you all at the 2015 RMDC.
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Ms. Jacquie Alford Dr. Roger Anderson Ms. Stephanie Anderson Ms. Carolyn Anello Dr. Justin Baltz Ms. Kristen Barden Ms. Pat Barga Ms. Lauren Barnes Dr. Elizabeth Barr Dr. Nelle Barr Dr. Edward Barrett Dr. Eric Beckman Dr. George Beilby Ms. Myra Bender Dr. Dennis Black Dr. Roger Boltz Dr. Janie Boyesen Dr. Terry Brewick Dr. Sarah Broten Dr. Ron Brown Dr. Kenneth Burson Ms. Kristy Cagle
Dr. Richard Call Ms. Linda Chin Dr. Nick Chiovitti Ms. Patrice Clements Dr. Thomas Croghan Dr. Eric Dale Dr. Kim Danzer Dr. Erica Derby Dr. Robert Devin Dr. Michael Diorio Ms. Krishanna Ellis Ms. Jan Foster Dr. Karen Foster Dr. Karen Franz Dr. Mitchell Friedman Dr. Diane Fuller Dr. Larry Gabler Ms. Becky Garrison Dr. George Gatseos Ms. Janet Gatseos Ms. Lelia Gibson Ms. Heather Gill Dr. Paul Glick
Hands-on learning at the RMDC
Enjoying the Expo Hall Reception Ms. Andrea Glover Dr. Guy Grabiak Dr. Bruce Greenstein Dr. Brian Gurinsky Dr. Alan Gurman Ms. Chris Hillenbrand Ms. Ina Horvath Dr. Keaton Howe Ms. Suzanne Hubbard Dr. Curtis Johnsen Dr. Collis Johnson Dr. Jed Jultak Dr. Brett Kessler Dr. Don Kleier Dr. David Klekamp Ms. Jennifer Klekamp Dr. Beth F. Kreider Ms. Trystin Leighton Dr. Ken LeVos Dr. Justin Liddle Dr. Stace Lind Dr. Clifford S. Litvak Dr. Jeffrey T. Lodl
Attendees enjoying the Friday Night Party
Dr. Scott Maloney Ms. Brittany McDonald Ms. Paige McEvoy Ms. Stacey McKee Ms. Adrienne Meyer Ms. Robin Meyer Dr. Deborah Michael Ms. Lori Mirelez Ms. Misty Mitchell Dr. Sheldon Newman Ms. Mary Nobles Ms. Chrissy Oihus Dr. Michael Okuji Dr. Ian Paisley Dr. Cameron Pangborn Ms. Kimberly Parsons Dr. Michael Poulos Dr. Nick Poulos Dr. Ron Resnick Dr. Letha Robison Mr. Rocky Rose Dr. Darrel Schuler Dr. Carrie Seabury
Inside the Pacific Dental Services mobile dental clinic Ms. Tina Segura Ms. Kinsey Shriver Dr. Bernard Slota Dr. A. Patrick Smithwick Ms. Grace Snearline Ms. Shannon Sondrol Ms. Kristy Stallsworth Dr. Heather Stamm Dr. Gregory Stoll Ms. Laura Tappero Dr. Robert Teitelbaum Ms. Mary Thompson Dr. Terri Tillis Dr. Jay Tippets Ms. Yesenia Urbina Dr. Eric W. Van Zytveld Dr. Larry Weddle Dr. Dawn Wehking Mr. Bill Wiering Dr. John Weissman Dr. Arthur Yagudayev Dr. Marianne Yancey Dr. Hesham Youssef
WE NEED YOUR
SUPPORT
THANKS TO OUR MWDI SPONSORS!
Go to mwdi.org to donate today! Includes cash donations and sponsorships; this does not include donated services and equipment.
Mile High Founding Members (Contributions of $5,280+) Rocky Mtn. Dental Partners - Aspen/Aurora/Cherry Creek Terry L. Brewick, DDS - Governor's Park Dental Group Brighton Smiles - Jaci Spencer, DDS Burnham Oral Surgery - Dr. Michael Burnham, DDS, MD The Doctors at Mountain Range Dentistry, Dr. Nicholas Chiovitti & Dr. Paul K. Mizoue Mark S. Ehrhardt, DDS Larry Gayeski, CPA Alan Gurman, DDS Roger D. Nishimura, DDS Ohmart Orthodontics Ian Paisley, DDS Shon Peterson, DMD, MS Robert T. Rudman, DDS Michael Scheidt, DDS & Kathryn Scheidt Stamm Dental, Heather Stamm & Kai Kawasugi Larry T. Weddle, Jr., DMD Cassady B. Wiggins, DMD
JARCHITECT OE
Benefactors (Contributions of $2,000+) 2013 MDDS Delegates to the CDA Dr. Kimberly Danzer The Dental Center Mitchell Friedman, DDS Anil Idiculla, DMD Sheldon Newman, DDS & Linda Newman Sedona Periodontics - Dr. Chris Sakkaris Sean W. Shaw, DMD Periodontics Dental Implants Joseph K. Will, DDS
Patrons (Contributions of $500+) Alpha Omega Dental Fraternity Bank of America Jack W. Choi, DDS, PC Colorado Society of Oral & Maxillofacial Surgeons, Inc. Charles S. Danna, DDS Karen D. Foster, DDS George G. Gatseos, DDS GHP Investment Advisors Paul L. Glick, DDS HJ Bosworth Company Michael B. McKee, DDS James C. Nock, DDS Alexander H. Park, DDS, PC Ridgeview Pediatric Dentistry Michael N. Poulos, DMD Edward F. Rosenfield, DMD, MS Christopher J. Sakkaris, DDS, PC Eric W. VanZytveld, DDS Dr. Gregg Lewis Jacob Williams Dr. Herbert T. & Lenore Williams
Young Dentistry for Children
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CLINICAL
THE PATHWAY TO PREDICTABILITY By John C. Cranham, DDS
A
s our skills evolved during our training in dental school, we focused on the biologically based aspects of dental disease. Dental caries and periodontal diseases were the primaryenemy. We learned their etiologies, and honedour skills to eliminate and control these types ofproblems. Preparation design, caries excavation, the manipulation of restorative materials and the handling of periodontal root planing instruments made up the major part of the dental school clinical experience. As our focus on graduation requirements expanded, we kept our eye on the number of crowns, bridges, partials and complete dentures we had to complete. If we left dental school with a solid understanding of tooth preparation for 1-2 indirect restorations, ideal retraction/soft tissue manipulation, had the ability to make a clean, crisp, readable master impression, the appropriate bite registration technique to capture the patient’s habitual bite, and could create a good provisional crown, then we likely had a very good, fundamental education. These extremely important skills bind all Dentists together because they are the skills that combat traditional biologically based dental disease. They are also the skills that seem to serve us well for the first few years of practice. As time evolves we begin to notice patients with other problems. It may be a patient who needs multiple post-operative adjustments following simple restorative procedures. It might be a patient who continually breaks her own teeth, fractures the work we put in her mouth, or with habitual, moderate to severe tooth sensitivity after operative care. We begin to notice patients
Our goal is harmony in joints, muscles, teeth and their supporting structures
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whose teeth are wearing away, who complain about spaces opening up between their teeth after we place posterior crowns, or who have headaches, or TMJ noise. The question is, do we have a greater responsibility as Dentists, other then just creating a biologically healthy environment? Can we go beyond the elimination of periodontal disease, caries, and protecting weak teeth with crowns? Is it possible that the patient’s occlusal scheme could be creating force vectors that lead to the issues previously described? It is our belief that optimum oral health is about creating anatomical and functional harmony with all parts of the masticatory system (joints, muscles, teeth and their supporting structures). Teeth that look bad, are missing, wear, become mobile, migrate
" In essence, dental school taught us how to handle biologic disease, and solve basic biomechanical problems. It also gave us a glimpse at restoring patients with multiple missing teeth (dentures, RPD’s and bridgework)."
Disharmony in the masticatory system leads to occlusal disease.
causes him to simply guess when creating contours. This typically leads to the case going back and forth between the lab and the dental practice, leaving everyone, including the patient, extremely frustrated. In this model any hope for patient satisfaction, future referrals, as well as profitability, is greatly diminished.
or shift position, and/or break, are indicators that an appropriate change in the arch to arch relationship and/or position/ contour of the teeth is required to improve the esthetics as well as stability of the patient’s occlusion. If harmony does not exist between the TM Joints, muscles of mastication and the interdigitation of the teeth, OCCLUSAL DISEASE will likely follow. Some part of the system, usually the patient’s weakest link, will break down. What every Dentist begins to experience is that when the same restorative protocols that worked for single tooth dentistry are applied to sextant or full arch dentistry, predictability disappears. The primary reason for this lack of predictability is not spending time in the treatment planning phase to determine how the size, shape, contour, or position of the teeth need to be altered to not only look better, but to function optimally. This lack of advanced determination and communication of the determinants to the dental laboratory technician
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been met prior to placing the restorations in the mouth. The Dentists that commit to learning these protocols will experience greater enjoyment and profitability in their practices. They generally will work fewer clinical hours, have less stress and higher net incomes. This is all possible by following a proven path to the most important quality in any Complete Dental Practice learning to be PREDICTIVE
What differentiates a Complete Dentistry practice from a Usual and Customary Practice? The difference is the ability to go beyond treating the biologic issues of the teeth and gums, to diagnosing and treating the entire Masticatory System. The Complete Dentist has the knowledge and ability to create functionally stable occlusions as well as the skills to create beautiful smiles. Achieving this level of proficiency requires a commitment to learning
how the joints, muscles and teeth (the masticatory system) are designed to work together in functional harmony. It requires learning a protocol for complete evaluation and diagnosis that allows for the precise determination of functionally correct, highly esthetic, tooth contours. It requires learning laboratory communication tools so there is no guesswork required when the technician creates restorations – from a single crown to full mouth rehabilitation. And finally, it requires learning verification protocols to ensure all of the esthetic and functional goals have
John C. Cranham, DDS maintains a restorative practice in Chesapeake, Virginia. He began studying with Dr. Peter Dawson during his first year in private practice and successfully implemented the Concept of Complete Dentistry® in his general practice. Because of his exceptional clinical skills and knowledge, outstanding ability to communicate and teacher’s heart, Dr. Dawson invited John to be a member of the Dawson Academy faculty in 2004 and appointed him Clinical Director in 2008. John is an internationally recognized speaker on the Esthetic Principles of Smile Design, Contemporary Occlusal Concepts, Laboratory Communication, and Happiness and Fulfillment in Dentistry.
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EVENT CALENDAR APRIL 2014 April 24 Denver Implant Study Club - Dr. Aldo Leopardi Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 5:00pm – 9:00pm (720) 488-7717 For more info go to: knowledgefactoryco.com April 25 MDDS Practice Enhancement Day Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 8:30am - 4:30pm (303) 488-9700 For more info go to: mddsdentist.com
MAY 2014 May 2 A Practical Approach to Oral Surgery for the General Dentist Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 9:00am - 4:00pm (303) 488-9700 For more info go to: mddsdentist.com
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May 8-10 Dawson Academy - Functional Occlusion: From TMJ to Smile Design Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 8:00am - 5:00pm (800) 952-2178 For more info go to: mddsdentist.com May 23-24 Dawson Academy - Evaluation, Diagnosis & Treatment of Sleep Disorders Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 8:00am - 5:00pm (800) 952-2178 For more info go to: mddsdentist.com May 23 Implant System Comparison Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 9:30am - 12:30pm (303) 488-9700 For more info go to: mddsdentist.com
May 31 MDDS Luau Cherry Creek State Park - Dixon Grove Picnic Shelter - 4201 S. Parker Road, Aurora, CO 80014 11:30am - 3:00pm (303) 488-9700 For more info go to: mddsdentist.com
JUNE 2014 June 5-7 CDA Annual Session Vail Marriott Mountain Resort in Vail, CO (303) 740-6900 For more info go to: cdaonline.org/dentalprof/ annual-session/annual-session June 12 Denver Implant Study Club - Dr. Aldo Leopardi Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 5:00pm – 9:00pm (720) 488-7717 For more info go to: knowledgefactoryco.com
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Spring 2014
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June 19-21 Dawson Academy - Examinations & Records Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 8:00am – 5:00pm (800) 952-2178 For more info go to: mddsdentist.com June 21 MDDF Shred Event 5150 West 80th Ave, Westminster, CO 80030 9:00am – 12:00pm (303) 730-2500 For more info go to: mddf.org June 27-28 Nitrous Oxide/Oxygen Administration Training Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 Friday 8:00am – 5:00pm Saturday 8:00am – 12:00pm (303) 488-9700 For more info go to: mddsdentist.com
JULY 2014 July 17-19 ADA New Dentist Conference Sheraton Kansas City Hotel at Crown Center For more info go to: ada.org/newdentistconf.aspx
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Friday, May 23, 2014
IMPLANT SYSTEM COMPARISON Presented by Dr. Brian Butler, MS
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The MWDI is owned and operated by the Metro Denver Dental Society
Metro Denver Dental Society | 925 Lincoln St., Unit B | Denver, CO 80203 | (303) 488-9700
Articulator
Spring 2014
FINANCE MANAGEMENT
GLOBAL RESERVE CURRENCY THE U.S. DOLLAR
By Edward Leone Jr, DMD, MBA, RFC
A
reserve currency is a currency that is held in significant quantity by many governments and institutions as part of their foreign exchange reserves. If Japan were to buy a barrel of oil from Saudi Arabia, the transaction would take place in dollars and not yen or riyals. Foreign exchange reserves available for international trade are as follows: U.S. Dollars 65%, Euro 25%, Japanese Yen 3%, British Pound Sterling 4%, China’s yuan .9% and Swiss Franc .2%. It is clear that the U.S. dollar as the global reserve currency represents a significant competitive advantage to the US regarding international trade since we do not have to be highly concerned over currency risk in our international purchases and the demand for dollars from other sovereign governments engaged in international trade is significant. These dynamics along with trends toward innovation and entrepreneurialism also make the price of U.S. goods and services competitive internationally while other countries are using cheap labor, lack of aggressive regulation, natural resources and regional symmetries to foster competitive advantage. There have been rumblings from countries such as China, Russia, Japan, Brazil and India along with others to get away from the dollar as the reserve currency with the motive of diluting the competitive advantage which this status gives the U.S. Many of these countries are trying to forge currency agreements, which include their currencies or a substitute exchange vehicle generated by the IMF (International Monetary Fund). Globally, credibility of the U.S. Government is tarnished as a result of its growing national debt and the future prospect of servicing this debt. What is the potential for the U.S. dollar to be challenged as the global reserve currency? We must take into consideration that the global GDP for 2011 was $63 trillion and that the U.S. economy represented 25% of that production.
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China, the second largest economy, is at half that of the U.S. economy. Although GDP growth over the last five years in the U.S. has been at a slow pace when compared to historic data, it is growing and remains dynamic and flexible. Other countries including both established and emerging economies are not doing as well regarding a variety of economic and political issues. What currency could possibly be substituted for the U.S. dollar? The Euro, yen and yuan don’t come into consideration nor do other currencies given the small quantities available internationally and the significant challenges the countries that sponsor these currencies face. China holds a significant portfolio of U.S. bonds and could see valuation changes due to inflation and further bail out activity by the US Government with printed dollars. China’s yuan or renminbi is not a suitable substitute since it is not fully convertible to other currencies and China does not have a strong and open bond market. According to some economists, China’s anticipated economic growth will exceed that of the U.S. in 7 to 30 years. It is likely that the U.S. Government will continue to live on borrowed money and the printing press until leadership in government changes. This must happen eventually since the current path is not sustainable in the long term. It may be by international agreements that several currencies will share global reserve currency status in the future, but in the near term there is no substitute for the dollar. Why should dentists care about all of this? Very simply, if the U.S. Government has trouble financing its debt internationally, interest rates will have to go up dramatically. This will slow growth of our economy significantly and present many business challenges to dentists and other business owners. Although we deal day to day with our patients who are in close proximity to our practice locations, we do purchase supplies and equipment from international sources. Prices for these items will go up, and we will also see considerable competition from dental tourism.
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SOCIAL MEDIA ONLINE REPUTATION MARKETING – IS IT BUILDING YOUR PRACTICE OR COSTING YOU A FORTUNE? By Brian Devine, President of Top Line Management
W
elcome back to the discussion around online reputation marketing or ORM. If you remember from my last article, you learned just how important your online reputation has become including the key take-away which came from the old marketing adage that “a satisfied patient will tell anyone who asks, whereas the unhappy patient will tell anyone who will listen.” And today, that unhappy patient can tell a million of their closest strangers how they feel via the internet.
your practice with incorrect information. Google, Judy’s Book, Facebook and all of the others will allow profiles to be set up about a practice to make sure that their listings are complete, but they could contain the wrong information.
Let’s continue our discussion about the five core principles of online reputation marketing that we started in the last article.
The second thing to do to contribute and direct the conversation is to start blogging. Here is a great statistic from Hubspot, “business blogging leads to 55 percent more website visitors.” Putting good content out on the web is like having good bait for fish, right? You’re putting something out there that is attractive to searchers, and it’s attractive to the search engines.
The five core principles of online reputation marketing that you want to remember are: 1. Listen to what your patients are saying both online and offline. 2. Contribute to the conversation by being proactive and responding quickly to comments. 3. Delight patients by exceeding expectations. Remember, everyone in your office plays a key role in delighting your patients.
Blogging is a great way to create content that shows up in the search engines and hopefully helps to bury anything that’s negative being said about you online. Once you’ve created that content, do everything that you can to make sure it reaches as many people as possible. Other ways to improve your online presence are:
4. Collect feedback, referrals, and testimonials.
1. Add social media sharing buttons throughout your blog and website.
5. Plan how you will respond before it is necessary.
2. Email the content you are writing to your patients. For example, put it in a monthly newsletter.
As promised, we’ll cover numbers 2 and 3 in this article today. You want to be proactive about making sure that there are enough positive comments about you online so that any negative reviews are counterbalanced by an overwhelming number of positive reviews. In this way, you are in better control of the conversation and can bury the negative things that are being said about you. Now, you can’t control everything that’s being said about you online, right? You have to accept that. You can do your best to delight your patients. You can do your best to try and rescue any situation that has gone wrong, as some will inevitably. Unfortunately, you’re not going to win 100 percent of these battles. It’s important that you do your best to make sure that you are adding enough content to the conversation, so that the ratio of positive to negative content that appears online about your practice is tilted in your favor. Okay, so let’s talk about some specific strategies with which to do that. One is to set up profiles in all of the key directories and networks where people are likely to post a review about you and your practice. Google+ [Google Plus] Local is the most obvious and most important one, but there are lots and lots of others out there. Yelp, Insider Pages, LinkedIn, Facebook, Twitter, SuperPages are some other options. There are so many options for posting reviews today that we can’t list them all. The list keeps growing. Unfortunately, most practices that I talk to do not proactively set up and manage profiles on all of these directories. As a result, there is the possibility that a profile exists about you and/or
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Without your knowledge, people could be posting comments about your practice. So what should you do? First, make sure that you take ownership of those profiles in the key directories and networks to allow you to manage the information that is there.
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There are many ways to publish content online but they key is to make sure that you’re creating content on a regular basis and blogging is a great way to do it. How about making educational videos and posting them to YouTube? People love videos that teach them how to do something. Here is an amazing stat from Forrester, “… any given video stands about a 50 times better chance of appearing on the first page of search results than any given text page in the index.” So Google and other search engines really love video, and there’s a reason why—because people really love video. The number of ideas for videos is endless and you’ve just got to be creative. Video is an absolutely fantastic way to get solid, positive content about your practice out there online. The third thing, and this is probably most important is to delight your customers and be easy to work with. We all instinctively understand this, right? But understanding it and doing something about it are two very different things so it's critical that you do something about it. It’s time to promote and create remarkable patient service at your practice. Hire people who enjoy providing great service and really encourage them to do so. One of the best ways to do this is to take care of your team. There have been all kinds of studies that show that happy employees equal happy patients.
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Spring 2014
Happy team members tend to smile more and go above and beyond to take care of patients. So anything that you can do to create a happy and positive culture in your practice will result in more happy patients. I understand that idea is a bit intangible. So what can you do more specifically? Establish metrics and rewards within your practice and reward the team members who are doing a great job so that you continue to promote that great patient experience. Encouraging your team to collect reviews from happy patients is also fantastic. Then share patient praise with your team so that you are enforcing a culture that promotes the idea of taking care of patients.
Dental Construction Specialists Ask us how we can save you time and money on your next office project. Phone: (303)637-0981 Web: www.bvgci.com
How about saying thank you to your patients? It's amazing how a good old-fashioned, handwritten note can go a long way. We’re all so accustomed to email and text messages that we’ve completely gotten used to poor patient follow-up. It's amazing how much you can accomplish with just a simple, handwritten note. Or, you can consider small gifts, edible arrangements or postcards. All of these things are useful tools that will foster a great feeling among your patients, better reviews and lots of personal referrals. If you’ve gotten this far then you likely have a bunch of actions to take at your office. Next time we’ll cover collecting reviews and planning responses. For now, start contributing to the online conversation and work on new ways to delight every patient that comes through your door.
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CLASSIFIEDS Meeting Space; Hands-on; Clinic for your Event The Mountain West Dental Institute is open and available for your meeting, course, study club, etc. 2 auditoriums seating up to 140, banquet hall, executive conference room and a full clinic with 4 operatories! High-tech A/V always included with recording/streaming abilities. Discounted rates for MDDS Members & Assoc. Members. Contact Jill Kingen events@mddsdentist.com or 303.488.9700 or visit mwdi.org. Sleep Apnea Diagnostic Equipment for Sale Pharyngometer, Rhinometer, 2 Embletta home sleep study units, $500 and other sleep apnea aids. SGS retail cost $26,000 but will sell for $14,000 OBO. Reply to danceattack73@hotmail.com Job Board Dental Hygienist is Available Looking for a dental hygienist with skills that are above and beyond to help grow your practice? Community College of Denver graduates are well-versed in patient education, radiology and complex patients with extensive perio needs. We also provide them with advanced skills in salivary testing, laser pocket decontamination and adjunctive oral cancer screening tools. We maintain a comprehensive list of current and former graduates that are seeking both full and part-time positions, and would love to help match your practice with the perfect hygienist. Contact Michelle Kohler at 303-365-8334 or Michelle.Kohler@ccd.edu Dentist Non-profit looking for part time Dentist to join our team. 2-3 days per week position may lead to full time opportunity. Prefer two years of experience with active license requires ability to do molar endo and surgical extractions. Ideal candidate should be a leader team player and a self-starter. E-mail resumes to a.salazar@howarddental.org Non-Profit Seeking Dentist Non-profit public health agency looking for a General Dentist to join our team 2-3 days per week. Minimum of 5 years’ experience preferred. Active license and professional liability insurance required. Must be able to do molar endo, surgical extractions, prosthodontics, and work well with senior citizens. Current Medicaid number a plus. Ideal candidate is team-oriented, motivated, and has excellent communication skills. E-mail resumes to humanresources@tchd.org Space Sharing Centennial Co General dentist located in East Centennial has a space sharing opportunity for a general dentist or specialist. Seven operatories state of the art equipment great location. To inquire please call 303-801-8148 or email gr8gjsmiles@gmail.com
Dental Office Space Highlands Ranch/Littleton Share space with specialty practice in high profile dental/medical building 2 days a week. Highlands Ranch/ Littleton. Reply to danceattack73@hotmail.com General Practices for Sale with CTC Associates: Practice listings along the Front Range in Denver (Cherry Creek), Lakewood, Aurora, Littleton, Colorado Springs, Lamar and Fort Collins. Additional opportunities in several smaller mountain towns in the southwest, west, and central parts of the state. We also have opportunities in New Mexico, Utah, Idaho, Alaska and Hawaii. For a summary of each current practice opportunity, go to www.ctc-associates.com or call Larry Chatterley and Susannah Hazelrigg at (303)795-8800. Ortho Practice for Sale with CTC Associates: New, beautiful, high tech, spacious Orthodontic practice for sale in Colorado Springs. This practice offers private consultation room, large imaging room, 5 operatories, digital imaging and paperless charts, with plenty of room to expand. Contact Marie Chatterley with CTC Associates at (303)249-0611 or marie@ctc-associates.com. Practices for Sale: Listings in Colorado: Denver, Centennial, Boulder, Arvada, Parker, Colorado Springs, South I-25 corridor, Central & Western Colorado, Grand Junction and WY & KS. For more information and listing description(s), please visit our website: www. adsprecise.com; new listings added frequently; Peter Mirabito, D.D.S., Jed Esposito, M.B.A., ADS Precise Consultants 855-461-0101. Practice Sales, Practice Appraisals, Partnerships & Buy-In’s. Announcements & Services Transition Services with CTC Associates: For more information on how to sell your practice or bring in an associate, or for information on buying a practice or associating before a buy-in or buy-out please contact Larry Chatterley and Susannah Hazelrigg at (303)795-8800 or visit our website for practice transition information and current practice opportunities www.ctc-associates.com.
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“I
own multiple locations and this is not my first lease negotiation, yet it was by far my best experience. I only wish I would have known Carr Healthcare Realty for my other negotiations, as I am sure they would have been much smoother than they were.” Landon Blatter, DMD Aspen Springs Dental
Colin Carr President
303.817.6654 colin@carrhr.com
Christian Gile Principal Denver Metro
303.960.4072 christian@carrhr.com
At Carr Healthcare Realty… We provide experienced representation and skilled negotiating for dentists’ office space needs. Whether you are purchasing, relocating, opening a new office, or renewing your existing lease, we can help you receive some of the most favorable terms and concessions available. Every lease or purchase is unique and provides substantial opportunities on which to capitalize. The slightest difference in the terms negotiated can impact your practice by hundreds of thousands of dollars. With this much at stake, expert representation and skilled negotiating are essential to level the playing field and help you receive the most favorable terms.
Roger Hernandez Colorado Springs Southern Colorado
719.339.9007 roger@carrhr.com
Kevin Schutz Boulder Northern Colorado
970.690.5869 kevin@carrhr.com
If your lease is expiring in the next 12 – 18 months, allow us to show you how we can help you capitalize on your next lease or purchase.
Lease Negotiations • Office Relocations • Lease Renewals • Purchases