Florida
Dental
Association
TODAY’S FDA % LED 7 I . F 4 1 LS LAW IL E B M 3 OF ECA 201 B in
2013 FLORIDA LEGISLATIVE SESSION 272 BILLS SIGNED BY GOVERNOR
286 BILLS PASS BOTH HOUSES
532 BILLS PASS ONE HOUSE
Legislative Issue ? ? ?
Your Legislators ISSUES WATCH 1,848 BILLS FILED
lcd Profiles How a Bill Becomes a Law
VOL. 26, NO. 1 january/february 2014 VOL. 26, NO. 1 JANUARY/FEBRUARY 2014
WE KNOW disability iNcOmE prOtEctiON. WE KNOW dENtists.
Insuring your most valuable asset, your ability to earn income. What would happen if you became disabled? Disability insurance protects your income and provides an important benefit for your financial future.
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D % 7 FILE . 14 LS LAW L BI ME 3 OF ECA 201 B in
2013 FLORIDA LEGISLATIVE SESSION 272 BILLS SIGNED BY GOVERNOR
286 BILLS PASS BOTH HOUSES
532 BILLS PASS ONE HOUSE
contents cover story
42
How an FDA Idea Becomes Law
1,848 BILLS FILED
news
literary
12 news@fda
70 Letters to the Editor
19 FDA Submits Letter to AHCA
77 Book Review
20 Take it or Leave it
columns
features
3 Staff Roster
22 What Do I Do?
5
25 Yesterday I Couldn’t Even Spell LCD, and Today I am One
6 Legal Notes
27 For LCDs, Relationships are the Key 29 FLA-MOM Needs Volunteers! 30 FNDC2014 Speaker Preview — Laura Jamison
President’s Message
11 Information Bytes 47 Diagnostic Discussion 64 Dental Staff: A Hygienist Everyone Can Admire 80 Off the Cusp
32 FNDC2014 Speaker Preview — Dr. David Beach 38 New GAO Staffers
classifieds
53 Composite Resin
72 Listings
58 The Restorative Cycle in Dentistry 67 Health Care Reform: FAQ Updated! 68 FNDC2014 Exhibitors
Read this issue on our website at:
www.floridadental.org.
www.floridadental.org
Today’s FDA is a member publication of the American Association of Dental Editors and the Florida Magazine Association.
January/February 2014
Today's FDA
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florida dental assocIation january/february 2014 VOL. 26, NO. 1
Accelerate
your proFeSSional groWth MiaMi Winter Meeting
Feb. 21-22, 2014 • Jungle Island, Miami Speaker: Dr. Jose-Luis Ruiz www.sfdda.org • 305.667.3647 • sfdda@sfdda.org
nWDDa annual Meeting
Feb. 21-22, 2014 • The Grand at Sandestin Resort Speakers: Dr. Alex Fleury – New Dimensions in Endodontics; Dr. Joe Steven Jr. – Efficient Dentistry www.nwdda.org • 850.391.9310 • nwdda@nwdda.org
aCDDa Winter Meeting
FRIday, Feb. 28, 2014 embassy Suites, West Palm beach Speakers: Rita Zamora & Dr. Michael Ragan – Marketing Your Dental Practice with Facebook & Social Media www.acdda.org • 561.968.7714 • acdda@aol.com
CFDDa annual Meeting
FRIday, MaRch 14, 2014 Weston Lake Mary Orlando North Continuing Education Session with Dr. John Burgess www.cfdda.org • 407.898.3481 lindaannelowell@gmail.com
neDDa/JDS/CCDS Continuing eDuCation
FRIday, MaRch 21, 2014 Tournament of Players championship clubhouse Hot Topics in Aesthetic and Restorative Dentistry with David S. Hornbrook, DDS, FAACD www.nedda.org • 904.737.7545 • ddeville@nedda.org
CFDDa iSlanD getaWay
April 24-27, 2014 • Puerto Rico Great Times, Great Profession “Let’s Make Memories”
WCDDa 2014 SuMMer Meeting
Aug. 8-10, 2014 • ritz-CArlton nAples, Fl For a complete listing, Nine hours of continuing education credit go to www.floridadental.org/fda-master-calendar.aspx. www.wcdental.org • 813.654.2500 • wc.dental@gte.net For a complete listing, go to www.floridadental.org/fda-master-calendar.aspx.
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Today's FDA
January/February 2014
editor Dr. John Paul, Lakeland, editor
staff Jill Runyan, publications manager • Jessica Lauria, publications coordinator Lynne Knight, marketing coordinator
council on communications Dr. Thomas Reinhart, Tampa, chairman Dr. Roger Robinson Jr., Jacksonville, vice chairman Dr. Richard Huot, Vero Beach • Dr. Scott Jackson, Ocala Dr. Marc Anthony Limosani, Miami • Dr. Jeff Ottley, Milton Dr. Jeannette Hall, Miami, trustee liaison • Dr. John Paul, editor
board of trustees Dr. Terry Buckenheimer, Tampa, president Dr. Richard Stevenson, Jacksonville, president-elect Dr. Ralph Attanasi, Delray Beach, first vice president Dr. William D'Aiuto, Longwood, second vice president Dr. Michael D. Eggnatz, Weston, secretary Dr. Kim Jernigan, Pensacola, immediate past president Drew Eason, Tallahassee, executive director Dr. David Boden, Port St. Lucie • Dr. Jorge Centurion, Miami Dr. Stephen Cochran, Jacksonville • Dr. Lee Cohen, Palm Beach Gardens Dr. Don Erbes, Gainesville • Dr. Don Ilkka, Leesburg • Dr. Jolene Paramore, Panama City Dr. Rudy Liddell, Brandon • Dr. Tom Ward, Miami Dr. Ethan Pansick, Delray Beach, speaker of the house Dr. Paul Miller, New Port Richey, treasurer • Dr. Bryan Marshall, Weekiwachee, treasurer-elect Dr. John Paul, Lakeland, editor
publishing information Today’s FDA (ISSN 1048-5317/USPS 004-666) is published bi-monthly, plus one special issue, by the Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. FDA membership dues include a $10 subscription to Today’s FDA. Non-member subscriptions are $150 per year; foreign, $188. Periodical postage paid at Tallahassee, Fla. and additional entry offices. Copyright 2014 Florida Dental Association. All rights reserved. Today’s FDA is a refereed publication. POSTMASTER: Please send form 3579 for returns and changes of address to Today’s FDA, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.
editorial and advertising policies Editorial and advertising copy are carefully reviewed, but publication in this journal does not necessarily imply that the Florida Dental Association endorses any products or services that are advertised, unless the advertisement specifically says so. Similarly, views and conclusions expressed in editorials, commentaries and/or news columns or articles that are published in the journal are those of the authors and not necessarily those of the editors, staff, officials, Board of Trustees or members of the Florida Dental Association.
editorial contact information All Today’s FDA editorial correspondence should be sent to Dr. John Paul, Today’s FDA Editor, Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. FDA office numbers: 800.877.9922, 850. 681.3629; fax 850.681.0116; email address, fda@floridadental.org; website address, www.floridadental.org.
Advertising Information For display advertising information, contact: Jill Runyan at jrunyan@floridadental.org or 800.877.9922, Ext. 7113 Advertising must be paid in advance. For classified advertising information, contact: Jessica Lauria at jlauria@floridadental.org or 800.977.9922, Ext. 7115.
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Contact the FDA Office
800.877.9922 or 850.681.3629 1111 E. Tennessee St. • Tallahassee, FL 32308
The last four digits of the telephone number are the extension for that staff member.
Executive Office Drew Eason, Executive Director deason@floridadental.org 850.350.7109 Rusty Payton, Chief Operating Officer rpayton@floridadental.org 850.350.7117 Graham Nicol, Chief Legal Officer gnicol@floridadental.org 850.350.7118 Judy Stone, Agency Relations Manager jstone@floridadental.org 850.350.7123
Accounting Jack Moore, Chief Financial Officer jmoore@floridadental.org 850.350.7137 Leona Boutwell, Bookkeeper – FDHF & A/R lboutwell@floridadental.org 850.350.7138 Deanne Foy, Bookkeeper – PAC & Special Projects dfoy@floridadental.org 850.350.7165
Florida National Dental Convention (FNDC) Crissy Tallman, FNDC Convention Manager ctallman@floridadental.org 850.350.7105 Elizabeth Bassett, FNDC Exhibits Planner ebassett@floridadental.org 850.350.7108 Ashley Liveoak, FNDC Meeting Assistant aliveoak@floridadental.org 850.350.7106 Mary Weldon, FNDC Program Coordinator mweldon@floridadental.org 850.350.7103
Governmental Affairs Joe Anne Hart, Director of Governmental Affairs jahart@floridadental.org 850.350.7205 Alexandra Abboud, Governmental Affairs Coordinator aabboud@floridadental.org 850.350.7204 Casey Stoutamire, Lobbyist cstoutamire@floridadental.org 850.350.7202
Tammy McGhin, Payroll & Property Coordinator tmcghin@floridadental.org 850.350.7139
Ron Watson, Lobbyist rwatson@floridadental.org 850.350.7203
Mable Patterson, Bookkeeper – A/P mpatterson@floridadental.org 850.350.7104
Information Systems
Communications and Marketing
Larry Darnell, Director of Information Systems ldarnell@floridadental.org 850.350.7102
Jill Runyan, Publications Manager jrunyan@floridadental.org 850.350.7113
Lisa Cox, Database Administrator lcox@floridadental.org 850.350.7163
Lynne Knight, Marketing Coordinator lknight@floridadental.org 850.350.7112
Ron Idol, Network Systems Administrator ridol@floridadental.org 850.350.7153
Jessica Lauria, Publications Coordinator jlauria@floridadental.org 850.350.7115
Florida Dental Health Foundation (FDHF) Stefanie Dedmon, Coordinator of Foundation Affairs sdedmon@floridadental.org 850.350.7161
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Member relations Kerry Gómez-Ríos, Director of Member Relations kgomez-rios@floridadental.org 850.350.7121
Kaitlin Alford, Member Relations Assistant kalford@floridadental.org 850.350.7100
Josh Freeland, Membership Assistant jfreeland@floridadental.org 850.350.7111
Christine Mortham, Membership Concierge cmortham@floridadental.org 850.350.7136
Sandy Merrill, Membership Coordinator smerrill@floridadental.org 850.350.7110
FDA Services 800.877.7597 or 850.681.2996 1113 E. Tennessee St., Ste. 200 Tallahassee, FL 32308 Group & Individual Health • Medicare Supplement • Life Insurance Disability Income • Long-term Care • Annuities • Professional Liability Office Package • Workers’ Compensation • Auto Scott Ruthstrom, Chief Operating Officer scott.ruthstrom@fdaservices.com 850.350.7146 Carrie Millar, Membership Services Manager carrie.millar@fdaservices.com 850.350.7155 Carol Gaskins, Assistant Membership Services Manager carol.gaskins@fdaservices.com 850.350.7159
Porschie Biggins, Membership Services Representative pbiggins@fdaservices.com 850-350-7149
risk experts
Debbie Lane, Assistant Membership Services Manager debbie.lane@fdaservices.com 850.350.7157 Allen Johnson, Support Services Supervisor allen.johnson@fdaservices.com 850.350.7140 Angela Robinson, Customer Service Representative angela.robinson@fdaservices.com 850.350.7156 Jamie Chason, Commissions Coordinator jamie.peddie@fdaservices.com 850.350.7142 Kristen Barrett, Membership Services Representative kristen.barrett@fdaservices.com 850.350.7171 Marcia Dutton, Administrative Assistant marcia.dutton@fdaservices.com 850.350.7145 Maria Brooks, Membership Services Representative maria.brooks@fdaservices.com 850.350.7144 Nicole White, Membership Services Representative nicole.white@fdaservices.com 850.350.7151 Pamela Monahan, Commissions Coordinator pamela.monahan@fdaservices.com 850.350.7141
January/February 2014
Dan Zottoli Atlantic Coast District Insurance Representative 561.791.7744 Cell: 561.601.5363 dan.zottoli@fdaservices.com
Dennis Head Central Florida District Insurance Representative 877.843.0921 (toll free) Cell: 407.927.5472 dennis.head@fdaservices.com
Joe Dukes Northeast & Northwest Insurance Representative 850.350.7154 Cell: 850.766.9303 joe.dukes@fdaservices.com
Joseph Perretti South Florida District Insurance Representative 305.665.0455 Cell: 305.721.9196 joe.perretti@fdaservices.com
Rick D’Angelo West Coast District Insurance Representative 813.475.6948 Cell: 813.267.2572 rick.dangelo@fdaservices.com
Today's FDA
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President’s message Terry Buckenheimer, DMD
Won’t You Be a Strong Advocate for the Dental Profession? When members are asked what benefits add value to their membership, many respond with, “Advocacy.” The relentless pursuit of protecting the Dental Practice Act in our state is one of the Florida Dental Association’s (FDA) primary goals. The FDA and its accomplished team of lobbyists; Joe Anne Hart, Ron Watson and Casey Stoutamire, work to further the ability of dentists to provide quality care to all who seek it. They do the “behind the scenes” work that many of us are not able or willing to do. It is a full-time job that requires constant monitoring and positioning prior to, during and after the Legislative Session. There are many influences on the dental profession from outside agencies, groups and non-dental foundations. Legislators are often bombarded with information from these groups that does not depict the same views that our member dentists have. The dentists’ perspective needs to be expressed to these legislators so that their vote on these issues will reflect a more positive view on dentistry. This is where the Legislative Contact Dentists (LCDs) play a significant role.
www.floridadental.org
LCDs are dentists who maintain a relationship with a legislator back home in their local district. They are the primary contact of the legislator and their staff regarding dental issues, and can educate them on the specifics of these issues. Hearing how a bill affects the practice of a constituent dentist and the treatment of their patients is powerful. This issue of Today’s FDA provides details on how you can get involved as an LCD. Another effective way for members to get involved is to participate in the FDA’s Dentists’ Day on the Hill (DDOH) on April 2, 2014 in Tallahassee. FDA dentists will gather in the capital city on the evening of April 1 to hear an update on issues that have an impact on dentistry. A unified voice from the majority of dentists in the state can be an effective force. This is one of the major reasons why our membership numbers must increase. Won’t you be a strong advocate for our profession? Sitting back and voicing frustration gets no results — rally behind one of the bills that you feel passionate about or have a particular interest in. Our non-covered services legislation is gathering momentum against the unfair practices of the in-
surance industry to set fees for services that their plans do not cover. This bill is passing swiftly through the Senate Committees but has difficulty in the House. Get your representative to co-sponsor our bill and be a positive influence in the passage of this piece of legislation. This year, DDOH will occur the week immediately following our first Mission of Mercy (MOM) event in our state. The MOM event will be held in Tampa on March 28-29, 2014 at the State Fairgrounds and will positively reflect on the desire and willingness of the dental profession to help those desperately in need of care. All those in attendance at DDOH will be able to promote to their legislators the positive impact dentists have in their communities! I look forward to standing beside you to make a difference!
Dr. Buckenheimer is the FDA president. He can be reached at tlbdmd1@gmail.com.
January/February 2014
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Legal Notes
FDA Peer Review Protects You While Conforming to Florida Law Graham Nicol, Esq.,
Health Care Risk Manager, Board Certified Specialist (Health Law)
Recently, a member wrote in response to an info@fda article about peer review: “I was involved with peer review in New Jersey. The system here is very different. I would have expected some uniformity within the ADA [American Dental Association] guidelines. In New Jersey, the decision is binding on both parties, and the patient gives up their rights to legal action when both parties enter peer review.” This has brought about an excellent discussion topic on an important member benefit, the Florida Dental Association’s (FDA) Peer Review Program. I worked with the FDA’s Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in creating the Peer Review manual. The FDA’s program departs from the ADA guidelines in order to comply with Florida law regarding discoverability and admissibility, which is quite different than that of federal law. Also, the 6
Today's FDA
FDA’s program is unique in that it is designed to avoid reporting of properly filed “patient mediation requests” to the federal National Practitioner Data Bank (NPDB). The Florida forms were, for example, customized to prohibit the patient who files the mediation request from putting anything in writing requesting a payment based on an allegation of poor quality care. The Florida forms prohibit interlineation (where a patient can write in something on the form that may trigger the FDA to report to the Florida Board of Dentistry or the NPDB). As another example of the Florida program not following the ADA guidelines, the FDA’s forms include a release of liability of both the association (component, affiliate or FDA) and the individual dentists participating in the Peer Review Program. The departures from the ADA guidelines add value to FDA membership. It is great to see such interest in one of the FDA’s most important — but often overlooked — membership programs: peer review. The FDA sponsors a training program for Peer Review volunteers or those just thinking about becoming more involved. If you are interested in having the FDA present a Peer Review training workshop, please contact your component dental association and request one. The FDA has a limited
January/February 2014
amount of funding to conduct Peer Review workshops, which also provide one hour of free continuing education for dentists who attend. The second part of the question asked if the FDA program ensures that, once a settlement is reached and actually funded by the dentist, it is legally binding against the (hopefully by this time, former) patient. Under Florida law, a release of liability, like any other contract, must be supported by what lawyers call “consideration.” In the context of peer review, consideration means that you have actually funded the settlement. In other words, the release paperwork — even if signed by the patient — is not valid until after the settlement has been funded. Importantly, the FDA Peer Review chair will not enter into a settlement with the patient unless the FDA member-dentist approves it. In almost every case that is mediated, the settlement amounts to a full (or partial) refund of fees previously paid. Once your component dental association receives the settlement amount, they make sure the patient signs the paperwork. Your association will not release the funds until after the patient signs the appropriate paperwork (also known as a “release of liability”). Having your component dental association deal www.floridadental.org
Legal Notes with the paperwork allows you to avoid disruption to your practice. This can be a great member benefit when dealing with disgruntled, perhaps even unreasonable, patients. As a member, you and your front office staff are relieved from any obligation to ask the patient for his or her signature on the release. Also, as an FDA member, you will be given the signed original document and be reminded to treat it with equal dignity as part of that patient’s dental records. You never want to lose or destroy a liability release form until after the statute of repose has expired! The third part of the member’s question was, assuming the settlement is funded and the patient signs the release of liability form, does that mean the patient gives up their right to legal action? Without getting too technical, the patient may
still, in theory, sue you in civil court, but in practice it is unlikely. You (or your lawyer) would then have to introduce the signed (and funded) release of liability paperwork as evidence in support of your motion to dismiss and/or for summary judgment. That’s why FDA members are given the original release and reminded to keep it with the patient’s record. Importantly, the FDA release form will protect your personal financial assets as well as your practice and its employees. Make sure you are personally named as an individual on the form as well as your business entity. If you are unincorporated, you will not have a business entity but most dentists choose a professional services corporation (either a PA or an LLC) as their business organization. In that instance, the release would read “John Smith, DDS” and “Dental office
of John Smith, PA.” The reason you want yourself, your business organization and your employees included in the release is so that one does not get sued in lieu of (or in addition to) the others. The FDA is proud of its Peer Review Program. It helps members to avoid Board of Dentistry complaints and costly civil litigation. The FDA wants you to succeed in your professional practice and Peer Review helps you to do exactly that. This article is for informational purposes only and is not intended to be a substitute for professional legal advice. If you have a specific concern or need legal advice regarding your dental practice, you should contact a qualified attorney. Graham Nicol is the FDA’s Chief Legal Counsel
mediation makes sense with the FDA Peer review Mediation Program MEDIATION VS. LITIGATION The Peer Review Mediation Program settles disagreements between patients and dentists more economically and efficiently than the legal system and is available only to FDA members. This program is free of charge. Only cases involving problems with actual treatment and procedures are eligible for mediation. Mediation takes place at the local level, so problems can be resolved more effectively.
FOr MOrE INFOrMATION
about the FDA Peer review Mediation Program 800.877.9922 • fda@floridadental.org www.floridadental.org/peer-review
www.floridadental.org
Cases not eligible for the program include: malpractice litigation; formal regulatory investigations; disputes over dental fees; treatment that occurred more than 12 months before the patient’s last appointment with the dentist; and cases involving dentists who are not FDA members.
January/February 2014
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Legal Notes
HIPAA Risks for Florida Dentists: Windows XP, Copiers and Mobile Devices Graham Nicol, Esq.,
Health Care Risk Manager, Board Certified Specialist (Health Law)
The following situation is a true story: In December 2009, two laptops were stolen from a Covered Entity in Gainesville, Fla. The laptops contained sensitive patient records, which included protected health information (PHI), Social Security numbers, names, addresses and phone numbers. The Covered Entity did not take care to secure these laptops, so when they were stolen, the unencrypted information was readily accessible. The laptops were sold to an individual with a history of dealing in stolen property. The laptops contained personal information of Juana Curry and William Moore. Curry’s sensitive information was used by an unknown third party in October 2010 — 10 months after the laptop theft. Bank of America accounts were opened in Curry’s name, credit cards were activated and the cards were used to make unauthorized purchases. Curry’s home address was also changed with the U.S. Postal Service. Moore’s sensitive information was used by an unknown third party in February 2011 — 14 months after the laptop theft. At that time, an account was opened in Moore’s name with E*TRADE Financial, and in April 2011, Moore was notified that the account had been overdrawn. Curry and Moore sued the Covered Entity for negligence, negligence per se,
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January/February 2014
breach of contract, breach of implied contract, breach of the implied covenant of good faith and fair dealing, and breach of fiduciary duty. In Resnick v. Avmed Inc., 693 F.3d 1317 (11th Cir., 2012), the facts of which are quoted above, the 11th Circuit Court of Appeals ruled under Florida law that the claims should proceed against the Covered Entity. The Resnick case shows that Florida plaintiffs’ lawyers now view the federal standard, even though it does not authorize a private cause of action, as a de facto minimum standard of care for patients. In other words, if you fail to protect PHI in Florida in violation of HIPAA, expect your patients to sue. In Resnick, identity theft that caused significant financial damage to patients was involved, but Florida dentists should be aware that courts from other jurisdictions have ruled that even the threat of future identity theft, without an actual financial loss by the patients effected, is a sufficient basis for a lawsuit. See, e.g., Krottner v. Starbucks Corp., 628 F.3d 1139, 1142–43 (9th Cir.2010) (finding an injury in fact where plaintiffs alleged a data breach and threat of identity theft, but no actual identity theft); and Pisciotta v. Old Nat’l Bancorp, 499 F.3d 629, 634 (7th Cir.2007) (same). If civil liability risk is not enough to focus your attention, think about this: The U.S. Department of Health and Human Services, Office of Civil Rights (HHSOCR) is now actively enforcing the
federal Health Insurance Portability and Accountability Act (HIPAA), and the federal Health Information Technology for Economic and Clinical Health Act (HITECH). Florida law applies to all dentists and federal HIPAA-HITECH applies to Covered Entities and their Business Associates. Previously, HHS-OCR responded to complaints but now they audit. So if PHI is improperly used or disclosed, in addition to getting sued by your patients, expect the federal government to investigate and prosecute. Further, under the new Omnibus Rule, unauthorized use or disclosure of PHI is now presumed to be a data breach requiring the Covered Entity to notify and mitigate the damage caused by their negligence. Depending on the size and frequency of the data breach, you may be legally required to notify HHS-OCR, notify the individual patients affected and further announce the data breach to the public in the local newspaper. Mitigation means you may have to pay for credit protection services or refund money stolen by third parties from your (by now, former) patients. Adverse publicity, mandatory government fines ranging from $100-50,000 for each violation, open-ended civil liability risk, and your ethical obligations as a professional mean you should take records security seriously. Financial information is obviously the greatest threat. Do you have your patients’ credit card numbers stored electronically or
www.floridadental.org
Legal Notes
otherwise? Then you are at risk. But remember that the Resnick case involved social security numbers, names and addresses, not necessarily credit card information. Because the risk and damages are heightened but you cannot decrease the amount of PHI you have, it may be time to think through a few liability risks: the end of Windows XP, greater use of mobile devices, storage in the cloud and copier technology. If your practice or your Business Associates use Microsoft XP as an operating system, you need to know that Microsoft has announced there will be no more security updates as of April 8, 2014. Electronic records on those devices then will be wide open to hackers and you will undoubtedly be in breach of HIPAAHITECH security rules. Contact your information technology provider now (before the rush) and move your office computers and medical devices to a newer, more secure operating system. Mobile telephones present extra risk compared to office computers or laptops. They are easier to steal and easier to lose. While some are protected with fingerprint technology, none can be remotely swiped clean of data. However, they can store as much data, as well as transmit and receive it faster, than some older computers. Also, smartphones are always with you and may insidiously tempt you to blog casually about your day, text messages to gossip about patients, or even audibly record or take pictures of patients. Most doctors instinctively recoil and would never do this. But think about this: If your practice buys the www.floridadental.org
Top Three HIPAA Concerns to Address Today: •
•
•
Talk with your information technology (IT) provider regarding Microsoft XP. Consider privacy and security policies on mobile phones and cloud computing. Find out if your copier/scanner has a hard drive.
smart phones for employees, or even just allows them to bring their own personal device to your workplace, how do you know your non-medical staff is using them properly? How do you prevent high-tech office gossip among coworkers? What if one of your employees is also your patient? HIPAA-HITECH means you are no longer safe to assume people will use common sense and act ethically. Now, you need office policies codified in writing and enforced by your HIPAA privacy and security officer. Cloud computing has similar security challenges. Is the data you store in the cloud encrypted, and if so, how well? Have you checked your password strength lately? Do you change it regularly? Who else knows it? Will your Internet service provider indemnify you for their data breach? As technology improves, how much security is enough?
own it; maybe you lease it. Do you know if it has a hard drive? You need to know because hard drives store all information copied on the machine. What happens to that hard drive when you sell the copier, return it or have it serviced? Do you have software to erase the data from the hard drive? Do you have a Business Associate agreement with the copier company? Have you taken measures to protect this data from employee theft? Like me, you may just now be thinking about these questions. Just realize that HIPAA-HITECH requires you to analyze precisely such risks and vulnerabilities and account for them in your office confidentiality and records-storage policies. Dentists need to think about records confidentiality in a whole new way. Electronic records and telemedicine present great opportunities if done correctly and serious risks if done incorrectly. These are things not taught in dental school so think about retaining reputable information technology assistance for your practice. This article is for informational purposes only and is not intended to be a substitute for professional legal advice. If you have a specific concern or need legal advice regarding your dental practice, you should contact a qualified attorney. Graham Nicol is the FDA’s Chief Legal Counsel.
Finally, think about your humble office copier or scanner. You use it daily to copy or scan medical records. Maybe you
January/February 2014
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Information Bytes
Legislative Action Center Keeps You Informed By Larry Darnell
Director of Information Systems
The Florida Dental Association’s (FDA) Legislative Action Center is an effective tool to help you keep your elected officials informed on important dental issues. As an FDA member, you have access to a program (powered by Voter Voice) that allows you to email your legislators directly from the FDA’s website. This program provides pertinent information that is useful in your advocacy efforts with legislators, and helps direct your interaction with your legislators on specific issues. The FDA’s Legislative Action Center is available through the FDA’s website: www.floridadental.org. Log into your member account to access this information. Under “Advocacy and the Law” on the main menu, and then “Legislative Action Center,” you can review the FDA’s position on legislative issues. You also can get involved in various legislative campaigns that will encourage you to contact your state legislator(s) on key issues and initiatives to ensure that we are consistent with our message and speak with one voice. If you do not know who your state legislators are, enter your home voting ZIP code and a list of your elected officials will be displayed. If you know a legislator and you are interested in becoming a Legislative Contact Dentist (LCD), you can pursue that as well by contacting the Governmental Affairs Office at 800.326.0051 or gao@floridadental.org. Advocacy is a key aspect of your membership with the FDA. Making sure your legislators are aware of dental issues when
www.floridadental.org
“
Advocacy is a key aspect of your membership with the FDA.
”
voting on various bills is a great way to stay involved in the legislative process. And, of course, at Dentists’ Day on the Hill, scheduled for Wednesday, April 2, you will get a chance to speak to your legislator(s) in person on FDA issues in Tallahassee. Mr. Darnell is the FDA’s director of information systems and can be reached at 850.350.7102.
January/February 2014
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news
@ fda
important news for FDA members
2014 Membership Dues
The second mailing of your 2014 dues investment statements started hitting mailboxes the week of Jan. 27, 2014. We love how our members promptly respond to taking care of business! For those who have renewed, thank you for your investment and for taking advantage of the various forms of payment options we offer. If renewing for 2014 is still on your to-do list, these are some of the options available to you: Mail: Payment in full via check or credit card, or credit card payment plan. Phone: Call the Membership Services Number (800.877.9922), and pay with your credit card by phone. Online payment in full or credit card payment plan: If you opt for a payment plan before Feb. 24, 2014, your Total Investment Amount will be divided into eight equal payments. Your last installment will be processed in September 2014. To pay your dues online, please visit www.floridadental.org/dues.
FDA Promotions The Florida Dental Association (FDA) is proud to announce that three of its employees have been promoted! Ms. Kerry Gómez-Ríos, Ms. Gómez-Ríos initially hired to fill the new Membership Concierge position, has taken Mr. David Higgins’ place as the director 12
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of member relations, as he has accepted a position as executive director of the Florida Podiatric Medical Association. In addition, the FDA recognized the excellent customer service abilities of Ms. Christine Mortham and Ms. Kaitlin Alford. Ms. Mortham has been the association’s member relations assistant and receptionist for two and a half years and Ms. Mortham before that, the administrative assistant in the FDA Governmental Affairs Office for five years. She has been promoted to membership concierge to establish a unique and personalized relationship Ms. Alford with both new and current members. Ms. Alford, previously the FNDC meeting assistant, will be using her experience interacting with our members in her new position as member relations assistant. Let’s congratulate these ladies on their new roles!
FDA and FDAS Staff to Attend Seminar February 11th The Florida Dental Association (FDA) and FDA Services’ offices will be temporarily closed on Feb. 11 from 8 a.m. to 1 p.m. The staff will be attending a training seminar to better serve our members. We apologize for any inconvenience, and we will be happy to serve you as soon as we return to the office that afternoon.
January/February 2014
Alert: Dental Assistants Are Not Independent Contractors and They Cannot Do Scaling Several Florida Dental Association (FDA) members have called asking whether dental assistants can lawfully be classified as independent contractors. The answer is, emphatically, no. Assistants cannot lawfully be categorized as independent contractors because they must work under the supervision of a dentist. They cannot work independently, on their own, without a doctor’s authorization. The simple test is whether the dentist has the authority to tell an assistant what to do; regardless of whether the doctor exercises the authority or not. Assistants are under the control of the dentist and are therefore employees, not independent contractors. If there is any question at all, contact your accountant because the Internal Revenue Service (IRS) routinely audits small businesses for worker misclassification. In most of the situations described to the FDA’s legal department, the classification as an independent contractor was made to avoid the Fair Labor Standards Act (minimum wage and overtime); Social Security, Medicare and federal income tax withholding; Florida unemployment compensation tax (now called re-employment assistance); the socalled employer mandate (really a tax) to provide health insurance coverage to employees under the Affordable Care Act (“Obamacare”); and, Florida workers’ compensation coverage requirements.
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Often, the dental assistant (the putative “independent contractor”) and the doctor agree in writing that it is their collective intent to treat the assistant as an independent contractor rather than an employee. The fact, standing alone, that both parties have agreed via contract unfortunately does not control the issue. The actual working conditions and whether the dentist has the authority, if he or she chooses, to tell the assistant when to come into work; what to do while at work; when to leave work, etc. are the primary (but not exclusive) analysis. Regardless of what the contract says, the facts control, and under Florida law, assistants cannot practice independent of a dentist’s supervision. Therefore, assistants are employees, not independent contractors. If audited, the IRS, the Department of Labor, the Florida Workers’ Compensation Compliance department, etc. will hold the assistant is an employee. As their employer, you will be held liable not only for the underlying benefit in dispute, but also for fines and penalties for improperly reporting worker status. Also, several members have reported that they use their dental assistants to perform scaling. By doing so, they clearly exercise control over an employee’s terms and conditions of employment. But more troubling than the independent contractor/employee misclassification, is the fact that under Florida law, scaling cannot be delegated to a dental assistant regardless of the dentist’s level of supervision. Think through your
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business practices and contact the FDA at 850.681.3629, or others, for help if you’re unsure.
Your FDA Working to Prevent Cumbersome Record Keeping Rules The Florid a Board of Dentistry (BOD) recently created a task force to study potential rule changes/clarifications for BOD rule 64B5-17.002 Written Dental Records; Minimum Content, Retention. On October 22, the task force, chaired by Dr. Wade Winker, met for the first time and reviewed draft changes. Afterwards, the FDA Governmental Action Committee as well as the Board of Trustees reviewed the proposed changes and made several suggestions alterations, attempting to prevent unintended consequences. On January 16, the task force met via conference call for a second time to review proposed changes. Led by BOD liaison Dr. Don Ilkka, Dr. Winker listened to the FDA concerns, and was seemingly receptive to our suggested alterations. There will be another task force meeting prior to a final draft being presented to the full BOD for a final vote. The FDA thanks Dr. Winker and the entire membership of the BOD for their dedication and hard work to better the profession of dentistry and to help protect patients. Without the FDA and the volunteers that participate in these types of activities, rules may have passed that would have resulted in unintended consequences to dentists in Florida.
FDA Past President Dr. Roger Hehn Dies at 91 In Jacksonville, Dr. Roger Hehn, a specialist in oral and maxillofacial surgery, practiced for 45 years, rising to the top of his profession. He died in late NoDr. Hehn vember of renal failure and was 91 years old. “He was gifted in so many ways,” said Dr. Earl Williams, who practiced with him for a number of years. “He was one of the most proficient and efficient surgeons I’ve ever worked with. He had good hands, a good heart and a good mind. He was one of those individuals who’s a little larger than life. When he was talking to you, you felt like you were the only person in the world.” His medical trips to Ometepec, Mexico began in 1970 after learning of the need while serving on Riverside Presbyterian’s world mission committee. He returned each year with a group of doctors and also did mission work in Central and South America. Jacksonville Rotary clubs helped fund Dr. Hehn’s trips, and local hospitals and businesses provided medical supplies, Williams said. It also was valuable training for the residents who Dr. Hehn taught and took with him from the oral and maxillofacial program that he helped start at the former University Hospital. At various times, he was chief of oral and Please see news, 14
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news@ fda news from 13
maxillofacial surgery at three hospitals, as well as the first non-physician to serve as chief of staff at University. He always was involved in professional organizations and served as past president of the Florida Society of Oral and Maxillofacial Surgeons, the Jacksonville Dental Society, the Northeast District Dental Society, the Florida Dental Association and second vice president of the American Dental Association. Dr. Hehn was called “one of the most highly respected dentists in the country” when he received the Florida Dental Association’s 1979 Service Award. He retired in 1992 and for a while continued to teach at University.
Fort Pierce dentist, Michael Huber and Daughters Killed in Plane Crash Dr. Michael Hubert and his daughters, Abby and Tess, were killed when their Cessna went down in Jacksonville on Dec. 8. Huber was flying his older daughter back to college at the University of North Florida. Friends say Huber had been flying for more than a decade and made the flight to Jacksonville hundreds of times. The National Transportation Safety Board is investigating the cause of the crash. Longtime employees and patients at Dr. Huber’s Fort Pierce dental office are grieving by hanging a black wreath on the front door. “It’s been very difficult for us to tell the patients, ‘I’m sorry but Dr. Huber and his children have perished in a plane accident.’ They are all very upset,” office manager Jenny Heller said. He is more like a family member to her than a boss.
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As for Dr. Huber’s dental practice, staff says nearby dentists have been filling in to help with emergencies. They say they still aren’t sure who will take over the practice permanently.
Dan Bertoch Memorial Grant Dr. Dan Bertoch devoted much time to advocacy for the dental profession. It is in his spirit that the West Coast District Dental Association (WCDDA) created a memorial Dr. Bertoch fund in his name to provide funding for first-time attendee(s) to Dentists’ Day on the Hill (DDOH) in Tallahassee. Applications are being accepted for the April 2, 2014 event. The grant can be used toward transportation and accommodations. For an application, please contact the WCDDA office at 813.654.2500 or email Kelsey Tidler at Kelsey@wcdental.org. If you would like to make a donation toward the Dan Bertoch Memorial Grant, please make the check payable to WCDDA, memo: Dan Bertoch Grant, and mail to 1114 Kyle Wood Lane, Brandon, FL 33511 or call 813.654.2500 with credit card information.
Welcome New FDA Members These dentists recently joined the FDA. Their membership allows them to develop a strong network of fellow professionals who understand the day-to-day triumphs and tribulations of practicing dentistry.
January/February 2014
Atlantic Coast District Dental Association
Francy Arciniegas, Coconut Creek Andrew Corsaro, West Palm Beach Myriam Jourdan, West Palm Beach Idelbis Lago-Sanchez, West Palm Beach Katherine Lozada, Tamarac German Ochoa, Weston Sandra Puerto, Davie Tanmya Ravi, Coral Springs Daniel Rozen, Parkland Sean Tomalty, Boca Raton Central Florida District Dental Association
Samantha Annas, Lake City Dennis Bear, Gainesville Andrew Byrnes, Altamonte Springs Lindsey Chang, Sorrento Steven Chang, Ocoee Andrew DaCunha, Winter Park Iris Garcia, Gainesville Mikilena Hall, Gainesville Charlotte Hill, Cocoa Beach Jordan Johnston, Gainesville Shovon Kasem, Ocoee Christina Monford, Gainesville Hoang Nguyen, Apopka Christine Phan, Lake Mary Ross Schwartz, Gainesville Northeast District Dental Association
Awbree Galpin, Jacksonville Jacquelyn Miller, Fernandina Beach Northwest District Dental Association
Benjamin Grooters, Tallahassee Anthony Le, Panama City Sara Nofallah, Tallahassee South Florida District Dental Association
Dina Bobrova, Hallendale
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news@fda West Coast District Dental Association
Eftekhar Arshadi, Tampa Rebecca Downie, Tampa Atom Edenson, Tampa Hugo Galdos Santalo, Naples Nichole Lubberts, Tampa Jordan Teder, Naples Nada Yacoub, Wesley Chapel Kyle Yerton, Largo
In Memoriam The FDA honors the memory and passing of the following members: Chester Aikens Jacksonville, FL Died: December 5, 2013 Age: 62
Carlos R. Rodriguez-Feo Miami, FL Died: June 24, 2013 Age: 76
Stephen Kobernick Clearwater, FL Died: November 23, 2013 Age: 51
Gene Hammons Gainesville, FL Died: October 11, 2013 Age: 78
Michael Huber Fort Pierce, FL Died: December 8, 2013 Age: 60
Joseph Pipkin Orlando, FL Died: November 17, 2013 Age: 91
John Parsons Fort Myers, FL Died: January 4, 2014 Age: 79
Roger Hehn Saint Augustine, FL Died: November 20, 2013 Age: 91
Ronald Copenhaver St. Petersburg, FL Died: January 5, 2014 Age: 67
Membership Concierge
Meet the new FDA
christine MorthAM As Membership Concierge, Christine helps new and current members take advantage of all the benefits the FDA and ADA offer, and with a personal touch.
Just like a hotel concierge, she has a wealth of information to help you navigate your association. Call her with your questions!
800.877.9922 Dr. Casas was Selected as one of the Leading Physicians of the World by the International Association of Internists (IAI) in 2009.
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or 850.350.7136 cmortham@floridadental.org Christine Mortham
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AHCA
FDA
Submits Letter to AHCA
Advocating for Keeping Dental Separate FDA President, Dr. Terry Buckenheimer, submitted a letter on behalf of the Florida Dental Association (FDA) advocating for the association’s position to keep dental funds separate as the state transitions to statewide managed care. To view a copy of this letter, please go to http://bit.ly/17ArssT. FDA-supported legislation has been filed — HB 27 by Rep. Jose Diaz (Miami) and SB 340 by Sen. Anitere Flores (Miami) — to keep dental funds separate and continue the Pre-paid Dental Health Plan (PDHP) program that is in place today. This would result in a less complicated system and ensure that more tax dollars go Buckenheimer toward patient care and less toward program administration. The FDA thanks Rep. Diaz and Sen. Flores for their support and will work tirelessly with them to pass this legislation. FDA member dentists who participate in the PDHP have expressed many concerns about the transition. Several issues that continually need to be resolved include: prior authorization requirements; timeliness of claims payment; and, provider grievances, to name a few. The FDA is working to resolve these concerns, which will help ensure participation in the PDHP and also help increase access to dental care for children enrolled in Medicaid. If you have any questions or need additional information, please contact Casey Stoutamire at cstoutamire@floridadental.org or 850.224.1089.
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Non-covered Services
Take it or Leave it: What Does the Passage of Non-covered Services Legislation Really Mean?
By Ron Watson
FDA Lobbyist
In 2009, several dental insurance companies around the country began implementing new contract provisions that required discounts for services not covered by the plan. By 2010, this fast growing national trend started creeping into Florida contracts. At the same time, Rhode Island was the first state to pass legislation on noncovered services, prohibiting insurance companies from including these unfair provisions in dental contracts. Since that time, and with the assistance of the American Dental Association (ADA), 33 other states have successfully passed similar legislation. Due to the regulation of insurance products historically being a “states’ right” issue, state by state passage is required in order to remedy this problem. During the 2010 Session, the Florida Dental Association (FDA) filed a bill that would prohibit Florida insurance companies, health maintenance organizations (HMOs) and pre-paid limited health service organizations
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(PLHSOs) from dictating how much dentists can charge for services not covered by the plan. Unfortunately, the bill did not pass and it became clear that this issue would take some time getting through the process. In lobbying legislators, the FDA stresses how this bill is needed to protect Florida’s small businesses from being strong-armed by big insurance companies into a “take it or leave it” contract with unfair provisions. We argue that dental insurance plans and discount medical card plans should continue to be separate and distinct entities and not used as leverage to force one onto the other. Passage of the bill will help stop the removal of dentists from networks when they do not agree to “take it,” thereby protecting access to care. We remind legislators that if dentists “leave it,” this affects continuity of care for existing patient/practitioner relationships, and it also affects the patient by impeding proper treatment planning. In addition to 2010, the FDA filed legislation on non-covered services in 2011 and 2013. Even though the legislation failed to make it to the finish line during those sessions, the FDA got the legislation further each year than the previous year. The Senate has been consistent in its support of the FDA’s legislation on non-covered services. During the 2013 Session, non-covered services legislation passed off the Senate floor in four different bills. We must build on that momentum to get the bill to the finish line during the 2014 Session. The insurance industry has numerous lobbying groups that represent their interests, and are viewed by many legislators as very influential and generous during campaign season. As we continue to educate legislators before the 2014 Session, the effort to get the support of the House of Representatives needs to be refined. Many House leaders and members, after discussing the merits of the bill, have simply said, “If the dentists don’t like the terms of the contract, don’t sign it.” And, “I am not for big government, why should government get involved in two parties negotiating a private contract?” as many believers of less government have argued. Also, support for “the free market” approach is often mentioned as a reason to oppose this legislation. We have responses to those arguments, but we need your help to deliver the information directly to each legislator and help them understand the impact of this legislation on your practice if not adopted.
January/February 2014
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Non-covered Services
Successful passage of this legislation in the Florida House in 2014 will only happen with the help of all dentists who participate in organized dentistry. We need support from the grassroots level, and that’s where you can help. SB 86 by Sen. Jack Latvala (R-Clearwater) and HB 31 by Rep. Ron Renuart (RPonte Vedra Beach) are the FDA supported bills on non-covered services for the 2014 Session. In an effort to get the House bill moving, dentistry needs the strong support from each House member who supports the FDA’s efforts on non-covered services. One way to show support is to get as many “co-sponsors” as possible to sign onto HB 31. Signing on as a co-sponsor simply means the legislator agrees to have their name printed on the bill as a way of demonstrating that they strongly support an issue. Contact your Florida House of Representatives member today and urge them to cosponsor HB 31. Similar legislation on non-covered services has been adopted in 33 other states. This is the FDA’s priority legislation for the 2014 Session. Help us help you! Do not be forced into “take it or leave it” contracts anymore in Florida.
&
“
Successful passage of this legislation in the Florida House in 2014 will only happen with the help of all dentists who participate in organized dentistry.
”
Mr. Watson can be reached at 850.350.7203 or rwatson@floridadental.org.
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January/February 2014
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Call to Action
What Do I Do …
I Just Received a “Call to Action” From the FDA By Casey Stoutamire FDA Lobbyist
The 2014 Legislative Session is rapidly approaching and the Florida Dental Association’s (FDA) Governmental Affairs Office (GAO) is preparing all the tools in our arsenal to advocate on your behalf. However, we cannot do it alone — we need your help! The GAO will periodically send legislative and call-to-action alerts during the interim committee weeks and throughout Session. These alerts are to notify you of pending legislation that will be heard in either a House or Senate committee or on the floor, and to ask you to contact your legislator immediately about a particular issue. Your quick response is crucial as things move at a furious speed in Tallahassee during committee weeks and Session. Often, we have just one day (or sometimes hours) to alert the legislators when dental issues are up for a vote, and ask them to either support or oppose a bill or an amendment. When legislators (and their staff) see dentists involved and advocating for their profession, it resonates. It seems as if every day a new set of challenges that affect organized dentistry pop up. Unless we, the FDA members and staff collectively, speak up for the interests of organized dentistry, no one else will. So, please watch your inbox for legislative alerts and respond quickly so that your voice is heard in Tallahassee! A sample legislative/call-to-action alert may look like the one on the next page. Please read the alert carefully, as it will explain exactly what the GAO needs you to do. The alert will provide you with a link to the FDA’s Legislative Action Center website. Once there, you will see guidelines and a customizable message to send to your legislator. It is quick, easy and painless! The GAO thanks you for all your help! Ms. Stoutamire can be reached at 850.350.7202 or cstoutamire@floridadental.org.
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Call to Action
Call to Action Dear Dr. ______, The Florida Dental Association (FDA) is working to get co-sponsors in the House for HB 31 by Rep. Ron Renuart (R-Ponte Vedra Beach). We need to show that there is overwhelming support in the House to ensure that HB 31 gets a chance to be heard in all of its committee references. HB 31 has been referred to House Innovation (chaired by Rep. Jason Brodeur, R-Sanford), Insurance and Banking (chaired by Rep. Bryan Nelson, R-Apopka) and Health and Human Services (chaired by Rep. Richard Corcoran, R-Lutz). We would like to thank the following members who have already placed their name on the bill as co-sponsors: n n n n n n n n n n n n n n n n
Rep. Larry Ahern (R-St. Petersburg) Rep. Dennis Baxley (R-Ocala) Rep. Lori Berman (D-Boynton Beach) Rep. Daphne Campbell (D-Miami Shores) Rep. Tom Goodson (R-Titusville) Rep. Gayle Harrell (R-Port St. Lucie) Rep. David Hood (R-Daytona Beach) Rep. Ed Hooper (R-Clearwater) Rep. Travis Hutson (R-Palm Coast) Rep. Debbie Mayfield (R-Vero Beach) Rep. George Moraitis (R-Fort Lauderdale) Rep. Kathleen Peters (R-St. Petersburg) Rep. Pat Rooney (R-Palm Beach Gardens) Rep. David Santiago (R-Deltona) Rep. John Tobia (R-Melbourne) Rep. Carl Zimmerman (D-Dunedin)
We need your help today! Please contact the legislator in your district and ask them to “co-sponsor HB 31.� Attached are key talking points on non-covered services. Terry Buckenheimer, DMD FDA President Go to the link below to log in and send your message: https://www.votervoice.net/link/target/flda/4tgi2Rg3W.aspx
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Your Practice The “Power of 3”
When you join organized dentistry, you become a member of three remarkable organizations.
Together, these organizations form a partnership with you that helps you succeed every day.
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American Dental Association
■ Journal of the American Dental Association — the most trusted scientific publication in dentistry and ADA News. Plus, the ADA provides web content on practice management, continuing education, evidence-based dentistry and national laws and rules that affect your practice. ■ Ethics Hotline — This new member service is designed to help new dentists and other members manage ethical challenges that may arise in day to day practice by consulting with experienced dentists. ■ Trusted Science — The ADA Seal of Acceptance is a trusted symbol of dental product safety and effectiveness. Organized dentistry drives scientific research on issues such as infection control and managing oral diseases. The ADA Center for Evidence-based Dentistry provides systematically assessed evidence to support clinical decisions.
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Florida Dental Association ■ Florida National Dental Convention — the best continuing education value in the Southeast! Members preregister for frEE and can earn up to 18 frEE CE credits. A huge Exhibit Hall showcases the latest technology. ■ Online CE — Convenient, always available and best of all, frEE. Earn up to 30 credits per year. ■ Your Voice in the Florida Legislature — There is power in numbers, and the more dentists the fDA represents, the stronger its influence on laws that effect your everyday practice. ■ Fantastic Savings! Most dentists could pay their dues with savings from using the services of the fDA’s Corporate Affiliation Program and the insurance programs offered by fDA Services. Visit www.fdaservices.com.
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Your District Dental Association ■ Close to Home! Looking for colleagues and maybe some of the best friends you’ll ever make? District dental associations offer you the chance to share meals, opinions, advice, support, politics, continuing education and family events at local venues with your professional colleagues.
Dentists across Florida benefit from membership in three associations.
Dr. Yvette Godet Gainesville Central Florida District Dental Association
Dr. Tanya Orr Santa Rosa Beach Northwest District Dental Association
Dr. Federico Schmid Hidalgo Fort Lauderdale Atlantic Coast District Dental Association
Dr. Nishith Patel Bradenton West Coast District Dental Association
Dr. Beatriz Terry Miami Springs South Florida District Dental Association
Dues Investment Statements were mailed in November and January. Call 800.877.9922 or go to floridadental.org/dues to renew your membership.
Dr. Cecil White Jr. Atlantic Beach Northeast District Dental Association
Legislative Contact Dentist
Yesterday I Couldn’t Even Spell LCD, and Today I am One By Dr. Robert Bruce McDonald
A crusty, old retired dentist friend of mine once told me that voting is not really a big deal, because if it were, our government wouldn’t let us do it. I think there is some pretty good wisdom there. I have voted in every presidential election since I was 18, but I often wonder how much good it does and if anyone ever hears my one single voice. Years ago, my good friend and mentor, Dr. Teri-Ross Icyda, told me that if I wanted to be heard and really have an impact in politics, then I should become a Legislative Contact Dentist (LCD). I did some research and it seemed pretty daunting; me — a nobody — going face to face with a state legislator. Ignoring my reservations, I signed up and immediately called my state representative’s office. Imagine my shock after explaining the whole LCD program to him, when he instantly agreed to have lunch with me.
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As the years went by, we became good friends and twice a year I would round up all my dentist buddies and we would have a lunch meeting with Rep. Stan Mayfield. Easy as that. Joe Anne Hart at the Florida Dental Association’s (FDA) Governmental Affairs Office (GAO) would provide us with all the legislative information we needed to pass along to Stan; then, we would spend the rest of the time learning the juicy inside scoop on what was happening in Tallahassee. We learned way more from Stan than he ever learned from us.
you are or how you did this, but this is how the LCD program is supposed to work!”
One day during the legislative session, I was busy in my office healing the masses and I received a call from Tallahassee. It was none other than Rep. Stan Mayfield. He told me that he was in his Capitol office with the FDA’s president, executive director and the FDA lobbying team, along with several other legislators all begging him to sponsor a bill on dental hygiene scope of practice. He informed them that he wasn’t going to do anything related to dental without first checking with his LCD back home: me. I stammered a bit and then, for lack of anything better to say, told Stan that if the president of the FDA was for it, then I was for it. Stan said that’s all he needed to hear and then handed the phone to the bewildered FDA President, Dr. Alan Friedel, who said, “I don’t know who
The point of all this babble is that you really can have an impact on politics and it is pretty darn easy. All it takes is a few phone calls and lunch from time to time. And don’t worry, the legislators have to pick up their own lunch tab.
I was an LCD to Stan until he died from cancer in 2008. Stan’s wife, Debbie, successfully ran for his representative seat and I have been an LCD to her ever since. Stan and Debbie are good people and friends to dentistry. I called Debbie’s office a couple of days ago and asked her to cosponsor HB 31, the “non-covered services” bill. “Anything I can do to help,” was her reply.
So my advice to any dentist, young or old, who wants to be heard and have an impact on politics is to become a Legislative Contact Dentist. It’s easy, doesn’t take a lot of time, the GAO staff does all the work and it is one of the most rewarding things I have ever done in dentistry. Dr. McDonald is part of a group practice, Ocean Oaks Dental Group in Vero Beach. He can be reached at oceanoaksinfo@ gmail.com.
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Making a Difference TogeTHer!
Dentists’ Day on the Hill 2014 It’s a family affair! Bring your spouse!
Briefing
LegisLATive visiTs
Tuesday, April 1, 2014 7 p.m. • Doubletree Hotel
Wednesday, April 2, 2014 Capitol • Tallahassee
Hotel Room Block Marriott Courtyard/Apalachee Pkwy. • $199 per night • Call 800.321.2211 and request the “FDA” room block.
sponsored by
For more information: 321.452.5500 • Email: JWSRGN@aol.com • www.floridadental.org/ddoh
Legislative Contact Dentist
For LCDs, Relationships are the Key By Dr. Tina Thomas
I have been a Legislative Contact Dentist (LCD) in the Highlands County area since 1996. If I could define the process in two words, it would be: servant leadership. It’s about putting the needs of the group over your
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own and building relationships. Being an LCD is not something I sought out, it just evolved over time. Relationships are the key. Sometimes there is dissension among the dental profession, but being able to bring everyone together to create a united front is important. We support our local lawmakers throughout the process, when they run for office and when they need our help on issues. We also work closely with other groups in Highlands and Citrus counties, the Optometric Association, Highlands County Medical Association, among others.
As LCDs, we develop a reciprocal relationship with legislators. If something important to the dental profession needs support, legislators work with us because we have worked with them. Over the past several years, I’ve worked with Rep. Joe Spratt (R-LaBelle), Sen. Denise Grimsley (R-Sebring) and Rep. Cary Pigman (R-Sebring). Each legislator has been invaluable and supportive of the challenges facing dentistry. Dr. Thomas is a general dentist with a practice in Sebring. She can be reached at drtina@strato.net.
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FLA-MOM’s First event Providing Free dental ServiceS For the UnderServed
who:
members of the fda, fdhf and community volunteers concerned about access to care when: march 28-29, 2014 where: florida state fairgrounds in tampa, fl
register to volunteer at www.flamom.floridadental.org detai le d i n for mation about duti e s on th e we b s ite
Anal
tHAnKs tO Our sPOnsOrs
Loca thetic
lgesics
al anescs
FLA-MOM needs vOLunteers! i n divi duals or team s can volu nte e r.
dentists ● General: Perform amalgam or composite resin fillings. Optional limited oral surgery. ● Prosthodontics: take impressions, write prescriptions for and place temporary partials ● Pediatric: mostly care for children 10 and older; some younger patients may be evaluated for treatment. ● Anesthetic: Deliver local anesthetic to patients prior to treatment ● Dentist for Patient Exit: answer patients’ questions about the treatment and aftercare.
dental assistants ● Assist dentists in restorative, oral surgery, pediatrics, adult, or prosthodontic department. ● Assistants will be paired with their employer dentist (or other dentist who has requested them). Otherwise, assistants will be paired with an available dentist.
other dental volunteers ● Sterilization ● Lab Technician: Fabricate or repair oral prosthetics — mainly treatment partials. ● Central Supply: should have a good understanding of dental supplies and dental terminology ● Hygiene Support: Help turn over chairs in the hygiene department by wiping down, running instruments to sterilization and gathering supplies as needed. No experience necessary. Must have had your heptavax shots. ● Radiology: Must be trained in panoramic or intraoral X-rays. ● Dental Equip Tech: Start-up equipment and perform maintenance as needed on units including air suction, water, handpieces and cavitrons.
dental hygienists ● Cleanings with or without a cavitron. Pediatric section also available.
Pharmacists ● Oversight of prescription intake, processing of prescriptions, prescription filling and patient counseling. ● Includes pharmacy techs and students (supervised).
non-dental volunteers ● Set-up ● Patient Education: Provide basic oral health care education to patients while they wait to receive care. ● Crowd Control: Assist in keeping the patient line and waiting areas operating smoothly. ● Handyman (woman) / Sanitary Engineer: Empty trash bins, sweep, mop and perform other general odd jobs as needed. No experience necessary. ● Registration: This includes patient and / or volunteer registration. ● Patient Greeters: Welcome patients, provide name tags and patient numbers. ● Patient Ambassador: Escort patients between various departments ● Translator: ensure patient has an understanding of treatment. ● Patient Exit Area: Distribute patient goodie bags and assist patients in completing an online exit survey. ● Waiting Area Coordinator: Check in patients as they enter the department waiting area ● Hospitality: Serve and clean up food and beverage service for patients and volunteers. ● Data Entry and Filing: Using scanners and computers to track patient care provided and file completed patient registration forms alphabetically. Basic knowledge of how to use a computer required.
Make this a community effort! recruit volunteers for your team from your civic group or church.
FNDC2014 Speaker Preview
Inspecting Your Indicators By Laura Jamison
Baseball is an American passion. My son, Wil, is a catcher. His growth over the years has been guided by many coaches, and one in particular stands out to me. Kevin Alwan was the manager of his 10-year-old team. He was a quiet coach, always taking notes, recording statistics. When I asked him what he gained by keeping all of his notes, he said, “I know I am not the best coach in this league. I am not even a good ball player. What I do have is information and that gives these boys an edge during every game. I keep track of each player’s batting performance. I can predict with certainty where the ball is going to be hit and in knowing that, I can position my players. In addition, I can tell you with certainty, which plays the opposing coach is likely to call next for the batter. So I am able to tell my batter what to prepare for.” Statistics determine games. If you’ve heard about the story, “Moneyball,” you may know that the Oakland Athletics recreated the game by getting control of one tactic, getting each batter to base. Doing that one at a time, they won games! What does this have to do with your dental practice? I have been consulting since 1986 and I don’t know everything that there is to know in each client’s practice. What I do have is information: the practice numbers. Trends predict patterns. Patterns can be corrected. You just need to look at indicators from a period of time and know what the numbers should be and then find the way to make adjustments. Inspecting your indicators can be the most important skill you will ever develop because it gives you clarity and a sense of control that your practice outcome can be directed.
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FNDC2014 Speaker Preview
Here are three keys: Business decisions can be made objectively or subjectively. I demonstrate subjective decision making by showing a Magic 8 Ball. I ask it, “Should I give raises this year?” When I shake the Magic 8 Ball and it says, “Ask again tomorrow,” most people laugh and grasp how silly this is. Facts, figures, history and documentation will empower you. One number means nothing until you have something to compare it to. How did your practice do this month? Compared to what? Last month? The neighbor’s practice? In your practice, you can compare the goal to the actual; three months or more in trends, or apples to apples by looking at the same time frame one year ago. It gives your analysis depth and dimension. If you only look at one month and find that you are short of your goal, evaluate if that is the trend. How does it compare to last year? The numbers will tell you if something is out of line. It is up to you to learn to compile, analyze and correct the pattern. There are tools that can be used to evaluate why certain trends exist. Go back through appointment schedules, new patient treatment plans and A/R reports to evaluate what did or didn’t work.
What practice indicators should be evaluated? Office managers and dentists tell me that they choose not to look at their numbers because they are overwhelmed by how many there are to look at. Here’s a tip. More detailed reports are only necessary if you see a problem in the basic trends. The indicators to track are:
These numbers can be requested from any office management software. I prefer my clients to use an Excel spreadsheet to show all of the above numbers in one snapshot. Once a trend is determined, request more detailed reports. Save yourself time and make it easy to track your trends with Revenue Goal Planner which can be ordered at www.rgplanner.com. Team members may wish to be enlightened and can even be encouraged to take responsibility for numbers that they have the most direct impact over. Overhead should not be shared in depth with a team, but it does surprise many to know that dental offices operate at 60-75 percent overhead. They may assume that the doctor takes home 90 percent of collected fees if they aren’t educated about this. Team members can even be held accountable for numbers when salaries are reviewed. Empower your team with knowledge of the numbers they have the most influence over. Numbers may not be your thing. It is an acquired skill. As with the baseball manager, I believe that managing is about knowing your numbers. Keep it simple. You may find that the drudgery of the numbers will set you free. Ms. Jamison is the owner of Jamison Consulting and is a speaker, dental consultant, author and coach. She will be a speaker at FNDC2014 and will be presenting the Administrative Mastery Series held on Thursday and Friday, June 12-13, 2014. On Thursday, “Inspecting Your Indicators” will be held in the morning, and “Team Building” will be held in the afternoon. “Exceeding Patient Expectations” will be held Friday morning, and “Say This … Not That!” will be in the afternoon. Ms. Jamison can be reached at laura@jamisonconsulting.com.
m doctor’s production per day and per hour m hygienist’s production per day and per hour m collection percentage m number of new patients m case acceptance of new patients and patients of record m A/R aging m overhead
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FNDC2014 Speaker Preview
Endodontic Diagnosis: Simple Strategies for Complicated Situations By David A. Beach, DMD, MS
Introduction The first step in endodontics is reaching the correct diagnosis. Our goal ultimately is to treat the offending tooth and alleviate the patient’s symptoms. If the patient is experiencing pain that is of non-odontogenic origin, we want to avoid unnecessary endodontic therapy and find the true cause of their pain. A study by McCarthy et al. has shown that patients can localize odontogenic pain 73.3 percent of the time1. Simply put, sometimes the patient cannot tell which tooth is causing their symptoms. Likewise, pain in the posterior of the mouth is more difficult for the patient to localize than when it is in the anterior region. We have all seen the patient who can identify their pain as emanating from “the back of the mouth,” but cannot pinpoint which heavily restored molar is the true source. As inflammation or infection spreads from the confines of the pulp space to the periradicular areas, the patient is able to localize their pain 89 percent of the time1. A good example of this is when the patient’s symptoms expand from only sensitivity to temperature, to now include sensitivity to chewing as well. It is easier for the patient to feel more specifically the origin of the pain. So why is this important? In order to correctly diagnose the offending tooth, we need to try and duplicate the patient’s chief complaint. As it has been discussed, sometimes the patient
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FNDC2014 Speaker Preview will be unable to tell us which tooth is causing their pain and the onus will be on us to determine which tooth, if any, needs treatment. If a tooth is sensitive to cold and all we do is take a radiograph and tap on some teeth with a mirror handle, how can we be sure we are diagnosing correctly?
The Basics of Diagnosis Before discussing the various tests to aid in diagnosing the patient, the subject of pulp vitality needs to be addressed. Some clinicians struggle with the concepts of vitality and necrosis. To alleviate confusion, the best way to begin the diagnosis of a tooth is to divide the thought process into analyzing two simple categories of the suspected tooth: pulp status and periradicular status. Focusing on pulp status alone, a tooth can be basically classified as alive (vital) or dead (necrotic). This sounds ridiculously basic, yet it is the cornerstone of diagnosis and all the treatment that follows. If a tooth is alive, it is vital. If it is vital, it is NOT abscessed. Live teeth have live nerves and blood vessels. Live teeth feel temperature. Testing a live tooth with a cold stimulant will usually create a reaction in the tooth unless it is highly calcified or suffering from a recent traumatic event. Conversely, a dead tooth does not feel temperature. It cannot. There are no remaining live nerves and blood vessels transversing through the canals and pulp chamber. A necrotic tooth can abscess, manifesting problems in the periradicular bone. While this seems so basic, it is overlooked more than one would think. The following case illustrates this dilemma, and situations like it actually occur several times a month in endodontic practices across the country. Study the radiograph in Figure 1. The patient is an African-American Fig. 1: Radiograph of lower anterior female and is asympteeth with suspicious periradicular tomatic. The patient areas. was referred to an endodontist due to “multiple abscesses” and was placed on antibiotics by the referring dentist. The patient was told she may need “multiple root canals.” www.floridadental.org
Are these teeth necrotic? Are there multiple abscesses present? Should this patient be on antibiotics? The answers to all these questions start with the proper tests. Thermal testing with a cold stimulant produces a normal, positive response. The electric pulp tester (EPT) also shows a positive, “live” response. The patient is asymptomatic and the gingival tissues appear normal in color and texture. No, these teeth are not “abscessed,” they are vital and normal. No endodontic therapy is necessary. A simple vitality test and patient history would have steered the referring dentist away from incorrect thoughts of abscessed teeth and instead toward other possibilities. The condition shown in Figure 1 is periapical cementoosseous dysplasia. Other forms and variants exist, such as focal cemento-osseous dysplasia, florid cement-osseous dysplasia and cementoma. The key point is these teeth are vital. Vital teeth are not, and cannot be, abscessed. If we keep a clear line of pulpal status in our heads, we will simplify our diagnostic process greatly and avoid unnecessary antibiotic use, or worse, unnecessary endodontic therapy. It is possible for multi-rooted teeth to undergo partial necrosis, where some roots maintain vital tissue and others do not. Like many things in life, there are gray areas where exceptions to the norm exist. The overwhelming majority of the time, this type of tooth is painful enough that duplicating the patient’s chief complaint is not difficult. The patient usually can point to the tooth themselves. Rather than dwelling on “red herrings,” focusing on whether a patient’s symptoms are the result of a vital tooth or necrotic tooth will improve a clinician’s diagnostic abilities.
Fig. 2: Radiograph of tooth No. 19. Previous endodontic therapy visible and radiolucent periapical lesions present.
To drive the distinction between vital versus nonvital teeth home, examine this next case (Fig. 2). The patient is a 27-year-old male. His chief complaint is that cold drinks cause intense pain
Please see Endodontic, 34 January/February 2014 Today's FDA
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FNDC2014 Speaker Preview Clinical Tests
endodontic from 33
that lasts for several minutes. He was referred by his dentist for retreatment of tooth No. 19. Examination of the radiograph reveals tooth No. 19 to have previously completed endodontic therapy with apparent apical pathology. The patient’s chief complaint is the response to cold stimulation; this should immediately raise a red flag. A tooth with periapical lesions, let alone previous endodontic therapy, is not the likely the source of thermal sensation. Upon testing the teeth in the quadrant with a cold stimulant, it was found that tooth No. 20 was the offending tooth. A hairline crack was found upon further examination. Is there a problem with No. 19? Yes, but retreatment of tooth No. 19 would not have addressed the patient’s chief complaint. In this situation, root canal therapy was necessary on tooth No. 20 to address the pain to cold temperatures and retreatment of tooth No. 19 was necessary to address the other issues associated with that tooth.
Fig. 3: The mental foramen is in close proximity to the apex of tooth No. 20. It could be mistaken for a periapical lesion.
There are some common anatomic structures that can be mistaken for apical lesions. These include the mental foramen near lower premolars (Fig. 3), the incisive canal and the nasal floor.
When in doubt, test the vitality of the teeth in the area. If there is only one key point you take away from this article on diagnosis, it should be: Never rely on just one test if it does not duplicate the patient’s chief complaint! Unfortunately, some clinicians may try and formulate a diagnosis based on insufficient testing. Does a radiograph alone help us come to the correct conclusions? The answer is no.
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In order to duplicate the chief complaint, we need a variety of tests beyond the mere exposure of a radiograph and the crude “banging on teeth” with blunt objects like mirror handles. Yes, a radiograph of the painful area is a requirement in order to look for caries, cracks, periapical pathology, etc. At the very least, a clinician should test teeth with thermal stimulation (cold test), palpate the alveolar ridges, periodontally probe around the teeth, percuss the teeth and use a bite stick. These should be the “core” tests and most often, it will only require these tests to duplicate the chief complaint. Testing teeth with a cold stimulant can be accomplished in a variety of ways. Some clinicians use an ice cube or an “ice pencil” made from freezing water in a sterile, empty anesthetic carpule. The use of this technique is not as accurate as using a refrigerant spray on a cotton pellet2. The problem with ice cubes or ice pencils is that they melt. The cold ice water can then touch the gingiva or flow onto adjacent teeth and produce false responses. By using a refrigerant spray, a concentrated cold pellet can be created and each tooth in an area can be tested precisely. It is also beneficial to use a cotton pellet held by pliers, rather than a wooden cotton tip applicator. The wooden cotton tip applicator does not hold the cold temperature as long as a pair of metal pliers holding a cotton pellet. These are shown in Figure 4. Sometimes more tests are required to reach a correct diagnosis. In addition to what has been mentioned, other tests might include the EPT, selective anesthesia Fig. 4: Instruments to accurately perform a and tracing cold test. The refrigerant should be sprayed on a sinus tract. a cotton pellet held with pliers (left). The use of a wooden cotton tip applicator (right) is not as An important efficient. consideration with the EPT is that it merely tells us if the tooth is vital or necrotic. The numbers that are obtained from the digital readout do not tell us anything about the varying degrees of inflammation that could be present in a tooth3. A low reading www.floridadental.org
FNDC2014 Speaker Preview versus a high reading means the tooth is alive, and that is it. It does not mean the tooth is more or less inflamed. If the meter reads to its endpoint and the patient feels nothing, the tooth is likely necrotic. Sometimes the EPT is necessary to help confirm thermal vitality tests when the patient’s response to a cold test is unclear. But the myth that the various numbers on the EPT readout mean anything about a tooth being more or less inflamed is just that, a false interpretation of data. Selective anesthesia can be used in situations where a patient is having trouble distinguishing the source of pain. It is not a perfect test because it is almost impossible to precisely anesthetize just one tooth at a time to perform a vitality test. But in certain situations, anesthetizing an area and observing the patient’s response may help in the diagnosis. The following patient case will describe a situation where selective anesthesia prevented unnecessary endodontic therapy. A 64-year-old female patient was referred for endodontic therapy on tooth No. 21 (Fig. 5). Two days prior, the patient began experiencing spontaneous waves of sharp pain that lasted for a few seconds. The pain always began in the mandible, around the left premolar area. Testing tooth No. 21 and the adjacent Fig. 5: Preoperative radiograph of teeth produced vague tooth No. 21. Apical areas appear norresults. It appeared that mal. Restorations appear adequate. sometimes percussion or palpation would elicit pain, while other times the same tests on the same areas done in repeat fashion would give opposite results. An inferior alveolar nerve block, followed by infiltration around the area of the mental foramen, was administered. After allowing enough time to pass, the patient was then evaluated again. Despite signs of profound anesthesia, the exact same spontaneous waves of pain would occur about every 10-15 seconds. It was determined that the pain was non-odontogenic in origin and the patient was immediately referred to her physician. A day later the diagnosis of shingles was made and found to be the cause of the pain.
Tracing a sinus tract is important. This can be done simply by placing a gutta-percha point through the sinus tract and exposing a radiograph. While many times a lesion on a radiograph will be confined to a specific tooth, there are times when it is unclear as to where the sinus tract is draining from. The following case will illustrate a situation in which tracing the sinus tract lead to an unusual finding. A 54-year-old male patient was referred for endodontic therapy on tooth No. 31. A large swelling with a sinus tract was present between teeth Nos. 29 and 31. Radiographs of the area showed an absence of pathology at the apex of tooth No. 31 as well as tooth No. 29 (Fig. 6).
Fig. 6: Radiographs of teeth Nos. 28, 29 and 31.
Vitality tests revealed the two teeth adjacent to the swelling to have normal, live, vital pulps. Placing a gutta-percha point through the sinus tract led to the image in Figure 7. Clearly, the gutta-percha point traced to the area where tooth No. 30 had been extracted. According to the patient, the extraction was done about Fig. 7: Tracing a sinus tract. The gutta-percha point placed through the sinus tract traveled to six months an area within the bone between two vital teeth. prior. It was determined that endodontic therapy was NOT necessary on tooth No. 31, nor on tooth No. 29. The swelling was NOT from either of the remaining teeth. The patient was referred to an oral surgeon for evaluation and care. Please see Endodontic, 37
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FNDC2014 Speaker Preview endodontic from 35
There are occasions in which a clinician performs a battery of tests and still cannot come to the conclusion that the patient’s pain is originating from a tooth. If test results are just not adding up, the possibilities of sinus infection, bruxism, myofascial pain, temporomandibular disorders or periodontal infection should be explored4.
Conclusion The keys to successful diagnosis in endodontics revolve around duplicating the patient’s chief complaint and assessing pulp vitality. These two tenets are intimately linked. An accurate endodontic diagnosis sometimes cannot be formulated from a radiograph alone without testing the teeth in the area of concern. Vitality test results, clinical findings and the patient’s subjective symptoms should all “match” before any dental treatment is pursued. If the site of the pain does not appear to relate to the source of the pain, non-odontogenic origins should be considered. It has been estimated that we forget 80 percent of what we learn within 24 hours, and most of the remaining 20 percent in the week that follows5. This article presents the intricacies
of endodontic diagnosis with some supporting cases examples. Even the most advanced clinician needs a refresher course once in a while. For others, the information provided here will help them achieve new levels of success and excellence.
References
1. McCarthy PJ, McClanahan S, Hodges J, Bowles W. Frequency of localization of the painful tooth by patients presenting for an endodontic emergency. J Endod 2010; 36:801-805. 2. Chen E, Abbot P. Evaluation of accuracy, reliability, and repeatability of five dental pulp tests. J Endod 2011; 37:1619-1623. 3. Lado EA, Richmond AF, Marks RG. Reliability and validity of a digital pulp tester as a test standard for measuring sensory perception. J Endod 1988; 14:352-356. 4. Beach D. Assessing postoperative pain after endodontic therapy. Dent Today 2013; 32:90-93. 5. Masterson M. The Pledge. Hoboken, NJ: John Wiley & Sons, Inc. 2011:144.
Dr. Beach is an endodontist with a practice in Wesley Chapel. He will be a speaker at FNDC2014 and has two courses on Thursday, June 12, 2014. “Root Canals Gone Wild: Overcoming Problems in Endodontics” will be presented in the morning, and “DiagnosisBased Pain and Infection Management” will be presented that afternoon. He can be reached at beachendo@yahoo.com.
GAO Staffers
Alexandra A
bboud
) tamire (right
asey Stou (left) and C
New GAO Staffers Bring Strong Backgrounds and Great Experience to FDA
By Lynne Knight
FDA Marketing Coordinator
Alexandra Abboud Governmental Affairs Coordinator
“
Please give a brief description of your responsibilities. As Governmental Affairs Coordinator, my duty is to assist the Director of Govern-
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I also like waking up every morning knowing I am going to work in a place where new and innovative ideas are encouraged.
”
mental Affairs and other Florida Dental Association (FDA) lobbyists with the coordination and implementation of the FDA’s political and legislative agenda. One of my main focuses at the FDA is the activation and maintenance of the FDA’s grassroots efforts. These efforts include our Legislative Contact Dentist program and the FDA’s Legislative Action Center.
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GAO Staffers
Do you have specific bills/areas you specialize in? My job is to know a little bit about each area that the Governmental Affairs Office covers and that the lobbyists focus on. Instead of having one specific bill to monitor, I help track all the legislation that the FDA is following throughout the Legislative Session.
What part of your job do you most enjoy? The part of my job that I most enjoy is that I am exposed to a wide variety of individuals who work in the legislative process. I like meeting and interacting with new people and am fortunate enough that I work in an office that allows me to experience all that I can. I also like waking up every morning knowing I am going to work in a place where new and innovative ideas are encouraged; a place that makes recently hired staff feel like they are a part of a family.
Least favorite part? Since I’m new … I don’t have a least favorite part of the job yet!
What experiences prepared you for your FDA position? While in college, I was an intern with the Attorney General’s Office and for one session, I worked in a lobbying firm. Before working for the FDA, I was a Legislative Analyst for the Florida Department of Health for a little more than a year. I believe that these various positions collectively helped prepare me for my job at
the FDA. Working at the Department of Health certainly gave me the legislative and political experience I needed to work in the Governmental Affairs Office at the FDA.
A little background? I am originally from New Jersey and moved to Ocala, Fla. when I was 13. I graduated from high school Summa Cum Laude from the International Baccalaureate program and went on to attend Florida State University. While in college, I was inducted into numerous honors societies, such as Phi Beta Kappa, and was heavily involved as an officer in Phi Alpha Delta Pre-law Fraternity. I graduated early, Magna Cum Laude with a B.A. in Political Science and History in 2012. I loved FSU so much, I decided to stay for my graduate studies and have recently graduated with a M.S. in Political Science.
Casey Stoutamire
“
It’s a great pleasure to work with legislators on behalf of our members.
”
the FDA Council on Dental Health and work with members and provide them with updates on legislative issues.
Do you have specific bills/areas you specialize in? I specialize in Public Health/Dental Medicaid and also help FDA members with issues they may be having with Medicaid managed care plans. I have worked on the legislation to “Keep Dental Separate Bill (Medicaid Managed Care)” and the Dental Student Loan Repayment bill.
Governmental Affairs Lobbyist
What part of your job do you most enjoy?
Please give a brief description of your responsibilities.
It’s a great pleasure to work with legislators on behalf of our members and to talk with FDA members and answer their questions or help resolve issues they may be having.
I lobby my assigned issues to the executive and legislative branches of government and work with Joe Anne Hart, our Director of Governmental Affairs to help create, coordinate and implement the FDA’s political and legislative agenda. I work with the actual bills and amendments, performing substantive analysis, drafting language, reviewing and editing. I represent the FDA and FLADPAC at various functions around the state and provide contribution opinions to FLADPAC. I serve as the lead support staff to
Least favorite part? Sometimes, no matter how hard we try, an issue may not get resolved because of outside politics. It has nothing to do with our issue and it is frustrating that we can’t get help for our members because of it. But, that’s a part of what makes this job exciting. Please see GAO, 41
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GAO Staffers
GAO from 39
What experiences prepared you for your FDA position? My time in law school prepared me for reading and analyzing bills, statutes, and amendments and also helped with my writing skills. It certainly gave me more confidence in public speaking and lobbying legislators. My previous positions at a non-profit in Tampa and another association in Tallahassee gave me a background in Medicaid, so I at least knew the basic lingo and overview of
University College of Law in St. Petersburg in 2009.
the program when I started at the FDA. Now I’m just getting up to speed on how it affects dentists and in particular, pediatric dentists.
A little background? I was born and raised in Monticello, Fla. — just 25 miles northeast of Tallahassee. There isn’t a stoplight in the entire county! I did my undergrad work at the at the University of Florida and graduated with a degree in criminology and Russian. I also graduated from Stetson
I just did my first sprint triathlon over Labor Day and ended up placing second in my division! Now I really enjoy biking and swimming. I also enjoy spending time with my family and getting together with friends. Lynne Knight is the FDA’s Marketing Coordinator and can be reached at lknight@floridadental.org
get to know joe dukes! your northeast & northwest districts insurance representative Welcome to a new FDAS insurance representative!
FDA Services is proud to announce the addition of Joe Dukes as the dedicated insurance representative for the Northwest and Northeast districts. Joe comes to FDA Services with ten years of experience in the insurance industry, with a specialty in health insurance and professional liability. His office is located in the FDA Headquarters in Tallahassee, but he will be traveling both districts visiting one on one with members. Please contact Joe at 850.350.7154 or joe.dukes@fdaservices.com, as a member insurance resource. Joe dukes
Northeast & NorthWest Districts iNsuraNce represeNtative
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JOE
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Becomes a Law how an fda idea
idea brouGht to fda GoVernmental action committee
fda house of deleGates approVes policy
lobbyinG • adding more sponsors
• Getting provisions amended to other bills • Garnering new support • educating legislators
fda proposes new leGislation
proposed leGislation written Governmental action committee with Gao staff support
fda finds sponsors legislators supportive of dental issues
typically, health care providers are the best sponsors for filing fda bills.
bill is filed numbered (sb or hb) & printed
• • • • •
fda member support district Visits dentists’ day on the hill legislative contact dentists responding to action alerts capitol Visits
road blocks • too many reference committees – indicates lack of leadership support • no sponsors or too few • time runs out • dies in committee process • legislator perceives no grassroots support
senate president assiGns committees to hear bill
house speaker assiGns committees to hear bill
typical senate committees for fDa bills
typical house committees for fDa bills
Health Policy • Banking & Insurance Governmental oversight & accountability appropriations
Health Quality • Health Innovation Insurance & Banking • Appropriations health & human services
committee hearinGs Results: Favorable • Favorable w/Amendment • Favorable w/Substitute • Unfavorable must pass favorably out all referenced committees
bill becomes law
GoVernor allows bill to become law without siGnature must sign or Veto within 7 days during session & within 15 days after session
GoVernor siGns bill
GoVernor Vetos bill but two-thirds vote of each house overrides veto
bill to the GoVernor fda writes letter to GoVernor urging to sign fda-supported bill or Veto fda-opposed bill
senate Vote
house Vote
unamended bill returns from other chamber or bill returns with amendments and house or senate concurs with the other chamber’s chanGes
bill returns with amendments and house or senate does not concur with chanGes — Goes to house/senate neGotiations conference committee majority of committee members of each house must agree to report. bill language usually changes to garner further support.
successful bill returns to the senate
successful bill returns to the house
senate president assiGns committees to hear bill
house speaker assiGns committees to hear bill
senate Votes & passes bill sends bill to house
house Votes & passes bill sends bill to senate
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CE thE Easy way
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tHe most coNVeNieNt WAY to Get ce credit to reNeW YoUr LiceNse bY feb. 28, 2014
december 1 Blood, Spit & Fears: A Painless OSHA Update Dr. Laney Kay Expires 2/28/14
EVERY ISSUE OF TOdAY’S FdA Earn online CE credit by taking a quiz on ”Diagnostic Discussion.”
January 1, 2014 Mastering Restorative Dentistry 2012: Treatment Planning the Materials, Techniques & Procedures Dr. Alan Atlas Expires 2/28/14
Diagnostic Discussion
Diagnostic Discussion By Drs. Indraneel Bhattacharyya and Nadim Islam
A 23-year-old female presented to Dr. Andonis Terezides of the Oral and Maxillofacial Surgery Dental Implant Center in Winter Park, Fla. for evaluation of bony expansion of the left maxilla. The area appeared to be an expansion of the maxillary alveolar ridge and was completely asymptomatic. The face on the affected side also appeared to be asymmetric. The patient’s dentition and oral hygiene appeared normal and no obvious dental pathology was noted. The area had been expanding for a few years with no previous history of inflammation, extraction or trauma to the area. The radiograph revealed a diffuse ill-defined “ground glass” opacification of the left maxilla extending into the sinus. A biopsy was taken from the area and submitted along with the computerized tomographic scans and panoramic radiograph to the University of Florida College of Dentistry, Oral and Maxillofacial Pathology Biopsy Service for evaluation and definitive diagnosis. Microscopic examination of the slide revealed numerous variably sized trabeculae of bone distributed in a dense fibrous connective tissue stroma. The trabeculae of bone were irregularly mineralized bone formed as “ginger root-shaped” interconnecting structures. Most of the bony trabeculae conspicuously lacked osteoblastic rimming.
Fig. 1: Panoramic radiographic
Question: Which of the following is the most likely diagnosis? A. Osteosarcoma B. Paget’s Disease of Bone C. Exostosis D. Florid Cemento-osseous Dysplasia E. Fibrous Dysplasia of Bone Please see diagnostic, 48
Fig. 2: Composite of images taken from CT scan
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Diagnostic Discussion A. Osteosarcoma Incorrect — though a good choice given the location and the patient’s age. However, several factors detract from this diagnosis. These include the long duration of the condition with slow expansion of the maxilla, the lack of any symptoms, as well as the lack of characteristic radiographic features of the involved bone. In addition, osteosarcomas usually present with swelling and pain as the most common symptoms. Radiographically, osteosarcomas most often present as a mixed radiolucent and opaque area with irregular “moth-eaten” or ill-defined indistinct borders. There is often a spiking resorption of the roots of teeth involved by the lesion. The classic “sunburst” or “sunray” appearance caused by osteophytic bone production on the surface of the lesion is noted in about one quarter of the cases of jaw osteosarcomas. The adjacent or associated teeth, in our experience, often show a “spiking” or “knife-edged” resorption. Osteosarcoma of the jaws, though an uncommon disease, usually presents in patients in their late 20s or early 30s, which on average, is older by a decade or more than tumors of the long bones. An important early radiographic change consists of a symmetric widening of the periodontal ligament space around an involved tooth or multiple teeth. The characteristic radiographic finding(s), when combined with symptoms, are important in making an early diagnosis. Osteosarcomas are the
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most common type of primary malignant tumor of bone. The distal femur and proximal tibia are the most frequent sites and only about 7 percent of all osteosarcomas occur in the jaws. Osteosarcomas are treated by radical surgical excision. Jaw osteosarcomas exhibit low rates of metastasis and a better prognosis than their long bone counterparts. The five-year survival rate ranges from 30-50 percent, with most patients facing local recurrence. B. Paget’s Disease of Bone Incorrect, but an important consideration in the differential diagnosis for any slowly developing bony expansile lesion involving the maxilla. However, it is exceedingly rare in individuals less than 40 years old. Moreover, since the lesion has been gradually growing for the last few years, the patient was probably in her late teens when the growth began. The other major point of consideration is that men are affected twice as often as women and the disease presents with severe bone pain. Both of which do not fit with the case presentation here. Paget’s disease of bone is characterized by an imbalance in resorption and deposition of bone, resulting in distortion and weakening of the affected bones. There is continuous abnormal turnover of bone with increased resorption and deposition of bone, with a net gain in deposition of new bone in an abnormal pattern. It is a relatively common bone disease and has an unknown etiology. The classic cases of Paget’s disease present with a mixed radiolucent/opaque appearance and appear “cotton-” or “wool-like” radiograhically. The disease may affect one bone (monostotic) or multiple bones
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(polyostotic). The bones affected become thickened, enlarged and weakened. Jaw involvement is seen in 10-15 percent of cases. Patients show marked elevations in serum alkaline phosphatase levels with normal serum calcium and phosphorus levels. Microscopic features include the presence of basophilic reversal lines in the bone that result in a “jigsaw puzzle,” or mosaic, appearance of the bone. C. Exostosis Incorrect. Though a consideration in the differential as a slow-developing bony growth, it is unlikely to involve large areas of the maxilla with extension into the sinus. In addition, exostoses rarely grow to large sizes and it is even rarer to see gross distortion of the face in young individuals. Exostoses are rare in patients less than 40 years old. Moreover, in this 23-year-old patient the lesion has been gradually growing for the last few years. Exostoses are localized bony protuberances that arise from the cortical plates of the jaw bones. Tori are the best-known examples of exostoses. These structures are usually bilateral and symmetrical. They occur as bony, hard, smoothsurfaced nodular growths along the facial aspect of the jaws. Palatal exostoses may also be seen but are noted on the palatal aspect of maxillary teeth. Unilateral or solitary exostoses may also occur and are usually associated with chronic irritation or bruxism. Occasionally, solitary exostoses may arise under a free gingival graft. Radiographically, exostosis may cast a radiopaque shadow overlapping the teeth and can be easily confirmed upon clinical examination. Facial expansion or asymmetry is extremely rare. Biopsy or additional treatment is usually not
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required unless removal is indicated for fabrication of a prosthesis or esthetics.
or osseous surgery should be avoided for the above-mentioned reasons.
D. Florid Cemento-osseous Dysplasia Incorrect. This may be considered in the differential diagnosis, but most cases of florid cement-osseous dysplasia involve middle-aged African-American females. However, the name “florid” implies widespread involvement, which is clearly not present here. Cementoosseous dysplasia (COD) typically does not cause expansion or facial asymmetry. Florid COD has a remarkable tendency to present bilaterally and symmetrically. Radiographically, the two conditions can easily be distinguished, since florid COD presents with irregular cotton- or wool-like lobular opacity, unlike the “ground glass” radiopacity seen here. Usually florid COD is not ill-defined. Most cases are asymptomatic and in rare situations, dull pain is reported. Many cases that have been reported as chronic sclerosing osteomyelitis or sclerosing osteitis actually may represent florid COD with secondary infection. Usually no treatment is required for asymptomatic patients since biopsy or surgical intervention may result in secondary inflammation. Radiographic and clinical (race and age) factors are considered sufficient for making a diagnosis. Elective extraction
E. Fibrous Dysplasia of Bone Correct. The age, location, radiographic presentation and microscopic features are consistent with the diagnosis of fibrous dysplasia. Fibrous dysplasia (FD) of bone is a sporadic, uncommon, skeletal disorder with a broad spectrum of manifestations. In the past, it also has been called osteitis fibrosa disseminata. FD is a poorly understood developmental tumor-like lesion that usually affects one bone (monostotic disease) in about 80-85 percent of the patients. Multiple bones may also be involved (polyostotic), but is relatively uncommon. Polyostotic disease may be associated with other conditions, such as multiple areas of cutaneous pigmentation and a number of hyperfunctioning endocrinopathies, including precocious puberty, hyperthyroidism, growth hormone excess and rickets/osteomalacia, in which case it’s known as McCune-Albright syndrome. When associated with soft tissue myxomas, it’s called Mazabraud’s syndrome. The skull is commonly involved in all types of fibrous dysplasia. The precise prevalence of the various forms of FD is unknown, but account for approximately 5 percent of benign bone lesions. The
monostotic form is considered to be 10 times more common than the polyostotic variant. The disease is considered to arise from mutations in the GNAS gene which leads to altered differentiation of bone via the cyclic adenosine monophosphate (cAMP) cell signaling pathway. FD is a genetic disease, but with documented vertical transmission from parent to offspring. This is an important point to note when advising patients with this condition. In addition, it has not been associated with any environmental exposures. Therefore, when the genetic defect arises early in intrauterine life, it involves multiple systems, including the craniofacial skeleton; when it occurs later on, it may affect only the facial bone. The disease is usually diagnosed in the first or second decade of life and produces a painless swelling of the affected area. The maxilla is involved more commonly than the mandible. Maxillary lesions often involve adjacent bones such as the zygoma, sphenoid and occiput (also known as craniofacial FD). The classic radiologic feature is the “ground glass” opacification that results from formation of poorly-calcified bone trabeculae Please see diagnostic, 50
Continuing Education Opportunity You can now earn continuing education credit for reading Diagnostic Discussion articles! Visit the FDA website at www.floridadental.org and click “Online Education” under the “Benefits and Resources” tab for this free, members-only benefit. You will be given the opportunity to review this column and its accompanying photos, and will be asked to answer five additional questions. If you have questions about this opportunity, email Publications Manager Jill Runyan at jrunyan@floridadental.org or call 800.877.9922. Be sure you are logged in to the members-only side of www.floridadental.org to access the online CE.
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arranged haphazardly. The lesions are poorly-defined with blending of margins into adjacent normal bone. The typical microscopic findings of FD show irregularly shaped trabeculae (often likened to a Chinese character) of immature bone in a cellular, loosely arranged fibrous stroma. The bone trabeculae are not connected to each other. Isolated involvement of the facial bones may be associated with a tendency to slow or stop growth after skeletal maturity is reached. It is possible to test patients with FD for the GNAS gene mutation. Management of FD is difficult since the lesions are usually ill-defined, and obtaining definitive margins is problematic. Also, due to their slow but continual growth, recurrence may present a major problem. Regrowth is more common in younger patients, and many surgeons believe that surgical intervention should be delayed for as long as possible. Periodic surgical recontouring also is recommended by many surgeons, mainly for cosmetic reasons. Radiation therapy for FD is contraindicated since radiation predisposes FD to malignant transformation. Medical management employed by some treatment centers uses bisphosphonates
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and calcitonin to control the abnormal turnover of bone. However, use of these medications in children is not without risks.
Some useful references: Phattarataratip E, Pholjaroen C, Tiranon P. A Clinicopathologic Analysis of 207 Cases of Benign Fibro-Osseous Lesions of the Jaws. Int J Surg Pathol. 2013 Dec 10. (EPub ahead of print).
Dr. Bhattacharyya
Leet AI, Collins MT. Current approach to fibrous dysplasia of bone and McCune–Albright syndrome. J Child Orthop. 2007; 1(1): 3-17. Alawi F. Benign fibro-osseous diseases of the maxillofacial bones. A review and differential diagnosis. Am J Clin Pathol. 2002; 118 Suppl:S50-70. MacDonald-Jankowski D. Fibrous dysplasia: a systematic review. Dentomaxillofac Radiol. 2009; 38(4):196-215.
Dr. Islam
Diagnostic Discussion is contributed by UFCD professors, Drs. Nadim Islam, Indraneel Bhattacharyya and Don Cohen, and provides insight and feedback on common, important, new and challenging oral diseases. The dental professors operate a large, multi-state biopsy service. The column’s case studies originate from the more than 10,000 specimens the service receives every year from all over the United States.
Akintoye SO, Lee JS, Feimster T, Booher S, Brahim J, Kingman A, et al. Dental characteristics of fibrous dysplasia and McCune-Albright syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 96:275-82.
Clinicians are invited to submit Dr. Cohen cases from their own practices. Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter.
Yasuoka T, Takagi N, Hatakeyama D, Yokoyama K. Fibrous dysplasia in the maxilla: possible mechanism of bone remodeling by calcitonin treatment. Oral Oncol. 2003; 39:301-5.
Drs. Islam, Bhattacharyya and Cohen can be reached at MIslam@dental.ufl.edu, ibhattacharyya@dental.ufl.edu and dcohen@ dental.ufl.edu, respectively.
January/February 2014
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Composite Resin
Composite Resin: Conservative, Durable, Beautiful By Dr. John Gammichia
When I was at the University of Florida College of Dentistry, there was only one restorative material for the posterior operative procedure: amalgam. I loved every minute of doing amalgam fillings. I loved trying to carve ideal anatomy into my amalgam restorations (I am still upset that I didn’t even place in the anatomy carving contest in my junior year of dental school). I knew composite was becoming more in vogue in the real world because my father, also a dentist, was restoring about half of his posterior restorations with composite resin. I asked the dental school faculty about composite for the posterior, and they said it was a big no-no. After I graduated in 1995, I started to dabble in posterior composites, but I was still under the impression it was a no-no until I went to see Gordon Christensen in 1996. He said that in some European countries amalgam was illegal, and he predicted that in five years amalgam would be obsolete in the U.S. In lieu of Christensen’s estimation, and because most of my patients were demanding better esthetics, I began to phase in composites at my office. I also began to really enjoy working with composite, so by 1998, we completely removed amalgam from the office — we even threw out the triturators. I took the “carving ideal anatomy” that I loved in amalgam and used the same principles on my posterior composites. Wow! It was nice! I was a young associate, so most of my procedures were simple restoratives; but the simple restoratives were looking really nice. So much so, that people who saw my work began to ask for it — and then tell their friends! My assistant asked me to redo her amalgam restorations. Afterward, she referred her mother to come in and get “the fillings that look just like a tooth.” This is how I began to build my practice. In my quest to get even better at posterior composites, I went and saw the self-proclaimed bondodontist, Dr. Ray Bertolotti. He was doing what some people would call revolutionary; I would call it “off his rocker crazy.” He was bonding everything. He believed in Kuraray’s bonding agents so much that he would bond everything to any-
thing. He would repair broken porcelain. He would do fillings and crowns without mechanical retention. He would repair instead of replace restorations. I loved it. I became a bondontist. I was doing a lot of posterior resins and I realized how much tooth structure I was saving. This was the crux of what was going on in my head. I was ultra-conservative and this was a perfect fit for me. I was doing what I thought was the best thing for the patient and I was actually saving the tooth at the same time. I was doing some pretty sweet-looking fillings but I also was stretching the boundaries of some of the products. I can’t tell you how many times patients have come to me for a second opinion because they have been told they need a root canal, post and core, and crown because they have decay. I have saved countless patients thousands of dollars, as well as hours in the dental chair doing unnecessary dental work, by simply being more conservative. Now, don’t get me started on over-treatment, but I think the underlying theme is that some dentists don’t trust the posterior composite; they don’t like doing small composite restorations and they don’t believe in the larger ones.
Please see composite, 54
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Composite Resin For example, a patient came in with a broken molar and was upset because she thought the tooth was going to have to be extracted since she could not afford a crown. I told her I would try to save it with a mesioocclusal-distolingual (MODL) filling. As I was removing the amalgam, both of the buccal cusps flaked off. What do I do now? Take the tooth out? I continued to work on the tooth. I reduced the ML cusp and did a military filling: a MODFL, four-cusp restoration. It was beautiful. I do a lot of composite restorations, but I was pretty proud of this one. Fig. 1
This truly is a service I can give someone. Even though “the best” treatment for this tooth, we can all agree, would probably be a full-coverage crown, I can hold the best off for a decade or so with something pretty darn nice. I am calling this the operative tri-fecta: very conservative, beautiful and durable. With a newfound confidence in my work and the materials, I brought this attitude to all the other the aspects of dentistry. Since I had gotten rid of all my amalgam and triturators, I had to incorporate the same philosophy when I did restorations on primary teeth. I now do only composite restorations on primary teeth. In addition to the amalgam, I threw all my stainless steel crowns away, too. So all my pulpotomies are now restored with compromers.
Fig. 2 composite from 53
Early on, I treated a patient in financial straits with a large mesioocclusal facial (MOF) composite restoration instead of a build-up and crown, and I have to admit that it looked pretty awesome. The patient was thrilled, I was thrilled — but I reminded him of the likelihood that this might not last. For the next few days, I expected a call informing me of the failure. But the call never came. When he returned for his recall appointment and sat in the chair, there it was: my MOF filling looking as awesome as it did the day I put it in. I originally thought it was an aberration. But five years later when the patient came in for a cleaning, low and behold, his tooth was looking pretty darn good. In the lean years of our economy, I found myself doing a lot of tooth reconstructions; they were all doing pretty well. In fact, now that times are not so lean, I am still implementing this kind of restoration. I have so much confidence in what I am doing and my patients love it. 54
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Fig. 3
Fig. 4
You may be thinking I am crazy, but I’m even able to fund my own research! I offer $10 to any child who has received a restoration from me to bring that tooth in when it falls out naturally and let me take a photo of it. I pay these children so I can see how my fillings do throughout the years, and they remember! One child brought in eight restored teeth — I had to write him a check! I now have a fairly large library of 3- to 8-year post-restoration successes, and the success rates of these fillings are off the charts.
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Fig. 6
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Composite Resin The reason I do dentistry this way is because I am trying to hold off the eventual crown. As dentists, we all know the life cycle of a tooth. The cycle begins when a child, usually around 12 years old, comes in with occlusal decay. The tooth is repaired with an occlusal restoration. Then, 10-15 years later, it will need a bigger occlusal restoration. An additional 10-15 years later, this tooth will need a crown. Another 15-20 years later, the crown will either need to be replaced or extracted. And finally, the time will come for an eventual implant. Fig. 7
Now, my objective is threefold: 1) Make sure the child doesn’t need an occlusal restoration; 2) When tradition says to do a crown, just do a bigger restoration; and 3) Make the restoration last longer. In order to do so, I have to start early. Although some procedures might make me feel a little uncomfortable, I have to use the best materials and do all my restorations with extreme care. I’m not the only dentist doing this, and I am certainly not the first one to think, “Let’s make posterior restorations last as long as we can.” Dental manufacturers spend an exceptional amount of money to improve what we are doing every day, so products keep improving. We know the degradation of our dentin bond starts almost immediately; we have learned that matrix metalloproteinases (MMPs) are the proteinases that break down our bond. Kuraray used this knowledge to make the “Gold Standard” of self-etching primers more golden. They have taken their CLEARFIL™ SE BOND and put MMP inhibitors in the primer. Not only that, but fluoride was added to the bonding agent to help prevent secondary caries. With CLEARFIL™ SE Protect, we get great bonding strengths; we are resisting degradation; and, we are preventing secondary caries. Talk about improvement. How long are posterior composites expected to last? The old school thought was 5-10 years, but, I am thinking much, much longer … and I’m not the only one. Finally, the long-term studies are coming around for posterior composites. Da Rosa Rodolpho et al. conducted a 22-year study observing 364 posterior composite fillings that were done in 1986 and 1990. They discovered that the annual failure rate was only 1.5 percent, and these fillings were done with products that can’t even hold a candle to what we use now! In 2010, Opdam et al. completed a 12-year study on amalgam versus composite and found in the low-risk group that large composite restorations showed a higher survival rate than amalgam. We all do our own in vivo research in our offices. I, probably much like you, watch very closely how things progress. At every recall appointment, I’m able to see how my work is holding up and evaluate the product that I am putting out there. I have been out of school for 18 years and I can count on my fingers how many of my own composite restorations that I’ve replaced. There are fillings that I’ve placed that are 17 years old and still going strong. The photo to the right is a 10-year post-op of a crown-saving filling.
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Fig. 8
Years ago, amalgam was the only posterior filling material. Times have changed. Composite is a material that is beginning to rival amalgam (and in some cases, porcelain). The esthetics are obviously on a different level than amalgam, but composites’ durability and versatility are now at least on the same playing field. I remember my dental school days when I enjoyed working with amalgam. Now, I feel the same way about composite — I love working with it. I love the esthetics and how I can try to make my restorations look so natural. I love how I can be conservative and save tooth structure. But mostly, I love how I can feel confident that I am doing what is best for the patient. Dr. Gammichia is a general dentist in Apopka and can be reached at jgammichia@aol.com. If you are interested in his lecture please visit his website www.PosteriorComposites.com.
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The Restorative Cycle in Dentistry By Dan B. Henry DDS, FACD, FICD
Clinical Relevance The replacement of failed restorative dentistry continues to be a major part of operative dental procedures performed in the U.S. and Canada.1,2,6,7 In addition, dental continuing education tends to concentrate on technical procedures with little emphasis on the long-term outcomes for restorative choices. The choice of restorative materials combined with the operator’s skill level has a profound influence on the life expectancy of a restoration. How long a restoration will last has direct consequences on oral health.
Summary This paper will discuss the importance of selecting restorative materials that are best able to survive within the environment in which they are placed. The clinical relevance for the use of direct gold, especially in younger patients or in virgin caries will be presented. In addition, the article is intended to present the oral health advantages of placing restorative materials with the highest probability of long-term success in various environments.
Introduction Restorative dentistry is an invasive and irreversible process that creates restorations with a finite life. Therefore, possibly the most significant consequence for the repair of dental defects and indeed for all operative interventions, is the need to replace restorations when they fail.1,2,3,4 The unintended consequence for all operative procedures is to place the patient’s tooth and/or the tooth site into a “restorative cycle” (RC) that will continue throughout the life of the patient. The fundamental concept of an RC brings into focus the loss of tissue around existing restorations on a recurring basis.
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The RC consists of three major events; the first is the loss of tooth structure due to trauma or the initial disease process. The second event is the loss of tooth structure due to the necessary process of preparing a tooth to receive a restoration. The final event occurs when the restoration fails and must be replaced. With the replacement restoration, the RC is repeated. All restorative options are subject to RCs. Add to this the human tendency to settle into routines, where the average dentist gives little thought, other than color, to the material chosen and even less thought to the “environment” in which that material is to be placed — and the RC is accelerated. There are a number of factors that determine the length of the RC for any given restorative material. These include the environment in which the restorative material is to be placed. For example, the age and health of the patient, diet, the occlusal loads brought by the patient, oral hygiene, plaque levels, and the type and levels of bacteria within the oral environment of the patient. Physical properties of the restorative material and the skill level of the operator, at the time of placement, also contribute to how long a restoration will last until it ultimately fails. This fundamental understanding of the finite life for all restorative procedures the patient presents, as they relate to the environment, should be one of the determining factors for which restorative material will be best to use in any particular restorative situation. Therefore, any attempt to quantify the predicted life of a restoration should help dentists and patients make informed decisions about restorative options. From review of the literature2, 6 and through personal observations from more than 30 years of restorative practice, it is the understanding of the author that posterior composite restorations, in general, have a life expectancy of 6-10 years. Therefore, the RC assigned to posterior composites would be 6-10. Similarly an RC of 12-18 would be assigned to alloy restorations. Cast gold would have an RC of 30-40 and gold foil/direct gold would have an RC of 45-55. In addition, this refers to first generation restorations. Second generation restorations, on
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average, would have RCs shorter than first generation restorations due to an increase in the size of the restoration and greater loss of tooth structure, leading to a weaker tooth less able to stand up to stresses within the mouth. In addition, changes in the “environment,� aging of the patient, changes in eating habits, systemic disease processes and unnoticed iatrogenic flaws, to name a few, will have direct influences on the life of restorations.
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Fig. 7
Fig. 8
Fig. 9
Fig. 10
Clinical Cases The RC and its effects clinically can be better understood by the following cases. The first case (Fig. 1-10) is virgin caries in a patient in his mid-50s. The patient is in good health and demonstrates good home care with a low caries rate. The patient will need the restoration to possibly last more than 45 years, thus a restorative material with a RC of 6-10 or even 12-18 will be insufficient. Restorations with longer RCs will better serve the needs of the patient. Because this is a first-time restoration where the occlusal load will not be directed on the restoration and cosmetic concerns are low, either a gold casting or direct gold would work well. Direct gold/gold foil was chosen to allow for a conservative preparation without having to flair the prep in order to place an indirect casting. In addition, due to the depth of caries, a base of Fuji IX was placed.
Fig. 1
Fig. 2
The use of EZ Gold, developed by Dr. Lloyd Baum from Loma Linda, Calif., allows for placement of a direct gold restoration of this size in a reasonable amount of time within a busy restorative practice. Another advantage of direct gold is that the restoration can be placed in one appointment without a lab fee. The prep design can be kept conservative without having to extend the proximal cavo-surface margins to accommodate for casting placement and finishing. Finally, the restoration has a significant chance of lasting 50 years in the environment in which it is placed. The next case (Fig. 11-14) is interesting on several levels. First, due to the age of the patient, the decision for what restorative material to use will have a profound influence on the future health of the tooth and tooth site. Another issue of concern is who is doing what and when. The environment is as follows:
Fig. 3
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The patient is 10 years old with caries into the dentin of the mesial pit of his six-year molar, and has good oral hygiene with a low caries rate. The patient is a bright, energetic young man with a good understanding of oral health and has the ability to undergo a procedure the will take approximately 45 minutes under a rubber dam. The author wishes to interject here that this is a situation that should be addressed further by everyone. Even though it might sound counterintuitive, in the author’s opinion, pediatric dentists should be doing direct gold restorations. It has been a personal observation that when patients leave the pediatric dental practice and come into a general restorative practice, a lot of the 6- and 12-year molars have composite restorations. A significant number of these restorations are failing with others not far behind. The problem with this situation is that a real opportunity to treat the patient with optimal care has been lost. Therefore, in the opinion of the author, direct foil should be taught in pediatric residencies. If the receiving restorative dentist acquires the patient with a direct gold restoration in the posterior teeth, there is a good chance that future replacement restorative work would be more manageable for long-term health of the patient and retention of the tooth. This case is a good example of the need for longer lasting RCs. Because this 10-year-old has a restoration with a RC of more than 50 placed, there is a good chance that the molar will remain intact, without need for full coverage and/or root canal therapy for the remainder of the patient’s life. Another point that should be made is that predictions for future success and/ or failure for restorative materials can only be made on current conditions and known history of the environment. Assuming conditions will remain the same, good hygiene and health, predictability of restorative materials should remain consistent.
Fig. 11
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Fig. 14
The next case (Fig. 15-20) is that of virgin caries on a patient in his late 30s. Again, the environment is that of a younger patient with good oral hygiene and low caries rate, with a good understanding of excellence in dentistry and a desire for health and longevity. In this case, pit and fissure caries were deep into the dentin; thus, a foundation of Fuji IX was placed after simple caries removal had been completed. The final prep was completed to ideal depth using the Fuji IX as the floor of the prep. EZ Gold was used to complete a Class I gold foil restoration that should give the patient years of service beyond other materials. Also, notice in the final photo, the posterior composite on the first molar that will need replacing shortly. Again, an opportunity lost, but at least salvageable with a gold casting.
Fig. 15
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Fig. 19
Fig. 20
The final case (Fig. 21-22) presents with the following environment: The patient is in his mid-30s with moderate to poor oral hygiene; is a tobacco user, smoking at least a pack of cigarettes a day; and, his diet consists of high carbohydrate and high sugar intake, including several sodas a day. He is interested in the least expensive treatment possible and really does not place oral health or dental care as a high priority. This patient is, in the author’s opinion, “below the line” for optimal dental care. However, the patient should be treated with respect and restorative choices should be selected that bring cost and reasonable longevity into play. This patient can be converted to an “above the line” patient who values oral health and long-term dental restorative care — he simply needs to be educated and shown the value of good dental care in a respectful and caring dental environment. In a case where there is poor oral hygiene with moderate to high dental carries, a restorative material should be selected that can stand up to the environment in which it is placed. Something needs to be done; waiting for the patient to realize the error in their thinking or putting in the latest material just because everyone else is using it, is inappropriate. In this environment, posterior composites would be a poor choice. Studies show there is significantly less recurrent caries around amalgam then resin composites5, as the author has discovered in personal observation. Therefore, alloy is best to consider in an environment such as this. Corrosion will seal the restorations, allowing for longer life in a marginal environment. In addition, the cost will be less than other materials allowing, in many cases, a patient with limited means and/or poor priority selection, to save their teeth. The author prefers a high copper alloy such as Tytin by Kerr. www.floridadental.org
The restorations should be polished. This not only will create a surface that is easier to clean, it is less likely to have food and plaque stick. By polishing alloy restorations or properly finishing all restorative materials, the dentist is establishing a trust relationship with the patient. In addition, longer life of the restoration is more likely. Also, by polishing and finishing all restorative treatment, the dentist is giving the patient the opportunity to see and feel the difference between restorative work that is not finished. It has been the experience of the author that this will help influence the patient to understand the value of good oral health and quality restorative work. Through this experience, the patient will be more likely to place high quality restorative work on a higher priority than it might have been. The operator will find that cost is not the problem with accepting quality restorative work; it is all about priorities and trust. When patients are educated about physical properties of materials and given the opportunity to experience quality restorative work, health and longevity become more important than cosmetics. Cosmetics are still important; it is simply placed in a more realistic position with relation to wants versus needs. Finally, if dentists perform routine outcome assessments for the restorative work they complete — documenting the time of placement and the time before a replacement is needed — then accurate RCs could be assigned to all restorative procedures within a given practice. RCs can be classified by material, restoration size and configuration, generation of placement and patient risk factors.
Fig. 21
Fig. 22
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Restorative Cycle
References
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It is the opinion of the author that having accurate information about how long various restorative options last before replacement is necessary will give the dentist who completed the procedure a better understanding about the long-term effects of the various restorative choices within his/her practice. In addition, it is the responsibility of all restorative dentists to be competent in the placement of all available restorative materials. There is no one restorative material or technique that is appropriate for all situations.
&
1. Moore, D.L. and Stewart, J.L. Prevalence of defective dental restorations, J. Pros Dentistry, April 1967 p373-378. 2. Fontana, M. and Gonzalez-Cabezas, C. Secondary Caries and Restoration Replacement: An Unresolved Problem, Compendium, January 2000, p15-24. 3. Henry, D.B. A Philosophy for Restoring Virgin Caries, J. Operative Dentistry, Sep/Oct 2008-Vol 33 #5 p475-483. 4. Henry, D.B. The Consequences of Restorative Cycles, J. Operative Dentistry, Nov 2009, Vol 34, issue 6, p759-760. 5. Hilton, T.J., Broome, J., Fundamentals of Operative Dentistry, Third Edition, Chapter 10 p295.
6. Roulet J.F., Review of the clinical survival of direct and indirect restorations in posterior teeth of permanent dentition, J. Dent, 1997, Nov, 25{6} p459-473. 7. Manhart J., Chen H., Hamm G., Hickel R., Benefits and disadvantages of tooth-colored alternatives to amalgam, J. Operative Dentistry, 2004, Sept/Oct, Vol. 29, {5} p481-508. Dr. Dan Henry is a Past-president of the FDA, and is currently President-elect of the American Academy of Gold Foil Operators. He practices general dentistry in Pensacola and can be reached at golddoc@bellsouth. net.
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Dental Staff
A
Hygienist e n o y
r e v E
Can
Admire:
Keeping the Hygiene Vibe Strong in the Dental Office
By Valerie Gagnon, RDH, BS/m
What? Social networks talk about us? “Dental diva?” Really? How can we promote our positive role when we see photographs and postings referring to us as divas or perhaps more unflattering terms around the World Wide Web? Helping the office promote a positive vibe with prevention is the first step. As hygienists we are dental providers, not only in scaling and polishing, but in helping the office strive to keep patients well-educated on their oral conditions, from the smallest of cavities to fullmouth reconstructions. We are among 64
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the front runners in keeping the mouth in great shape. We need to remind the practice (in little ways) that our recare appointments matter just as much as the full-mouth case that is entering through the office door. That full-mouth case may never have happened without our help or the help of the whole team together. We promote healthy mouths to help maintain healthy bodies. Here are a few tips for keeping that positive vibe strong in the dental practice: Look at other options in continuing education: marketing strategies, management, and sales. There are many classes that
January/February 2014
offer marketing strategies for dental practices. Sometimes you just need to do your research and see which class would best suit your practice. Ask your sales representatives; they have great resources to help you find the best classes to attend. Think outside the box and maybe take a college business class; that is a fantastic way to help develop that businessperson inside of you. Use the intraoral camera, not only to point out the plaque, but the patient’s smile as well. Maybe suggest whitening or a smile makeover. Dust off that intraoral camera and start using it on all of your patients.
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Dental Staff
Take pictures of their smiles and leave them on the screen so patients can look at them and critique their own smiles; you will be surprised at what they will ask you. Take a photo of an older restoration, maybe a leaking amalgam, and ask them questions about what they see. Have them do the initial diagnosis. Most of the time, the patient will be curious to know how it can be repaired. That will create happy dentists as well as better relationships with patients. We need to build trust, and having patients own their care, rather than us telling them what they need, will make a huge difference to our practices. Prediagnose. There are many tools to help screen patients for dental health. The DIAGNOdent is a fantastic instrument that can help prediagnose pit and fissure caries of nonrestored occlusal surfaces. Ask for referrals. Internal referrals are the best referrals. The patients are not only prepped to be there, but there is already a relationship built. It is said that most internal referrals become long-lasting patients as well. Ask the office manager or dentist about adding incentive for existing patients by adding a $50 credit to their account for every referral they bring in. Online advertisement. Ask your patients to write some feedback on various websites about their experience at your office. It can be a simple five-star rating to a full write-up about how they had a great time at your practice. Discuss various websites that your office may want to target. Maybe suggest hiring a company that specializes in social networking.
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Help the front desk by scheduling patients’ next appointments or collecting the patients’ portion of fees. Don’t hide from the front desk; embrace it. The staff will appreciate it and patients will own their appointments that you make for them. Whether it is a simple six-month recare or periodontal therapy, patients will be less likely to cancel since you built relationships with them during their visits. Also, know your fees and understand how insurance works. Ask the front desk person to train you; they will be glad to teach you how the insurance process functions. You will gain the ability to answer insurance questions easily and, again, build that relationship with your patients. You can ask the front desk person to tell you ahead of time if a patient’s collection is due at the end of the appointment. When necessary, you can collect the patient’s cash portion and relieve the front desk of some details. It also will help with accounts receivable. It’s a win-win for all. Find new ways to promote prevention to your patient. There are so many new and exciting things that you can do to help promote prevention in the office. A great thing you can add is a dental store. Stock it with exciting products that your patients cannot easily find elsewhere. Patients love to shop, and it gives opportunity for you to affect your patients’ choice of products. You can stock it with fluoride rinses, xylitol products or organic dental products. It will help with production for the dentist and help supply patients with healthy dental products at home.
“
We need to build trust, and having patients own their care, rather than us telling them what they need, will make a huge difference to our practices.
”
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Dental Staff
hygienist from 65
Make it personal during their visit. Talk to your patients and see what they’ve been up to. Are they getting married, expecting their first child or going on an exciting trip? Write it down and let the dentist know. This will help build trust and better relationships with your patients. It does not take long, just a few minutes before you lay them down and begin working. I’ve been in practice for the last 16 years, and I’ve asked every single patient how they are and what they’ve been up to in the last few months. That alone built long-lasting relationships with patients. Just having someone they can talk to will bring them joy, especially if you are the only one they can talk to. Watch the clock. I’ve often been asked how I stay on time with everything I do. All I can say is that I watch the clock and manage what I need to do ahead of time. Many dentists, patients, assistants and the front desk staff will thank you merely for staying on time. Simple time management steps can be taken: n time how long it takes for bitewings n time your periodontal charting n time your scaling n time your polishing n time the dentist exams
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These simple steps will help guide you in staying on time. I have timed myself to a T. From the moment patients sit in the chair and I ask how their day is going, my clock is running. Look, listen, watch. Read about the latest products that are available to the practice. Look at the research that backs the new products. Things to look for might include price or ratings from other offices. You can ask your sales representative about new products and if you can get samples of any to test in the office. You might also ask if there is something new on the market that your practice may be the first to try. Suggest advertising the latest and greatest within the community. Be part of the monthly newsletter. Suggest having a hygiene article included. The newsletter can be printed on paper and mailed or, as is becoming more common, emailed to patients. This creates less waste and it shows that your practice cares for the environment. The newsletter should be a team effort from everyone in the practice. The dental hygiene column can include topics on home-care methods or valuable information about oral health. You can add an article you may have read in a dental magazine, or include studies that come out on various dental topics that may interest your patients.
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These are a few examples that can better establish you, the hygienist, as part of the team and give you the ability to build value within the practice and for your patients. There are many more examples of changes that can be made, but it is up to you to take the first steps. Remember to have fun while doing so. Maybe schedule a team meeting. Ask the staff to brainstorm ideas for a stronger team that can help the practice grow in your community. It takes only one person to make this move, and that person is you. I also recommend starting slowly and not with the full-blown process. Take baby steps into this venture. Reprinted with permission by RDH Magazine. Valerie Gagnon, RDH, BS/m, has been in the dental community since 1992. She received her dental hygiene degree from John Abbott College (an affiliate of McGill University) in 1996. She received her bachelor’s in business management and is now pursuing her master’s in adult education and training. She currently is part of a pilot program as a clinical educator.
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Health Care Reform
Health Care Reform: FAQ Update! By Carrie Millar
FDAS Membership Services Manager
This is a general overview of the health care reform law as it relates to the small business dental practice. It does NOT attempt to cover the law’s provisions and should not be used as legal advice for implementation activities. There seem to be weekly, and sometimes daily, changes to the policies and rules for the major provisions of the Affordable Care Act (ACA) that took effect on Jan. 1. We will clarify some of these changes to the best of our ability. Will I be penalized if I don’t have coverage starting Jan. 1? The ACA
imposes tax penalties on individuals who do not maintain minimum essential coverage starting Jan. 1, 2014. However, in late October the Department of Health and Human Services issued a Q-and-A document* that listed exemptions to the mandate. Included in the list of exempted excuses from the penalty are individuals who remained uncovered for “a continuous period of less than three months”; meaning, that if you secure coverage by March 31, 2014 and remain covered for the rest of the year, you will not be penalized. What is a grandmother plan? This is a
term used to refer to group and individual health insurance plans that were in effect prior to 2014 but do NOT have grandfather status. Grandfathered plans were in force prior to March 2010. Can I keep my current individual/ group plan if I do not have grandfather status? Possibly. In mid-November, www.floridadental.org
President Obama announced a new administration policy that would allow you to keep your existing plan in 2014 if your insurance carrier allowed it. This is for individual and group plans that renew from January through October 2014, as of right now. Carriers that are allowing you to keep your current plan include: Florida Blue, Aetna, United Health Care, Avmed and Cigna. I have a grandfather plan; are there still changes to my plan? Yes, some of
the requirements of the ACA pertain to all plans, while others are only required of non-grandfathered plans (grandmother plans). The elimination of all lifetime maximums, addition of no-cost preventive care, maximum of 90-day waiting periods for new hires, and coverage for female contraceptives are just a few of these requirements for all plans. However, at renewal your carrier should provide a summary of benefit coverage (SBC) that outlines all policy benefits. Do I have to notify my employees of their health insurance options?
Yes! Part of the ACA required that by October 2013 employers notify all employees, regardless of size, on their health insurance options. The Department of Labor has issued sample letters that can be found at http://www.dol.gov/ebsa/. There is one sample letter for employers that do NOT offer group coverage and another for employers that DO offer group coverage. If I have a pre-existing condition will I be able to get an individual plan?
About FDA Services Inc. FDA Services (FDAS) is the wholly owned, for-profit insurance agency of the Florida Dental Association. FDAS is a full-service insurance agency and takes pride in managing the insurance portfolios of each and every client. Last year alone, FDAS contributed more than $969,000 to the FDA to help reduce membership dues.
market, cannot be declined or rated up based on pre-existing conditions. In fact, the only rating variances can be demographic area, tobacco use, age and family composition. What should I be doing right now? If
your health insurance plan, either group or individual, is too expensive or does not have enough coverage, then it would make sense to see what your options are now. However, to compare your options on the exchange to your 2014 renewal, you will have to wait until your renewal. Then you will be able to fully evaluate all your options. FDA Services’ experienced staff is ready to get to work for you. If you need a review of your current insurance policies, call us at 800.877.7597 or email insurance@ fdaservices.com. Ms. Millar can be reached at 850.350.7155 or carrie.millar@fdaservices.com. * http://www.cms.gov/CCIIO/Resources/ Fact-Sheets-and-FAQs/Downloads/enrollmentperiod-faq-10-28-2013.pdf
Yes! Starting in 2014, individual health insurance plans, whether purchased on the individual exchange or in the private January/February 2014
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Support the Companies FNDC Exhibitors
That Support Organized Dentistry
These exhibitors have made the commitment to attend the Florida National Dental Convention (FNDC). Not only do these companies exhibit the latest in technology, materials and equipment, but many sponsor events and continuing education programs at the FNDC. Take a minute to see if your supplier is on the list. Make an effort to stop by their booth in the Exhibit Hall in June for show specials. Please support those entities that help make the FNDC a rewarding member benefit. FDA Services Inc. is a major sponsor of the Florida National Dental Convention.
3M ESPE
A A-dec
A. Titan Instruments Accelerated Wealth Accutron Inc. ACTEON North America ADS Florida LLC Advantage Technologies Advantica AFTCO Air Techniques Inc. AMD Lasers, A DENTSPLY International Company Angie’s List Aseptico Inc. Aspen Dental Atlanta Dental Supply Atlantic Dental Sales Inc./Brewer Design
B Bank of America Practice Solutions
Bankers Healthcare Group Bayshore Dental Studio Belmont Equipment Benco Dental Bien-Air Dental Bioclear Matrix System by Dr. David Clark BIOLASE Bisco Dental Products BQ Ergonomics LLC Brasseler USA Bright Now! Dental/Smile Brands Inc.
C CareCredit
Careington International Carestream Dental Centrix Inc. Chase Dental SleepCare Citibank CliniPix Inc. Coast Dental P.A. Colgate COLTENE Crest Oral-B CUTCO Cutlery
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Letters to the Editor
Letters to the Editor Time is Running Out … Maybe You Can Help Me?
Response to Dr. Eli White’s Letter to the Editor, Today’s FDA Nov/Dec 2013 By James C. Paladino, DMD, MHA
By Richard L. Sherman, DDS, MS
Privatizing Florida’s Medicaid dental system into managed care began in October 2013. This will allow for-profit plans to determine the health care of Medicaid recipients. Of course, this privatization plan always had problems, but who cares? The term “for-profit” is all I need to hear … who cares about dentistry? I have been a dental Medicaid provider for more than 30 years. I have NEVER made a profit treating these patients. As everyone knows very well, the reimbursement fees for Medicaid in most cases fall well below the profit margin for a dental office. I personally “subsidize” the treatment of Medicaid patients since their fees don’t even cover my overhead expenses! This is where I need your help. How do I become a “for-profit administrator” and stop being a “profit losing” dental provider? Even though the entire Medicaid program would “fold” if it wasn’t for the actual dental providers (but who cares), it is obvious that over the years, thanks to the government, everyone else makes a profit on this system (owners and investors of managed-care companies, administrators, secretaries and processors working for these companies, providers of supplies for these companies, etc.) except for us — the people who actually make the system possible — the TRUE caretakers! So, can you help me? Since I am a Medicaid provider, I have already been fingerprinted and have had a criminal background check. Do I need more? I hope I don’t need too much money to start … don’t forget, I am a Medicaid dental provider, NOT the CEO of a managed-care corporation. Thank you in advance. Dr. Richard Sherman is a pediatric dentist in Pembroke Pines and can be reached at kidsmiledoc@gmail.com.
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President, Alachua County Dental Association
Dr. Eli White’s characterization of the current and pending Medicaid system as an “ostrich with its head in the sand to avoid reality” hits the nail on the head. As a non-Medicaid provider, I cannot comment on the specifics of operational procedures. However, I wholeheartedly agree with Dr. White that the Medicaid program will have a significant impact on all dentists, that there is a need to effectively coordinate the ideals of Medicaid policy with the reality of Medicaid operations among legislators, third-party administrators, FDA leadership, providers and patients. The existence of the Medicaid program is evidence that the majority of citizens recognize government’s legitimate role in addressing cultural inequalities of access to care. Appropriate evaluation of Medicaid policy is informed not only by reducing the inequality of access to insurance, but also by reducing the inequity of unequal access to appropriate care. Medicaid policy cannot operate strictly in the bubble of economics and politics. Even though the state, through Medicaid, has fulfilled a duty to reduce inequalities of access to insurance, stakeholders cannot “bury their heads in the sand” if it is not possible to provide or receive appropriate care within the system. Dr. James Paladino is a general dentist in Gainesville and can be reached at jacupa@aol.com. Editor’s note: Views and conclusions expressed in all editorials, commentaries, columns or articles are those of the authors and not necessarily those of the editors, staff, officials, Board of Trustees or members of the Florida Dental Association. For full editorial policies, see page 2. All editorials may be edited due to style and space limitations. Letters to the editor must be on topic and a maximum of 500 words. Submissions must not create a personal attack on any individual. All letters are subject to editorial control. The editorial board reserves the right to limit the number of submissions by an individual.
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C lassified a dvertising
Opportunities
The FDA’s online classified system allows you to place, modify and pay for your ads online, 24-hours a day. Our intent is to provide our advertisers with increased flexibility and enhanced options to personalize and draw attention to your online classified ads! The FDA online classified ad model is for “paid online advertising.” Effectively, the advertising rate you pay will entitle you to online classified ads with increased exposure. As an added benefit, we will continue to publish the “basic text” format of paid, online classified ads in our bimonthly printed journal, Today’s FDA, at no additional cost to you. All ads posted to the online classified system will be published during the contracted time frame for which you have posted your online classified advertisement. Our magazine is published bimonthly, and therefore, all ads currently online will be extracted from the system on roughly the following dates of each year: Jan. 15, March 15, May 15, July 15, Sept. 15, Nov. 15. The ads extracted at this time will then be published in the following month’s issue of Today’s FDA. Please view the classified advertising portion of our website at http://www.floridadental.biz/.
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Disability Insurance Attorney. What will you do if your disability insurance company denies your claim? When your financial security is at risk, the stakes are too high to go it alone. Disability Insurance Law Gro up represents dentists at all stages of the disability insurance claims process. Your insurance company has a team of attorneys representing its interests, shouldn’t you? Contact us for a free consultation at 888.644.2644, info@dilawgroup.com, or www.dilawgroup.com. FLORIDA — A blockbuster opportunity. Full or part time for General Dentists, Endodontists, Orthodontists, Pedodontists, Periodontists, and Oral Surgeons. Generous compensation with unlimited potential. Guaranteed referrals. Join our group specialty care practice with a significant general dental component. Established in 1975 in Aventura, Coral Springs, Delray Beach, Boynton Beach, Stuart, Ft. Pierce and Melbourne. Call: Dr. Feingold at 561.665.0991. Email: drfeingold@ dentaland.net. Dentist/subspecialist on large “one stop shop” medical campus. Looking for dentist and/ or dental subspecialist to come aboard our $15,000,000 (3,000 patients/week flow thru campus) “one stop shop” medical campus in Sarasota, Florida. Sarasota ranked #1 beach and #1 mid-size city for arts/culture in U.S. Surf to universityhealthpark.net. Call Don Harvey, MD at 941.724.3259. Temporary/Fill-In Dentist. Solo Private Practice for 20+ years (sold 2009). Exiting Active Duty Military soon. Licensed FL, AL, GA. Phone: 770.656.5269, email: drglassdmd@yahoo.com. General Dentist. MAY 2014 GRADUATE: 4th year dental student from Marquette University seeking quality oriented dental practice for Associateship or Partnership/practice purchase opportunity in SOUTH FLORIDA post-graduation (South Miami/ Brickell/Aventura/Coral Gables). Bilingual. Comfortable with Endo, Oral Surgery, and Cosmetic dentistry. CV Available upon request. Contact: 414.213.9397 or aalopez86@gmail. com. I am a 2012 graduate of the University of Pennsylvania School of Dental Medicine. I recently completed my General Practice Residency at Montefiore Medical Center, and I have started to work in the New York City area. Originally from South Florida, I am looking to relocate back in the next few months. I am looking for opportunities as a general dentist anywhere from Delray to Miami. CV available upon request. Contact: jamiesaltz@ gmail.com or 561.715.9828.
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Great Expressions has a neighborhood practice in Jensen Beach, FL and we have a full-time Pediatric Dentist position available. Our specialists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. When considering a career with GEDC, dental professionals can expect unlimited production based earnings, malpractice coverage, a stable patient base, covered lab costs, training opportunities, and long-term practice or regional career growth. To learn more please call Ross Shoemaker @ 678.836.2226 or visit us on the web at www.greatexpressions.com. Wonderful Opportunities. Opportunities with a growing company. Full time with Benefits — Health, Life, Vacation and Holiday, 200 Hours of CE, 401K. State of the Art Practices and well-trained team. These opportunities are throughout Florida. Please contact 904.545.6789 or 317.560.0901, email: cstarnes@heartlanddentalcare.com or sasmith@ heartlanddentalcare.com. Need an Associate? Need a job? There’s no fee for finding you a job! Call Doctor’s Choice Companies. Sandy Harris 561.744.2783, sandy@doctorschoice1.net. Dynamic Dental Health Associates, a new private fee-for-service group, is growing and expanding statewide in particular Jacksonville, Orlando, St. Petersburg, Sarasota, Port Charlotte and Fort Myers. Top Compensation, daily guarantee, health insurance, modern facilities with latest technology, great patient flow, no administrative headaches and professional mgmt. We also buy dental practices and create exit/ transition strategies for solo and group practices. If interested in selling your practice, please send email to Dr. Alex Giannini (agiannini@ ddpgroups.com), OR if interested in a Dentist position, please email your CV to careers@ ddpgroups.com or call 941.312.7838. Current Florida openings: Fernandina Beach, Spring Hill ($5K Signing Bonus), Pinellas Park, Sarasota, Venice, Port Charlotte and Winter Haven.
PART-TIME ASSOCIATE GENERAL DENTIST POSITION IN NORTHEAST FLORIDA: Our practice is a long-established private practice in the St. Augustine Beach, Florida area. We have a great team of professionals, a friendly patient base, a positive working environment and are in network with many PPO dental plans. If you are a general dentist looking for a part-time associate position (2 to 3 days per week) in a time-honored private practice, we encourage you to apply. Submit your CV/Resume and contact information to morsedds@bellsouth.net or fax to 904.471.5240. Dentist Opportunities. Dental Partners is one of the fastest growing family dental practice groups in the Southeast. We give you the ability to focus on patient care while earning a base of $125K-$200K and the opportunity to earn more based on production. Benefits package of medical/vision/life/FSA, 401K, professional liability and yearly CE allowance. Relocation and student loan repayment assistance program may be available. Email resume to areimiller@dentalpartners.com or call Ashley Reimiller, Director of People Development, 321.574.8003. General Dentist Needed, Boca Raton. If you love dentistry, have excellent chair-side and communication skills, and want to surround yourself with talented staff, we invite you to join our busy, state-of-the-art, paperless, practice. Part time or full time. Compensation: $600/day minimum, depending on qualifications, plus high percentage of collections. Call 954.703.9309 or email smilesofboca@aol.com. Florida — Orlando/Daytona/Jacksonville/ Tampa/S. Fla. Associateship not working? Not enough patients? Expanding group practice with 42 offices and 10 new locations opening this year. Top salaries. Training and mentoring for new/recent graduates. Both General Dentists and all Specialists needed. Fully digital offices. Call Dr. Andrew Greenberg 407.772.5120 (confidential, fax CV to 407.786.8763), visit www.greenbergdental.com or email to andy@ katsur.com. Oral Surgeon needed for busy Margate dental practice. One day per week (Fridays Preferred), very experienced support staff, computerized, digital X-rays, Friendly work environment. Call 954.973.0990.
ALABAMA — General Dentist. Cumberland Dental, a successful growing practice with clinics conveniently located in Birmingham, Tuscaloosa, Oxford and Gadsden, AL, is looking for full- and part-time General Dentists to join our team. We offer a generous compensation and benefits package, including malpractice, medical, life and disability benefits, and participation in a 401K with employer match. Future ownership is a possibility for interested and qualified individuals. Actively seeking a Part-Time Associate Dentist to work Monday and Tuesday in our Gadsden, AL office. Please contact Bonnie Kumar at 617.538.7380 or bkumar@amdpi.com. General Dentist position. 16-year Established Private Practice (1997). Full time or part time. Benefits for full time. Very busy practice. Prime location. Great opportunity for the right person. Experienced only (5 years min). All phases of General Dentistry (High Prosthodontics). Over $350k+ earning potential based on 4 days/week. The Villages. Call 321.945.9545 or fax resume: 407.302.9799. 3-4 Days FFS office. South Central FL practice, 45 min from Wellington, 1 hr. from Plantation, nonEast coast feel. Amazing staff and patients. Great opportunity for Good Doc. Must do: Molar RCT, Dentures and extractions. Well above average take home. kurthausy@hotmail.com. SEEKING PEDIATRIC ASSOCIATE. FT MYERS, FLORIDA. A world class pediatric dental practice is looking for a full-time associate to assist in managing patients in a brand new state of the art world-class facility. Perform all phases of Pediatric dentistry services with the opportunity to become partner. Requirements: DDS or DMD degree, licensed in the state of Florida; Background experience in conscious sedations and hospital dentistry; Experienced in interceptive orthodontic encourage, but not required; Monday-Friday, 9am-5 p.m., 401K, Paid Vacation, Pension and Bonus Potential. Interested parties email CV to Annemarie@tcreative.com or fax 407.650.2677. General Dentist. Ideal opportunity for an experienced dentist with strong clinical skills, positive personality and excellent communication skills. Full time associate dentist. Full schedule from the start. Endless potential for growth and compensation. Beautiful state of the art practice with amazing staff and owner doctor. If you are a Florida licensed dentist with a solid work ethic and a personable chairside manner, submit resume to fax: 772.464.2859 or email: sdcsmile@gmail. com.
Please see classifieds, 74
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Your Classified Ad Reaches 7,000 Readers!
classifieds from 73 Dentist Needed Downtown Miami! We are a new, private, busy dental office looking for a motivated, outgoing, skilled dentist for a FT/PT position. PT we have Tuesday, Thursday and/or Friday to grow into 5 days in the near future. We offer highincome potential and possibility of an ownership in the future. We are looking for someone longterm and offer tremendous growth opportunity. Bilingual/Spanish speaking is a big plus. 3+ years’ experience preferred. Email your resume to nhorst02@gmail.com. General Dentist Needed! Downtown Ft. Lauderdale, FL 33301. We are an established, private, busy dental office looking for a motivated, outgoing, skilled, general dentist for PT position. Mondays and Wednesdays are available. We are looking for someone long-term and offer tremendous growth opportunity. 2+ years’ experience preferred. Email your resume to nhorst02@gmail.com. General Dentist. Great Expressions Dental Centers has a current opening for a full-time General Dentist in Zephyrhills, FL. Our dentists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. When considering a career with GEDC, Dentists can expect unlimited production based earnings, full benefits, malpractice coverage, a stable patient base, and long-term practice or regional career growth. To learn more please call Ross Shoemaker @ 678.836.2226 or visit us on the web at www.greatexpressions.com. Periodontist Opening in South FL. Great Expressions has a neighborhood Specialty practice in Miami, FL (and in Kendale Lakes) and has a full-time Periodontist position available. Our specialists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. When considering a career with GEDC, dental professionals can expect unlimited production based earnings, a stable patient base, training opportunities, and long-term practice or regional career growth. To learn more please call Ross Shoemaker @ 678.836.2226 or visit us on the web at www.greatexpressions.com.
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Pediatric Dentist. Main Street Children’s Dentistry and Orthodontics is expanding throughout Florida! Whether a newer graduate, experienced associate, or practice owner we can provide you with a compelling career. Our doctors consist of board diplomates, university professors and published authors. All have made their home with us in a shared community of excellence and successful careers. Contact Robbie Thompson at 305.274.2499 x2041 or email careers@ mainstreetsmiles.com. NAPLES, FL General Dentist — Successful, Long-Established, Private Practice seeking a 3rd Dentist. Applicant must be Florida Licensed with a minimum of 2 years’ working experience. Exceptional Working Environment, Surrounded by Highly Skilled Professional Support Staff and a very Strong Patient Base. Start at 3 days per week with the Potential for a Future BuyIn. Previous Associate earned 175K working 3 days per week. Please email or fax Resume with contact information to: ddcnaples@aol.com or 239.262.7458. Orthodontist associate. Winter Garden/Dr. Phillips Seeking part time Orthodontic Associate to work Wednesday, Thursday and Friday. Must live within an hour of office. Experience preferred. Energetic and a heart for kids a plus! info@ championorthodontics.com. Prosthodontist or Advanced General Dentist. High-end multidisciplinary team seeking a motivated associate. A prosthodontist or an advanced general dentist. The center is located in an upscale area near Gulf Stream Plaza. Approximately one mile from the ocean. The practice recently underwent a modern and technological renovation. Please visit us online at www.ThePremierSmile.com. Our team coordinates and provides continuing education courses i.e. Invisalign, dental implants, cosmetics, sedation, and prosth. We employ a wonderful and highly trained staff that focuses on providing high quality care in a state of the art environment. We will provide the practice support needed for your success. Partnership opportunities are available. Please email CV to: info@ThePremierSmile.com or fax to 888.800.4955.
January/February 2014
Positions Available: Pensacola/Crestview/Santa Rosa Bch/Dothan, AL/Mobile, AL. Comfort Dental Care and Orthodontics, a premiere multispecialty practice, has immediate openings for General Dentists in NW FL — Santa Rosa Beach/ Crestview/Pensacola, as well as Greater Mobile, AL and Dothan, AL. Join a progressive, growing, private practice where only the sky is the limit for your future! Inquire today! legacysolutions4biz@ gmail.com. Associate Dentist. Beautiful office in South Walton County seeking a Florida licensed Associate Dentist. Great opportunity in the Emerald Coast. We are a general and orthodontic practice utilizing the newest technology such as, iTero and 3-D Cone Beam radiographs. We are in the process of designing and building a new office space which will include a separate surgical suite for in-office implant placement and general oral surgery, an in office crown and bridge lab and future space for a sleep center. We are searching for an energetic provider that is willing to think outside the box and grow with our practice. Please email your current CV to dlimousin. mbdo@gmail.com. General Dentist Needed for Growing Practice. It takes a special type of person to be a dentist at Klement Family Dental Care. Our culture is built around care, honesty and family, and our dentists always go the extra mile to ensure that every patient leaves with a happy, healthy smile. We’re seeking like-minded dentists who love dentistry, but don’t want all the headaches of running a business. This approach is designed to let you focus on what you do best. And our track record speaks for itself: our practice is thriving and expanding and we regularly hear from our patients how much they love us! careers@ klementdental.com Great Expressions Dental Centers has a current opening for a full-time General Dentist in Ft. Myers, FL. Our dentists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. When considering a career with GEDC, Dentists can expect unlimited production based earnings, full benefits, malpractice coverage, a stable patient base, and long-term practice or regional career growth. To learn more please call Ross Shoemaker 678.836. 2226 or visit us on the web at www.greatexpressions.com.
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Christie Dental has full time general dentist opportunity in Cocoa Beach. Christie Dental is currently seeking a General Dentist that appreciates the professional, financial and administrative benefits of group practice to join our team. Our doctors are offered a generous compensation and benefit package including: medical, professional liability, life and disability insurance; a 401(k) plan with employer match; and a continuing education allowance. Future ownership is available and encouraged. Doctors in our group enjoy traditional doctorpatient relationships while practicing in a team environment that offers the opportunity to discuss clinical cases with peers and support for professional/group development and growth. We are actively seeking full-time Dentists for our amazing beachside practice in Cocoa Beach, FL!
For Sale/Lease Dental Office Space for Rent. Dental space to share in our beautiful modern Tamarac location, ideal for general dentist or specialist. Our office is equipped with the latest dental technologies including digital x-rays and panorex, 3D cone beam CT scanner, denture lab with full-time technician on premises, computers and televisions in operatories and many other amenities. If interested please contact: Tamaracdentalspace@ gmail.com. Share/Sublease Office Space. General dentist has space available for sub-lease to general dentist or specialist. Prime office building. Great location. 5 ops (4 fully equipped) w/ large windows. Rent negotiable. Also, opportunity for transition as owner planning to retire in a few years. Dr. Lawrence Klein, 561.391.1114; cell: 561.212.8299 (text OK); lmklein@comcast.net. Beautiful, modern, fully equipped two operatory office for specialist. Ideal for endodontist. Can be converted to three operatories. Large referral area. Great location in NE Broward County. Close to everything. Available immediately. Call 561.271.5340. A GENUINE OPPORTUNITY. A free standing dental office fitted with 8 treatment rooms ... 4 of which are equipped. A modern office available for lease with an option to buy in beautiful, historic and population exploding St. Augustine. A U.S. 1 location that has had patients going to for over 25 years. Retiring dentist ... practice grossed 1.7M. rdixstaug@bellsouth.net.
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Key West, FL Dental Practice. Florida, Key West — Live and practice dentistry in paradise! Wellestablished, four-operatory dental practice with 1,850-square-foot, stand-alone building for sale. Great office layout, high quality staff, room for growth. Great opportunity! Call 305.394.2874 for details. Naples, FL Dental Practice For Sale On Best Offer. $89,000.00 (NEGOTIABLE) LIMITED TIME. ABSOLUTELY REDUCED PRICE FOR IMMEDIATE SALE. 3 OPS, IN THE MOST EXCLUSIVE HIGHEND AREA IN NAPLES. View website for more details. www.NaplesFloridaDentalPracticeForSale. com, email: NaplesFloridaDental@Yahoo.com. Buyers and Sellers: We have over 100 Florida dental practice opportunities, and the perfect buyer for your practice. Call Doctor’s Choice Companies today! Kenny Jones at 561.746.2102, or info@doctorschoice1.net. Website: doctorschoice1.net. Seminole County FL (Sanford). Good opportunity to take over thriving practice of 38 years with good patient flow. Doctor retiring. Building and practice separate, but both available. Gross income 5-600k. Listed for 330k. Three ops. Contact Dr. Roger Stewart, DMD, 407.323.5340. Sarasota, FL — The #1 Beach Destination in the USA! Established 30 year old practice with $302,000 Gross and 95% collection rate. Solid 3 day hygiene program with 1200 active patients — 25% PPO. Loyal and excellent hygienist and front desk secretary. 1100 sq. ft. business condo unit also for sale. Owner retiring. Contact Dr. Rotole at: rotoleswimsgood@verizon.net or 941.256.6903. Practice Sale: Pembroke Pines, FL — 12 y/o practice in high traffic area. Beautiful w/ ample parking. Equipped w/ latest tech — Dentrix, digital intraoral and pano radiography and lasers. 8 days of hygiene. 35 new pts/month. Rev. $1.3M. Call Michael Finnan at 561.722.0787 or Michael.Finnan@henryschein.com. Practice Sale — Central Florida Medicaid Based Pedo Practice. 9 Operatories in 3,800 SF Office. Owner Retiring! Gross Rev. $1.2M+. Contact Michael Finnan at 561.722.0787 or michael. finnan@henryschein.com.
Practice Sale — Small General practice in nice professional building on U.S. 1 central Pompano. Great potential as a “startup” practice! Gross Rev. $160K. Contact Michael Finnan at 561.722.0787 or michael.finnan@henryschein. com. Practice Sale — Brandon, FL — 6 Ops-Beautiful Reception Area-Lots of Space. Top-rated area schools. Parks — Ideal place to live, work and raise family. Easy access to Tampa and Orlando. Driving distance of Gulf beaches. Gross Rev $624K. Call Michael Finnan at 561.722.0787 or michael.finnan@henryschein.com. Beautiful 4 op satellite office in growing Wesley Chapel near Tampa. Digital pano, pelton crane chairs. Networked dentrix. Great start up for young DDS in upscale community. Nets 80k on 1 day/wk. My main office in Tampa. 60 yo DDS has Colorado license and moving to different pace. Turnkey practice for sale by DDS, no brokers. Bank financing available. Low overhead. michaeldkantor@verizon.net. Premiere Tampa Bay Practice. One of Tampa Bay’s Leading Dentists is retiring after 48 years. 5900 sq. ft., ATTRACTIVE, newer facility with onsite laboratory. Must see to appreciate! Dentrix, Dexis and i-CAT Classic. Very knowledgeable staff willing to stay. General, Implant and Restorative Practice. www.implantdentistrytampay.com. Contact Karen Davis 727.488.0217 or Morcie Smith 727.544.4385 or cell 727.254.9707. Dental Assisting School ready to go. Your staff do everything. Passive income. It is all there. Special Marketing module is included free that was additional to me. You will own the license and your territory. Easy. I have other ventures occupying my time. First reasonable buyer gets it. Please call now. 561.444.9565. Thanks. Newly Built Dental Practice Downtown Miami. This “retail space,” “street level” build-out was freshly completed less than 2 months ago. Large windows with heavy foot/car traffic encompass this 1,600sqft space with an extra 1,000sqft basement. Located in the heart of Downtown Miami, this modern practice is “turn-key” and selling “at cost.” Has website, major marketing campaigns, and already 200 patient count. nhorst02@gmail.com.
January/February 2014
Today's FDA
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Book Review
Book Review treatment is necessary in 8-15 percent of the time. On the other hand, in Chapter 2 the author states that his otoplasty procedures have led to excellent results with virtually no relapse. As with all procedures, an accurate diagnosis of the cause of misshapen or protruding ears must be made. Since ears are fully developed by eight years of age, it has been advocated to provide corrective surgery during four to six years of age.
Cosmetic Surgery for the Oral and Maxillofacial Surgeon Edited By: John E. Griffin, DMD and King Kim, DMD Published by Quintessence
Reviewed by Joseph Barnett, DDS
Cosmetic Surgery for the Oral and Maxillofacial Surgeon is a well-illustrated, practical and easy to follow how-to book on facial cosmetic surgery. It includes instrument setups as well as a thorough description of possible complications. Chapter 1 discusses rhinoplasty and emphasizes the difficulty of providing good function and esthetics in nose surgery. Patients should never be guaranteed an absolutely straight nose. Complications can include air flow, dryness, bleeding, discoloration and esthetic deformity. Re-
The primary reason for forehead lift surgery described in Chapter 3 is to lift the eyebrows and reduce associated dermatochalasis of the upper eyelids. It is cautioned that if the eyelids are treated, the possibility of a future need for a facelift or eyebrow lift must be considered. Removing eyelid tissue can make it impossible to lift the eyebrow without permanently opening the eye. A brow lift alone may alleviate mild excess upper eyelid tissue. The goal of facelift surgery is to provide a more youthful appearance. Surgeons must be sure patients have realistic expectations. The majority of patients require simultaneous facial rejuvenating procedures. Chapter 4 is extremely specific and includes the timing of vitamins, medications and incisions — in some cases to the minute. Tobacco users have a 12 times greater risk of skin necrosis than those who don’t and are required to stop smoking eight weeks before surgery. Hematoma occurred 9.2 percent when
preoperative systolic pressure was more than 150 mg Hg, compared to a 1.6 percent overall hematoma occurrence. The author considers a facelift to be the most image-altering cosmetic procedure performed; however, it is very clear that a healthy patient optimizes results. Chapter 5 recommends five procedures for esthetic improvement of the neck; the least invasive procedures were most predictable. Two procedures that were not recommended were submental skin excision with advancement and Z-plasty and facial percutaneous suspension. Chapter 6 was my favorite. A minimal incision facelift was said to be very predictable for the mild to moderate facial aging often found in 40- to 50-year-old patients. The chapter had great anatomy drawings, detailed technique photos and a series of before and after photos showing good results. Ironically, the photos are needed since many patients underappreciated the results unless they can see the photos. Chapter 7 was the longest chapter. Blepharoplasty is one of the most requested cosmetic surgical procedures. The first 20 pages describe the anatomy and extensive documentation necessary for this intricate and complex organ. Eyelid surgery is not recommended for patients with dry eyes. If CO2 laser incisions are used, then additional time Please see review, 78
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January/February 2014
Today's FDA
77
Book Review
candidates sought for fda leadership review from 77
is necessary for healing. Blindness is rare but can occur with lower lid surgery, usually due to orbital hematoma, indicated by severe, throbbing retrobulbar pain or proptosis. Dermal fillers and Botulinum Toxin, commonly known as Botox®, injection treatments are described in Chapter 8. Fillers are best for “static” lines whereas. Botox® is best for “dynamic” lines, which will eventually become “static” lines with age. The final chapter discusses facial skin rejuvenation and describes both CO2 and Er:YAG laser dermoplasty. Contraindications include psoriasis, keloids, infection, severe smoking and history of isotretinoin use. Premedication with antiviral and antibacterials is given to avoid possible herpes or infections that could scar the healing skin. There is great information on chemical peels and prescription Nu-Derm products at the end of the book. This is a well-documented, thorough textbook with numerous before and after photographs. It is written for oral and maxillofacial surgeons, who will want to purchase and refer to it often. They may also find it useful to review procedures with patients that are considering cosmetic surgery options. The reviewer claims no financial interest with the publication. Dr. Barnett is a periodontist practicing in Tallahassee. He can be reached at barnett@dozierandbarnett.com.
FDA speAker oF the house Deadline: Feb. 28, 2014 Elected by the FDA House of Delegates Duties: preside over all meetings of the House of Delegates; serve as ex officio parliamentarian of the Board of Trustees; and review all proposed resolutions of the Board of Trustees, councils and committees of the House.
FDA eDitor Deadline: Feb. 28, 2014 Appointed by the FDA Board of Trustees Duties: editorial supervision of all FDA publications; appoint volunteer associate editors as needed; and maintain open communications with other entities affiliated with the FDA.
For more information, call Rusty Payton, FDA chief operating officer, at 800.877.9922.
Applications available from your component dental association or the FDA website: www.floridadental.org/leadership-roster-forms
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OFF the cusp John Paul, dmd, Editor
Politics is not a Dirty Word (Mostly) “Those who decline to enter into politics are destined to be governed by their inferiors.” Plato paraphrased It’s Friday morning and I’m wearing a tie. I’m also wearing a scarf; can’t believe I even own a scarf much less willingly wear it. Wool coat below the knees, gloves and a hat that came from some Navy fellow in Russia that my buddy convinced he needed $7 more than he needed a warm head. Except for the ice forming on my beard, I don’t really notice that it is -7° before the wind chill. The only easy day was yesterday. Why is a good boy from the Sunshine State battling Jack Frost in Chicago, for the second time this month? The first time sorta made sense. My pal couldn’t fulfill her council duties and as first runner-up, it fell to me. She was busy having a baby in New York, so I figured I was getting the better end of the deal, and I stepped up. At the end of that trip, the airline told me I couldn’t go home because jet fuel turns to jello at -15°. Thank goodness for good friend number 2, Steve Zucknick, who noticed that when only five people line up to get on another plane — it isn’t full — and we talked our way onto the only flight leaving Chicago that day. About 15 minutes from heads up to wheels up.
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The second time, well, the answer is the same to most of my “Why am I here?” questions: You take the king’s coin, you do the king’s bidding. At some point, I forgot to say, “No.” I serve my profession and I serve my professional organization, and I serve so a few of you at home can serve in areas I would rather not (I will decline to be on the Board of Dentistry, the Board of Dentistry Liaison, or chief fundraiser for anything). Once, I told my father I wasn’t interested in all that political stuff and just wanted to help people. I think he’s still laughing about that. He reminded me that it’s all about politics and then left me to figure it out for myself. I think he knew I would step up when it was necessary and try to do the right thing. It really is all about politics and it is everyone’s job to stand up and try to do the right thing when your turn comes. How much you get paid, how much you have to pay, what you are allowed to do, which others are allowed to do what you do, where you are allowed to do it, and what will be your future are all determined by politics. Everyone who carries a license to practice has the responsi-
January/February 2014
bility to know what is going on in the Legislature. If all you follow are matters related to dentistry, I can live with that. Joe Diaz used to say the reason we can be successful is, “We are not Republican or Democrat, we are the Tooth Party.” Open your email from the FDA, read the Capital Report, follow the bills, go to Tallahassee for Dentists’ Day on the Hill, join FLADPAC, ADPAC, and the Century Club. Step into the booth and blacken those ovals, pull the levers, or punch out the chads (depending on your supervisor of elections). While you’re fighting the good fight, you’ll find a few really good friends who will go to bat for you —friends who, when they need you to, you will brave the frozen tundra. Photo of Dr. Steve Zucknick (right) and Dr. John Paul (left).
Dr. Paul is the editor of Today's FDA. He can be reached at jpdentz@aol.com.
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Any projected balance amounts or other projections shown herein are for illustrative purposes only. “Qualified members” refers to members who have met the five-year continuous coverage requirement.
800.877.7597 • insurance@fdaservices.com • www.fdaservices.com