THE #1 JOURNAL FOR NEW DENTISTS
Detecting
Oral Cancer Early PLUS Reduce Insurance Claim Rejections Improve Equipment Maintenance Learn the 3 Golden Rules of Occlusion SUMMER 2017
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FROM THE PUBLISHER’S DESK Dear Readers, Welcome to the Summer issue of The New Dentist™ magazine.
M
any new dentists spend a lot of time thinking about how they can attract new patients to their office. After all, that’s how you grow a young practice, right? Yes, attracting new patients is important, but those new patients won’t do you much good if they never come back. The key to success is building strong relationships with your patients. You want them to feel connected to you and your office— which makes them more likely to accept treatment as well as to refer family and friends. The goal is to keep patient retention numbers around 85 or 95 percent. Here are a few tips to help you get there: Get to know your patients. Take the time to build a rapport rather than rushing between patients as quickly as possible. Ask patients about their work and families. Talk with them about their oral health goals and address any concerns they have. Send handwritten thank you notes to new patients. They don’t take long to write but simple, personal notes can be very effective in creating connections and making your practice stand out. Thank patients who refer. Go beyond a phone call and send flowers or a fruit basket to their workplace. Not only is this a nice gesture, it will help create practice buzz. Acknowledge the parts of the visit patients dislike most. For example, most patients hate the thought of getting an injection and don’t realize there are pain-free options. To make patients more comfortable, explain your injection method and its benefits. Trust me, they’ll appreciate your efforts to make treatment as pleasant as possible. Keep in touch. Reach out in between appointments with birthday cards, articles and e-newsletters. These educational marketing efforts will help patients keep your practice and their dental health top of mind. Don’t keep them waiting. This is a sure way to lose patients to the practice down the street. To stay on schedule, communicate with your Scheduling Coordinator how much time is needed for each procedure and develop a system that helps ensure you’re never double booked. In this issue… We’ve put together articles with plenty of advice to help you connect with patients and grow your practice. Turn to page 12 to learn about the importance of oral cancer screenings and finding cancer early. Learn why insurance claims are rejected and how you can reduce the headaches these rejections cause on page 6, and take in tips from the experts on how to properly maintain your equipment on page 10. Dr. Daniel Domingue wraps up his three-part series on incorporating implants on page 8, and Dr. Jose-Luis Ruiz finishes his discussion on occlusal health in the final article of his twopart series on page 14. Dr. Lori Trost hits on the importance of life-long learning on page 18, and we introduce you to our new advisory board members on page 17. I’d also like to thank outgoing board members Drs. Bryan Basom, Katie Montgomery and Mary Shields for their service to The New Dentist™ magazine. We wish them all the best of luck in their careers.
Advisory Board
Christopher Banks, DDS Inwood, WV WVU, 2011
Rebecca Berry, DMD Oakland, ME Tufts, 2011
Julie Boerger, DMD Patchogue, NY University of Montreal, 2010
David Carter, DMD Zachary, LA University of Mississippi Medical Center, 2014
Hal Cohen, DMD Haverford, PA Temple University, 2010
Larry Dougherty, DMD San Antonio, TX Nova Southeastern, 2008
Dennis Frazee, DDS Mooresville, IN Indiana University, 2012
Lindsay M. Goss, DMD, MPH Chandler, AZ ASDOH, 2010
Erica Haskett, DDS New York, NY NYU, 2008
Crystal Johnson, DDS Powder Springs, GA University of Tennessee College of Dentistry, 2009
Aaron Layton, DDS Fort Collins, CO Indiana University, 2010
Leah Massoud, DMD Morgan Hill, CA Tufts, 2009
Michael Potter, DDS Quincy, WA University of Minnesota, 2014
Tyler Scott, DDS Loudonville, OH Ohio State, 2009
Matthew Silverstein, DMD, MPH West Hartford, CT University of Pittsburgh, 2012
Nicole Smith, DDS Newport Beach, CA NYU, 2009
Gregory Snevel, DDS Cleveland, OH Ohio State, 2011
Bryan Stimmler, DDS Brooklyn, NY University of Southern California School of Dentistry, 2009
Here to help,
Sally McKenzie, Publisher
2 THENEWDENTIST.NET S U M M E R 2 0 1 7
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TABLE OF CONTENTS
SUMMER 2017 S U M M E R 2 017 PUBLISHER
Sally McKenzie Sally@thenewdentist.net DESIGN AND PRODUCTION
Picante Creative www.picantecreative.com EDITOR
Renee Knight renee@thenewdentist.net SALES AND MARKETING
Contact Peggy Carpenter at peggy@thenewdentist.net or 877-777-6151. Visit our digital media book at www.thenewdentist.net/ mediabook.htm
12 FE AT U R ES Reduce Rejections
Copyright ©2017 The McKenzie Management Company, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without permission in writing from the publisher. Authorization to photocopy items for internal or personal use is granted by The McKenzie Management Company, LLC for libraries and other users registered with the Copyright Clearance Center.
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So, What’s it Gonna Take? 8 A Look at the Numbers Behind the Dental Implant Industry Are You Doing Enough 10 Equipment Maintenance? Detecting Oral Cancer Early The 3 Golden Rules of Occlusal Health
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14
The New Dentist™ Magazine 17 Welcomes the New Advisory Board Members Dr. Lori Trost on Lifelong Learning
The New Dentist™ magazine is published quarterly by The McKenzie Management Company, LLC (302 N. Chestnut St., Barnesville, OH 43713) on a controlled/complimentary basis to dentists in the first 10 years of practice in the United States. Single copies may be purchased for $8 U.S., $12 international (prepaid U.S. dollars only).
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18 D E PARTMENTS 2 Publisher’s Message
20 4 THENEWDENTIST.NET S U M M E R 2 0 1 7
20 Skinny on the Street 20 Index of Advertisers
Disclaimer — The New Dentist™ does not verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damages incurred by readers’ reliance on such content. The New Dentist™ cannot be held responsible for the safekeeping or return of solicited or unsolicited articles, manuscripts, photographs, illustrations, or other materials. The opinions, beliefs, and viewpoints expressed by the various authors and contributors in this magazine or on the companion website, www.thenewdentist.net, do not necessarily reflect the opinions, beliefs, and viewpoints of The New Dentist™ magazine or The McKenzie Management Company, LLC. Contact Us — Questions, comments, and letters to the editor should be sent to renee@thenewdentist.net. For advertising information, contact ads@thenewdentist.net or 877.777.6151. Visit our website at www. thenewdentist.net to download a media kit.
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Reduce Rejections By Renee Knight, Editor
Insurance claim rejections and denials can really hurt a new dental practice, costing you money as well as damaging patient relationships. Don’t just take the patient’s word for it. Remember to copy If you’re experiencing a high number of insurance insurance cards at every appointment. That way, if something rejections and denials in your practice, it’s likely is wrong on the claim, you can check the card and make the causing you plenty of problems. When insurance necessary correction. companies don’t pay submitted claims and The wrong group plan was attached to the claim. you’re forced to go through the appeals process, Never assume that because two patients work for the same it hurts your practice’s cash flow, backs company, they must have the same insurance plan, up accounts receivable and even Dr. Anderson said, because that likely isn’t TIP damages patient relationships— the case. Keep in mind these plans all have Update your software to the different maximums and waiting periods, making it very difficult for you to latest version to make sure you and attaching the wrong one guarantees grow your young practice.
have access to current dental the claim won’t be approved. codes, said Belle DuCharme, “Delta Dental of California or MinCDPMA, Senior Instructor/ nesota might have 100 different types Training Consultant for McKenzie of plans. There’s usually a group plan Management and Director of within Delta Dental that the patient is Training and CE for eAssist. This will help you avoid claim on,” Dr. Anderson said. “Even if patients denials and the cash flow work for the same company, they might problems they cause. have five or six different group plans within
This is something many dental offices struggle with, said Dr. James Anderson, CEO and founder of eAssist, with it fairly common for practices to experience insurance claim rejection rates of 25 to 30 percent—or even higher. Knowing why so many dental insurance claims are rejected or denied will help ensure yours get paid. Here’s some of the most common problems that come up and how you can avoid them.
The information in the claim doesn’t match what the insurance company has on file. These claims don’t
even reach the clearing house, with the software automatically sending out the rejection when the claim is submitted electronically, said Belle DuCharme, CDPMA, Senior Instructor/ Training Consultant for McKenzie Management and Director of Training and CE for eAssist. This could happen because the birthdate is off, the group number doesn’t match what the company has on file or the gender is wrong. These errors should be fixed right away and the claim resubmitted. Always verify patients are currently covered by insurance and that all their information is correct, Dr. Anderson said. 6 THENEWDENTIST.NET S U M M E R 2 0 1 7
that company, and that can be overlooked by the front desk person checking the patient in. It’s a mistake that happens all the time, especially if the practice experiences a lot of turnover.” The policy provisions weren’t followed. Insurance companies deny claims for many reasons, DuCharme said, and one of them is because policy provisions weren’t followed and the patient wasn’t eligible for the services provided. Maybe a policy provision states there’s a 12 month waiting period before insurance will pay for restorative work, or that insurance won’t pay for an implant if the tooth it’s replacing was extracted before the patient was covered by the plan. All too often, dental practices only get the benefits list from the insurance company and don’t take the extra step to see if any provisions in the policy would prevent a claim from
being paid, DuCharme said. So the practice, and the patient, thinks a procedure is covered when it really isn’t. The wrong code was used. This is a big problem, DuCharme said. Dental codes are added, changed and deleted every year, so if you’re not keeping up to date there’s a good chance you’re going to use the wrong code at some point— leading to a claim denial. Important information is missing. It isn’t enough to tell insurance companies what you did; you also have to tell them the how and why if you want the claim to be approved, said Tom Limoli of Limoli & Associates. Generate a claim of what you finished, and remember to include how the patient felt after the treatment and how the patient benefited. This information should be written in the chart notes and leave no question as to why the treatment was performed, Dr. Anderson said. Make sure your assistant takes detailed notes while you explain your treatment recommendations to patients, and that this information is included with the claim. Properly charting is also key. If you mark tooth No. 12 needed a crown and you really meant tooth No. 13, the claim will be rejected. “You need to make sure clinical documentation is being done the way you were taught in school,” Limoli said. “Treat the insurance company like your professor. The insurance company is holding the check like the professor held the gradebook.”
Dr. Anderson recommends following the SOAP (subjective, objective, assessment, and plan) notes method you learned in school. The insurance provider will recognize you know what you’re doing and will put more trust in your diagnosis and treatment. If your notes are messy and include spelling errors, don’t be surprised if your claims are rejected. “We call a claim that goes through from the beginning with all the necessary information and documentation a clean claim,” DuCharme said. “Insurance companies like to see clean claims and actually get to know dental offices by their claims. If they see a lot of claims that are missing information, with the wrong codes etc, they start to flag those offices and want extra documentation on every claim they send through because they know they’re sloppy.” To avoid errors, coding and clinical documentation should come from you, not the administrative staff, Limoli said. You included radiographs, but not the right ones.
Claims must include the appropriate radiographs that clearly document treatment, Dr. Anderson said. In many cases, insurance companies want to see before and afters, and will deny claims that don’t have both. Radiographs often don’t show all the necessary details, which is why Dr. Anderson recommends investing in an intraoral camera. If it’s not clear in the radiograph, even if you CONTINUED ON PAGE 19 >>
SUMMER 201 7
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So, What’s It Gonna Take? A look at the numbers behind the dental implant industry and what they mean for your practice. By Danny Domingue, DDS, FAAID, DABOI/ID
Editor’s Note: This is the final article of a three-part series about how to add implants to your practice.
C
ongratulations! You’ve decided to add implants to your practice. You have taken several courses, identified patients who would benefit from the treatment, and have placed and restored some simple, single tooth implants. You are ready to become an implant dentist. What does that mean in terms of your practice? Your staffing? Your patient mix? Your marketing? Your pricing? Your livelihood? A recent comprehensive empirical study of the practice of implant dentistry will help give you a better idea of what to expect. Here’s a quick overview of the 2016 Dental Implant Practice Benchmarking Study.
REVENUES, SALARY AND EXPENSES According to the study, implants will likely represent only about 5 to 10% of your patient visits. However, implants can possibly generate 30% or more of the revenue in your general practice. Not surprisingly, salary and benefits make up the highest percentage of a practice’s expenses—totaling as much as 38%. The average implant dentistry practice reported having between 7 and 16 staff members. The majority of implant dentistry practices consisted of one owner dentist and between two and five non-dental team members, which includes dental hygienists, front office staff, and chairside assistants. A handful of practices reported having a full-time Implant Treatment Coordinator. These team members were only found in practices that self-identified as being primarily implant-focused. The median salary paid to non-dentist staff was reported as follows: Dental hygienists $55,000 - $59,999 Front office staff $35,000 - $39,999 Chairside assistants $30,000 - $34,999 Implant treatment coordinators $40,000 - $44,999
An additional expense you will encounter is, not surprisingly, implant-specific materials. The good news? According to the 8 THENEWDENTIST.NET S U M M E R 2 0 1 7
study, this only accounted for 5% of total expenses. Laboratory fees added another 7%. The average cost for implants themselves was reported as $348. The next most expensive implant-related products were tissue grafting materials ($258), titanium mesh ($234), and bone grafting materials ($224). Less than 50% of implant dentists reported using 3D scanning and CAD/CAM in 2014. About one-third of the dentists who haven’t invested in one of these units yet plan to do so in the future. Be prepared to invest in fairly expensive equipment as your implant practice grows.
ATTRACTING PATIENTS INTERESTED IN IMPLANT DENTISTRY According to responses to the study, online marketing channels dominate the marketing and advertising landscape of implant dentistry today. Online search engine optimization (SEO) was reported as being used by 54% of respondents, social media by 51%, and online advertisements by 43%. Television and radio were used by 9% and 8% of practices respectively. Word of mouth and recommendations from current and former patients were reported by 84% of respondents as the most common ways new patients learn about the implant practice. Online search was mentioned by 60% and referrals from other dentist/doctors by 41%. CONTINUED ON PAGE 19 >>
Dr. Domingue is a Fellow of the American Academy of Implant Dentistry and a Diplomate of the American Board of Oral Implantology, the highest recognition possible for a general dentist practicing implantology. He was recognized as the youngest recipient of this certification in the world. He is the Founder and President of Acadian Southern Society, serves as Chair of AAID’s Membership Committee and is co-host of AAID’s Podcast.
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Are you doing enough
equipment maintenance? We recently spoke with experts about proper equipment maintenance. Here are their tips.
W
hen you invest in new equipment for your practice, you want that equipment to last. That’s why it’s so important to make proper maintenance part of your routine. If you haven’t already, now is the time to make daily, weekly, monthly and yearly maintenance a priority. To help you get started, we recently talked to maintenance experts from ASI Medical, Benco, DentalEZ and Burkhart Dental to get their best tips.
Tips from ASI Medical: Ideally, the dental equipment in your operatories should be inspected annually but at a minimum every five years to ensure maximum uptime during daily procedures. These areas should be included in periodic maintenance inspections of your dental delivery system: • Air Compressor. Make sure your air compressor is delivering oil-free, dry air to your equipment. A service inspection should be made to verify the dryer is removing moisture from the air lines and, if the air compressor is oil lubricated, that the coalescing filters are preventing oil droplets from entering the air stream. Oil or moisture coming out to the handpieces can damage certain components and interfere with restoration bonding. • Regulated Air Supply. Check the individual regulators in the junction box to each delivery system. These should be set to provide 80 psi to the dental unit. Excessive pressure can stretch out tubings and damage the small o-rings and gaskets in handpiece holders, control blocks and water relay valves. Check the filter on the regulator to ensure it’s clean; replace it if it’s dirty. • Dental Unit Components. The dental unit contains a number of small valves and components that use o-rings and diaphragms. As these soft components age they can begin to dry out and crack, causing leaks or issues operating the handpieces. Preventative maintenance entails replacing diaphragms and prongs or providing lubrication. The primary dental unit components to inspect include: • Foot Control. The interior valve of the foot control should be lubricated once a year. If it starts to stick or leak air, replace the o-rings inside. • Control Block. The diaphragm(s) in the control block hold back air and operate the flow of air and water to the handpieces. The diaphragms will stretch out over time or can develop small holes. These should be replaced every five years. • Water Relay Valve. The water relay opens and shuts off the water flow to the handpieces as the foot control is pressed and released. They can be serviced, but it is easier and more cost effective to replace them every five years.
10 THENEWDENTIST.NET S U M M E R 2 0 1 7
•
• •
•
Auto Handpiece Holders. The auto holders use miniature
air valves to indicate to the control block when a handpiece is removed. These valves should be lubricated every five years and replaced if they develop leaks. Air Water Syringe. Replace the button assembly and interior o-ring every five years. Handpiece Tubing. Handpiece tubings can wear from use and constant exposure to wiping with chemical disinfectants. Examine the sides of the tubing for hairline cracks or obvious wear and replace any suspect tubings. Water Lines and Bottle Systems. Most modern dental units use bottle systems. The bottles should be replaced every year because they are pressurized during use. Replace gaskets that seal the bottles annually. Verify current guidelines for maintaining water line disinfection with the equipment manufacturer to make sure you’re using the best, safest techniques.
Tips from Benco: • Listen to the manufacturer. Follow all recommendations from manufacturers and factory-trained distributors. • Have a plan. Don’t assume someone on staff is performing the required maintenance and don’t rely on just one person. Always have a backup. • Create maintenance protocols. This reduces downtime. • Plan to clean and lubricate evacuation and ejectors. Taking simple steps will reduce buildup. • Flush suction lines daily. This ensures prophy paste does not clog the vacuum system. • Clean sterilizers. Use a solution that reduces material build-up that occurs during the sterilization process. Burkhart Dental also suggests performing daily, weekly, monthly and yearly maintenance based on the type of sterilizer you have and manufacturer recommendations.
Chair maintenance tips from DentalEZ to keep chairs looking good as new: • Stay away from alcohol based cleaners. Use disinfectant wipes, but wring them out first. This helps remove all excess disinfectant so it doesn’t travel under touchpads or face plates to eat away at the plastic. • Maintain the upholstery. Wipe chairs down once a week with warm, soapy water to help remove residual disinfectants. Follow up with a furniture polish containing bees wax to help the upholstery keep its luster.
A checklist from Burkhart Dental
To help ensure your equipment is never neglected, Burkhart put together a checklist that focuses on daily, weekly monthly and annual maintenance.
Daily (morning and throughout the day)
Monthly
n Flush water through handpieces and syringe water lines. On self-
n Check or replace master water filter element and plaster trap.
n n n n n
contained water systems, fill bottles and flush. Check steam sterilizer distilled water levels and fill. Fill ultrasonic cleaner. Sterilize and lubricate handpieces, lube prophy angles, contra angles, and straight nose cones after each patient. Disinfect operatory equipment after each patient and flush handpiece waterlines. Check water level in self-contained water system bottles.
Daily (end of day) n Turn off nitrous-oxide and oxygen cylinders and/or alarm panel,
n
n n n
vacuum and air compressor systems, office master water switch delivery systems, x-rays, sterilizers, ultrasonic scalers and prophy jets. For delivery systems with self-contained water bottle systems, flush handpiece tubings, air/water syringes, ultrasonic scalers, and prophy jets with air. Allow systems to dry overnight. Drain ultrasonic cleaner and clean. Clean operatory HVE and saliva ejector tubings with vacuum line cleaners. Flush as required by manufacturer. Replace traps if necessary. Disassemble, clean and lubricate valves and o-rings on HVEs and saliva ejector valves.
Weekly n Check and/or change trap(s) on vacuum system, o-rings on handpiece
n Clean and lubricate lab handpiece and model trimmer. n Clean panoramic/ceph cassettes and intensifying screen. n Check rubber goods on analgesia systems for deterioration.
Replace if cracked or torn.
n Check controls of emergency oxygen unit and rubber goods
for deterioration.
n Check water bacteria and check and/or clean lab vacuum filter(s). n Check output intensity of curing lights with light meter. n Check and pull pressure relief valve on sterilizer. n Perform sterilizer cleaning procedures, per manufacturer.
Yearly n Change oil and air intake filters on air compressor, water filters for
vacuum system, and delivery system air and water filters.
n Check delivery system handpiece and vacuum tubing for cracks
or stiffness.
n Check intraoral x-rays for drift in tubeheads and arms and all
bushings and pins.
There’s a lot to think about when it comes to equipment maintenance. Follow these expert tips to help keep your equipment looking and operating at its best.
couplers and gaskets on handpieces.
MADE IN
U.
SUMMER 201 7
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Detecting Oral Cancer Early Why it’s so important to screen for oral cancer in your practice.
D
r. Ford Gatgens’s practice philosophy is simple: find ways to raise the level of patient care, whether that means investing in new technology or implementing strategies that make his practice more efficient. And to him, there’s no better way to do that than by actually saving a patient’s life. That’s why he invested in OralID, an adjunctive oral cancer screening device from Forward Science. OralID uses fluorescence technology to help health care professionals spot oral cancer, pre-cancer and other abnormal lesions at an earlier stage—often before they’re visible to the naked eye. The exam takes about two minutes, Dr. Gatgens said, and is an advanced oral cancer screening he offers to all his patients for free. This is important to Dr. Gatgens because he’s seen what oral cancer can do. While he knows patients who beat oral cancer that was discovered early, he also knows patients who were diagnosed late and passed away. “When I was in dental school, I don’t think they told me I would see that much oral cancer in my practicing career, but the incidence rate is on the rise,” said Dr. Gatgens, who’s been practicing for about 10 years. “We can really change the outcome of someone’s life. That’s an important, powerful message. It’s our duty to make sure we’re advocates in letting people know the risks and what’s going on out there.” While screening devices are a helpful tool, visual and palpation exams are just as beneficial—and should be performed on every patient at least once a year, said Brian Hill, stage IV oral cancer survivor and Founder/Executive Director of The Oral Cancer Foundation. These exams add about five minutes From the Advisory Board “We use VELscope as an adjunct for the hygiene staff. It promotes good oral health care delivered to patients.” -Dr. Tyler Scott
12 THENEWDENTIST.NET S U M M E R 2 0 1 7
By Renee Knight, Editor
to the appointment, but that five minutes could be a lifesaver. Whether you use an adjunctive device or choose to only perform visual exams, it’s important to make oral cancer screenings a priority in your young practice. Implementing screenings and educating patients about their risks will help build patient connections, grow your practice and, most importantly, save lives.
INCORPORATING A SCREENING DEVICE Oral cancer screening devices can help you find cancer at an early stage, but they also find everything else, including pizza burns, cheek bites and other traumas, Hill said. They detect areas in the tissue that are different, not just cancerous, so if you plan to invest in one of these lights, you’ll need to differentiate between what’s a potential problem and what’s harmless. Common abnormalities only last for about two weeks, Hill said, so it’s important to ask patients if they noticed anything before they came in for their appointment. If they say the sore has been there for a month or longer, you should refer the patient to an oral surgeon for a second opinion and to possibly perform a biopsy. If the patient didn’t know about the abnormality until you discovered it, have him or her come back in two weeks for another assessment, and then follow the appropriate steps from there. Although Dr. Gatgens chooses to offer these advanced exams for free, Hill said some dentists opt to charge a small amount, usually around $25, to make it a profit center for their practice. In many practices, the hygienist handles these exams, Forward Science Chief Executive Officer Robert Whitman said. As an incentive, he suggests giving hygienists a $5 bonus for every oral cancer exam they complete with the device. This gives hygienists, who already tend to be passionate about screening for oral cancer, more reason to complete the exam as well as to educate patients about the disease. WHAT TO DO WHEN YOU FIND AN ABNORMALITY Remember, even when you perform an exam, whether it’s visually or with a screening device, it’s not a perfect science, Hill said. You still might miss something, and that could
WHY DR. GATGENS CHOSE ORALID Dr. Gatgens wanted a device that was small, easy to use and affordable. Forward Science’s OralID comes in one piece, and he doesn’t have to worry about buying consumables—which made it easier for him to offer the advanced screening for free. This is also a benefit for new dentists, he said, who often have limited cash flow and need to be careful about where they spend their money. A growing company Forward Science manufactures all of its products in-house, President and CTO Brian Pikkula said, giving them more control over the process. The company first got its start inside Pikkula’s house, as he and Chief Executive Officer Robert Whitman worked to develop OralID. They now work out of a facility near Houston. Forward Science also offers other products, including CytID, PathID and hpvID. To learn more visit forwardscience.com. Marketing your device If you invest in an oral cancer screening device, it’s important to let current and potential patients know you have it, Forward Science Chief Executive Officer Robert Whitman said. Forward Science helps with marketing through its ID For Life Program. For a monthly fee, OralID users have access to digital marketing pieces, website content, press release templates, social media marketing assistance and a personal marketing consult, as well as other benefits. Ask questions Back of the mouth cancers are becoming more common—but they’re not as easy to see as front-of-the-mouth cancers, Hill said. That’s why it’s also important to ask patients questions about what’s going on in their mouths. If they’re starting to have a difficult time swallowing, for example, cancer could be the cause. 49,750 The approximate number of people in the U.S. who will be diagnosed with oral cancer in 2017. Source: The Oral Cancer Foundation
eventually lead to a lawsuit. Keeping detailed records and referring patients to an oral surgeon when necessary will help you avoid any legal issues. When you screen patients for cancer, note in their chart that the exam was completed as well as what you found, Hill said. If you recommend the patient comes back for a follow-up visit or if you decide to refer to an oral surgeon for a potential biopsy, note that in the chart as well. Document what the concerning area looks like and where you spotted it. Dr. Gatgens also takes photos that he includes in the chart and, in some cases, might order a cytology test to help determine if a patient needs a biopsy before he refers. If you decide it’s best to refer, have someone from your front office call and make the appointment before the patient leaves, and then note that in the chart as well, Hill said. The oral surgeon can then decide if it’s necessary to take a tissue sample and send it to an oral pathologist for biopsy. The biopsy process is easy and relatively painless, and will tell patients if they have cancer or another medical issue that requires treatment. It could even end up being nothing, but it’s vital that you take the proper steps to find out. “If you just watch and wait you own that patient’s problem,” Hill said. “Referring the patient out to get another opinion is a good self-defense and it’s also the best thing to do for the patient.”
TALKING TO PATIENTS ABOUT ORAL CANCER SCREENINGS Most patients don’t even realize they’ve had an oral cancer screening, Forward Science President & CTO Brian Pikkula said, so talking with them about it differentiates your practice. And if you use a device like OralID, it also shows you’re willing to invest in technologies that improve patient care. Dr. Gatgens and his team educate patients about the changing risk factors and the fact oral cancer isn’t just a
concern for older adults who smoke or drink heavily. HPV, which is transmitted through saliva, sexual and skin-to-skin contact, is causing an increase in oral cancer diagnosis in patients younger than 45, he said, which is something many people don’t realize. The conversation might be awkward at first, Dr. Gatgens said, but it can help you build connections with patients, as well as make them more aware of their cancer risk. “When a dental professional helps educate patients on even the simple things to look for, like red, white or black spots, they have empowered them to self-discover and self-refer, which has been fruitful in breast cancer and skin cancer. Early diagnosis of those cancers has been augmented through selfdiscovery,” Hill said. “That exists with oral cancer as well, especially ones in the front of the mouth that manifest in ways that are visible to the naked eye.”
MAKING A DIFFERENCE Making oral cancer screenings a priority, and educating patients about what you’re doing and why, will help you save lives as well as grow your practice. The screenings, whether you do them visually or incorporate a screening device, only add a few minutes to each exam but go a long way in fostering patient loyalty and maybe even referrals—not to mention the satisfaction you’ll get every time you spot cancer early and patients get the medical treatment they need before it’s too late.
Common oral cancer causes • Tobacco use • Excessive alcohol use • HPV Source: The Oral Cancer Foundation
To learn more about oral cancer and how to properly screen, visit oralcancerfoundation.org
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The 3 Golden Rules for
Occlusal Health
By Jose-Luis Ruiz, DDS
Editor’s note: This is the final article of a two-part series on occlusion.
E
xperienced dentists know that most restorative failures, as well as many post-operative problems including sensitivity, are caused by occlusal mismanagement.1, 2 We understand how important it is to manage occlusion for the longterm health of our patients’ dentition, as well as the longevity of our restorative work, yet only a small number of clinicians are active in early diagnosis and in educating patients about occlusion and occlusal disease (OD). Part 1 of this series offered a very simple and easy to implement system to diagnose and educate patients. One of the main reasons occlusion and OD management doesn’t receive the attention it deserves is because most dentists have a void in their education in regards to occlusion, and feel it is very complicated and expensive to seek education on the subject. This is expressed by Dr. Gordon Christensen, who suggests most school education, as well as many institutes, are impractical and tend to complicate and create confusion on a simple subject… yes a simple subject.3 Many traditional institutes tend to have excessively large occlusion curricula. This makes it expensive and time consuming to learn about occlusion. The multiple modules are often geared toward full-mouth rehabilitation dentistry, which is not a reality for most dentists. Early diagnosis, patient education and minimally invasive therapy can be both simple and predictable.3 Following the 3 golden rules of occlusion is a very easy way to remember the mechanical and physiological principles necessary to provide our patients with healthy and harmonious occlusion. It is very important to remember parafunctions are controlled by the CNS, thus we know an ideal occlusion will need retouched on a regular basis. This should re-enforce the need for a minimally invasive approach, versus the traditional idea that full-mouth rehabilitation with a perfect occlusion will cure a patient’s occlusal problems.
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THE 3 GOLDEN RULES OF OCCLUSION GOLDEN RULE NO. 1: Maintain bilaterally even contacts, ideally in CR.
The masticatory muscles can generate huge forces, often several hundred pounds of force per square inch,4 and for this reason having bilaterally even contacts throughout the dentition is mechanically sound. It allows for proper load distribution and is very important to a stable occlusion. When a tooth interferes with a full closure, it will trigger deflective interferences5,6,7 and cause signs of OD, such as hypersensitivity, abfractions, mobility, excessive wear or fractures, and muscle or TM pain. Posterior teeth deflections may create an occlusal avoidance pattern leading to excessive anterior tooth wear. Also, for muscles to function in coordination, teeth need to contact evenly. It is possible to induce muscle incoordination by introducing occlusal interferences as shown by Sheikholeslam and Riise.8 Additionally, although controversial in the literature, clinical experience shows occlusal interferences in the centric can trigger muscle or TM discomfort. Removing them will bring improvement of the symptoms.9 GOLDEN RULE NO. 2: Posterior teeth disclusion or anterior and canine guidance.
Anterior and canine guidance allow the immediate disclusion of molars and premolars when making lateral or protrusive movements, such as while chewing. This immediate posterior disclusion provides some important mechanical benefits, in that masticatory muscles significantly decrease activity and the amount of force applied to the anterior guiding teeth.10,11 Williamson found that when posterior teeth touch, the muscles can function with full force. When only anterior teeth touch, the forces decrease significantly.12 An additional mechanical benefit is that because the mandible works as a class III lever, the further a tooth is from the fulcrum (joint), the less force is applied to it. When a patient lacks this mechanical benefit during lateral movements, the posterior teeth grind over each other with full muscular force. It is typical to see these patients with severe signs and symptoms of occlusal disease (Figs. 1 and 2).
References
Fig. 1 The patient, who is a dentist, was in group function and had a history of fracturing teeth and restorations.
Fig. 2 Post occlusal equilibration and veneers, with proper canine guidance.
1. Ruiz JL. Achieving longevity in esthetic dentistry by proper diagnosis and management of occlusal disease. Contemporary Esthetic 2007 June; 24-27 2. Ruiz JL. Occlusal Disease; Restorative Consequences and patient education. Dentistry Today 2007 26(9):90-95 3. Christensen GJ, Ruiz JL. Interview: Restorative DentistryCurrent developments and a look in to the future. Dentistry Today 2008:Vol 27 No 2: 98-106 4. Gibb C. Mahan PE. et al. Limits of Human Bite Strength. J Prosth Dent 1986 Aug;56(2):226
Fig. 3 Severe lack of overjet leads to an envelope of function violation and severe pain, chipping and wear on tooth Nos. 8 and 9, both with a history of fractured restorations.
GOLDEN RULE NO. 3: Achieve an unobstructed envelope of function.13
During the chewing motion, the mandible doesn’t only swing laterally. It swings forward, or protrusively, during the closure movement, and returns back in to the centric stop. This is called the envelope of function. It varies from patient to patient, but Lundeen and Gibbs found the average was 0.37of a millimeter.14 The purpose of overjet is to allow space for this protrusive movement to occur without interference (Fig. 3). When the overjet is insufficient or the lingual morphology of the anterior teeth is not concave enough, an interference in the anterior path of closure will occur. The consequences of violating this principle while restoring anterior teeth are patients may complain of feeling their bite high and locked in. This often triggers parafunction activity. This interference in the path of closure may also cause a scraping of the anterior teeth and the typical wear pattern of severe “thinning” of incisal edges, or wear of the lingual surface of the maxillary anterior teeth and wear of the facial of mandibular anterior teeth (Figs. 3 and 4). It will also cause mobility, chipping and fractures. Educational
Fig. 4 Longer, more esthetic veneers fabricated with the proper overjet.
5. Dawson PE. Functional occlusion; from tmj to smile design. 2007 Mosby Chapet 1; pag 6
PHOTOS COURTESY OF DR. JOSE-LUIS RUIZ
6. Piehslinger E, Celar RM, Horejs T, Slavicek R. Recording orthopedic jaw movements. Part IV: The rotational component during mastication. Cranio. 1994 Jul;12(3):156-60
videos with great detail are available at RuizDentalSeminars.com.
7. Gibbs CH, Lundeen HC, et al. Chewing movements in relationship to border movements at first molar. J Prosth Dent 1988:46:308-322
THE IMPORTANCE OF SOUND OCCLUSION Proper management of occlusion is foundational in dentistry. Simple, early diagnosis and minimally invasive management is a “must know.” The occlusal disease management system allows for simple, early diagnosis by recognizing the 7 signs and symptoms of occlusal disease. Expending the few additional minutes to evaluate the presence of OD will permit the identification of patients whose pathological occlusion place our dental work at high risk. Knowing what a mechanically healthy bite should look like gives us a clear advantage when treating patients. Following the 3 Golden Rules of occlusion makes it possible for dentists to give patients physiologically and mechanically sound occlusion.
8. Sheikholeslam A. Riise C. Influence of experimental interfering occlusal contacts on the activity of the anterior temporal and masseter muscles. J Oral Rehab 1983; Vol. 10:207-14 9. Barker DK. Occlusal Interferences and the Temporomandibular dysfunction. 2004 General dentistry. Jan-Feb;56-62 10. Manns A. Miralles R. Influence of variation in anteroposterior occlusal contacts on electromyographic activity. J Prosthet Dent. 1989 May;61(5):617-23 11. Mann A. Chan et al. Influence of group function and canine guidance on electromyographic activity of elevator muscles. J Prosthet Dent. 1987 Apr;57(4):494-501 12. Williamson EH, Lundquist DO. Anterior guidance: Its effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent 1983;49:816-823 13. Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. Mosby, 2nd ed St Louis:CV Mosby, 1989:28-55,434-441 14. Lundeen HC, Gibbs C. The Function of Teeth. Book Masters Inc. 2005. Page 30, Library of Congress #2005930209
Dr. Ruiz is the Director of the Los Angeles Institute of Clinical Dentistry and Course Director of numerous CE Courses at University of Southern California (USC). He is Honorary Clinical Professor at Warwick University in England and member of the editorial board for Dentistry Today. He is also an Associate Instructor at Dr. Gordon Christensen PCC in Utah and an independent evaluator of dental products for CR (CRA). Dr. Ruiz was named as one of the “Leaders in CE 2006-2015” by Dentistry Today.
SUMMER 201 7
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The New Dentist™ magazine welcomes the new advisory board members The New Dentist™ magazine recently added three members to the advisory board. Advisory board members help guide our content and give us insight into the challenges new dentists face. Here’s some background on our new members and why they decided to join The New Dentist™ Team:
Dr. Crystal Johnson Dr. Johnson graduated from the University of Tennessee College of Dentistry in 2009. She worked in a small private practice before starting her own practice in 2011, which focuses on preventive care and restorative dentistry. Dr. Johnson is currently focusing on continuing education courses related to implant dentistry. She is a member of the Georgia Dental Association, American
Dental Association, and the Academy of General Dentistry. Why she joined the board: “Dentistry has so many variables and may seem daunting for many when entering this profession after graduation. I want to incite change that is positive and noticeable for new dentists—leaving a legacy that will be recurring for the next generation of dental trailblazers.”
Dr. Bryan Stimmler Dr. Stimmler graduated in 2009 from the University of Southern California School of Dentistry. After completing residency and practicing as an associate, he started a private practice in Brooklyn, NY, which focuses on complete care and cosmetic dentistry. Why he joined the board: “I enjoy collaboration and challenge, and
believe that by collaborating with others wishing to stay on the leading edge we can make each other, and the readers, better.”
Dr. David Carter David Carter, DMD, is a 2014 graduate of the University of Miss. Medical Center. After graduation, he completed a General Practice Residency at Louisiana State University Health Science Center. Currently, he is in the first year of his startup practice in Zachary, LA, where he practices beside his wife, Dr. Adriane White, an orthodontist. Dr. Carter is also a Captain in the Miss. Army National Guard. Why he joined the board: “My perspective is unique as a new business owner, newlywed and as an officer in the military. I believe my experiences will help advise for the best content to be presented to the young doctors and new practice owners.”
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www.vivalearning.com SUMMER 201 7
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BEEN THERE, Done That
Key Opinion Leader Dr. Lori Trost on becoming a lifelong learner.
D
r. Lori Trost knew from a very young age that she wanted to become a dentist. Her dad, who was a teacher, worked as a master carpenter during the summer months, and spending time with him as he practiced his craft helped Dr. Trost learn how to build, conceptualize, create a plan and work with her hands. Her intelligent and kind female pediatrician also inspired her, and the combination of these two influences in her life led her to a career in dentistry. She’s been a clinician for nearly 30 years now and said the best advice she has for new dentists is this: commit to becoming a lifelong learner. “Education keeps you current and excited about dentistry,” Dr. Trost said. “It also helps you attract the right kind of team members who will help you attract the right kind of patients. If you stay current with CE you can never go wrong.” While it’s important to stay up-todate on the latest technologies, techniques and materials the industry has to offer, Dr. Trost said dentists also should become students of the business. They just aren’t taught enough about the business side of owning a dental practice while in school, making it vital to seek out this education after graduation. No matter how talented you are clinically, you’re bound to struggle if you ignore the fact that you’re a business owner as well as a dentist. Surrounding yourself with good people is also key to establishing a successful practice, Dr. Trost said, as is finding a mentor who can help guide you. It’s easy for dentists to isolate themselves, so 18 THENEWDENTIST.NET S U M M E R 2 0 1 7
Products Dr. Trost can’t live without:
make an effort even more attractive option Omnicam from to connect with to patients looking for a new Dentsply Sirona colleagues early dental home. on. Join asso“Customer service and Traxodent from ciations like team building fall under a Premier Dental the American good leader, and you need Dental Assoboth of those elements to SureFil SDR bulk fill from ciation and have an exceptional pracDentsply Sirona the American tice,” Dr. Trost said. “When Academy of you’re a good leader, you Prime&Bond Elect General Dentistry at both the have better relationships Universal Adhesive local and national levels. You and better communication. from Dentsply Sirona can network with new and Team members will want to experienced dentists through come to work rather than Ceramir for Implant these professional societies, feel like they have to come cementation and might even find a mentor to work. They’ll want to crefrom Doxa who can serve as a sounding ate smiles and improve oral board and give you direction as health. That makes a huge Calibra Universal you begin your career. difference.” for most indirect “Remember your mentor Dr. Trost also suggests restoration doesn’t have to be a dentist,” investing in quality products. cementation from Dr. Trost said. “In my case, Using the best products posDenstply Sirona my mentor was my CPA. I sible provides predictability have a 35-year plus working and successful outcomes, and relationship with him. A mentor can that ultimately equates to patient satisfacreally help you take the right steps to tion. No matter what products or techbecome a better professional. And it niques you use, remain open to different will help you attract the right team if possibilities and never assume you know you have a good mentor.” what your patients want. Educate your Strong leadership skills will also patients, present every treatment option help you hire and keep quality team and then let them make the decision. And members, Dr. Trost said. When you’re when you make a mistake—which of a good leader, team members buy into course you will along the way—don’t be your vision and are more motivated afraid to admit it. Learn from your mistakes to excel. They’re also in a much better and use them as an opportunity to grow position to provide the top-notch care your practice and to grow as a dentist. patients expect when they visit your “Try to remain humble,” Dr. Trost said. office. If you take on leadership roles “That’s a huge quality we tend to lose sight in your community as well, you’ll of today. When you get down to it we’re all increase your visibility and become an really the same. We’re all human.”
Dr. Lori Trost received her DMD from Southern Illinois University and established Smiles of Distinction, a comprehensive restorative dental practice in Columbia, IL. She offers postgraduate courses to dentists and their team members on topics ranging from restorative and implant dentistry to minor tooth movement and digital technology to business management, communication, and office efficiency. She is a nationally recognized dental educator, author, and Shils Foundation recipient who brings a practical approach to patient care. You can contact Dr. Trost at trost@htc.net
Insurance continued from page 7
HOW TO AVOID DENIED CLAIMS describe the problem in detail in your Proper training, making sure the narrative, there’s a chance the claim will team member responsible for submitbe denied. When you include intraoral ting claims has the right skill set and images, you’ll see your denial rate drop. temperament to handle the job, and following the right protocols are all ways to avoid denied claims and the WHAT TO DO WHEN A CLAIM headaches they cause. You also can IS DENIED create a checklist to go through before When this happens, you have the claims are submitted, as well as have right to appeal, but there’s a time limit, the team member track and report how DuCharme said, and that’s usually a many rejections are received each day. year—though it could be less. You must Companies like eAssist also can determine why the claim was rejected help, DuCharme said. Its Dental and then gather the missing informaInsurance Billing Service works to tion before you can resubmit. Keep in collect the insurance money offices mind this resets the clock for the claim are owed and to keep insurance to be paid once it is approved, meaning account balances over 90 days old to it could be months before you see that a minimum. They review any rejected money. And sometimes the denial is or denied claims to fix any problems set aside and forgotten, and the appeal and get the claim paid. This never gets submitted. frees up team members Many practices will TIP to focus on other appeal the claim once areas of the pracor twice before If you’re replacing a crown or filling on a patient, it’s important tice, whether sending the bill that you know how old that crown that’s marketto the patient, or filling is, said Dr. James Anderson, ing, improvwhile others bill CEO and founder of eAssist. Most ing patient the patient right insurance companies won’t pay the communicaaway, DuCharme claim if the restoration isn’t at least tion or case said. This could five years old. Be sure to check that presentation. damage your before completing the procedure and to put the restoration’s “eAssist relationship with age in the narrative. sends out the your patients. They claims, does all the won’t be happy with the attachments, gets the additional charge, especially clinical notes and makes sure if you didn’t explain to them the claims are sent out clean so they get initial quote was an estimate that could paid,” she said. “If they’re not paid, change, depending on what their insurthey can write a good appeal.” ance covers. This is key for new dentists who “And if insurance eventually pays, have a lot of debt to pay off, DuCharme you have a credibility issue,” Dr. Andersaid. They need cash flow right away son said. “Patients know when a claim is so they can focus on building their rejected. They get a copy of the explapractice; they shouldn’t have to worry nation of benefits that says there was a about why insurance claims aren’t getrejection and why. If it says the treatment ting paid. wasn’t necessary, who is the patient going “If dentists file clean claims, they to believe, the new dentist or the insurget paid in a timely manner for the work ance company? You’d think they would believe the dentist because you’re a health they do,” she said. “That gives practices a good cash flow and less claims to care provider and they’re not paying you appeal. And you have happy patients money every month, but they tend to believe the insurance company. Now they because they don’t have to pay any unnecessary money out of pocket.” don’t trust you and your diagnosis skills.”
Implants continued from page 8
WHO OFFERS IMPLANT DENTISTRY More than three quarters of survey respondents were general dentists or dentists who exclusively provide implant dentistry services. The balance was specialists in the fields of prosthodontics (10%), oral/ maxillofacial surgery (5%) and periodontics (4%). Be prepared to offer both phases of implant dentistry — surgical and restorative. Nearly three-quarters of respondents provided both phases to their patients. When compared to the average general dentist’s net income, your livelihood will increase by at least 9% by adding dental implants to your practice.1 General members of the American Academy of Implant Dentistry reported a 43% differential. Those who earned a credential from the American Academy of Implant Dentistry reported a 66% increase over the average general dentist. GET THE STUDY A copy of the full study, titled “2016 Dental Implant Practice Benchmarking Study,”2 is available from the American Academy of Implant Dentistry. The 68-page study normally costs $395. I have arranged for readers of The New Dentist™ magazine to be able to purchase the study for $199. Simply use DANNY-17 as a promo code to receive the discount. You can order online at aaid.com/benchmark or contact the American Academy of Implant Dentistry by phone (312-335-1550) or email (info@ aaid.com). The first 25 dentists who order the study will receive both a printed version and a downloadable pdf. References 1. “Health Policy Institute reports dentists’ earning as stagnant;” ADA News; January 11, 2016 2. In 2015, the American Academy of Implant Dentistry commissioned McKinley Advisors, an independent research firm, to conduct the first comprehensive study of implant dentistry practice in the United States. The study asked approximately 10,000 practicing implant dentists about their actual revenue, expenses, and practice management/ marketing for the year 2014. Responses were received from more than 5% of those contacted.
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SKINNY
on the Street
The latest news on products and services for new dentists and their practices ImplantPro® Titanium Probes Brasseler USA® recently expanded its ImplantPro® family of products with new ImplantPro® Titanium Probes. A reliable alternative to plastic probes, ImplantPro Titanium Probes are ideal for use on implants and natural dentition. ImplantPro Titanium Probes feature precise, black markings on a smooth surface for a gentle diagnostic evaluation and improved patient comfort. ImplantPro Titanium Probes are made from non-heat-treated 6Al-4V titanium, keeping the Rockwell C hardness at a low 25-31 HRC and comparable to most implant abutments, then coated in bright zirconium nitride for optimal color contrast. All feature Brasseler’s distinctive, lightweight PEEK (Polyether Ether Ketone) handles for ergonomics. For more information visit BrasselerUSA.com or call 800-841-4522.
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Kidz Seal™ pit and fissure sealant from Taub Dental can be used in either a dry or wet field. Its viscosity and self-leveling features allow the proper association to enamel, creating exceptional marginal integrity. The sealant is self-leveling/self-adjusting, tooth integrating and offers adhesion. It does not allow microleakage. Kidz Seal™ also eliminates the need for occlusal adjusting and offers a color verification system. This system allows sealant program monitors to quickly and accurately record/document placed sealants for community health centers and schoolbased programs. Kidz Seal™ has been developed to increase retention rates for public health sealant programs, CHC programs, school-based programs, pediatric and family dentistry. The long-lasting durable pit and fissure sealant is available in packages of four 1.2 ml syringes and 20 tips, and CHC bulk packaging. For more information visit taubdental.com or call 800-828-2634.
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