2020 - Jan/Feb TFDA by Florida Dental Association

2019 Dentists’ Day2020 on the LEGISLATIVE Hill - March 11-12,AGENDA 2019 - Page 2 THE FDA'S

VOL. 32, NO. 1 • JAN/FEB • PEDIATRIC ISSUE

INSIDE!

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

Treating Minors • Productive Pediatric Scheduling Patients with Autism • Cyber Criminals & Your Data Therapy Dog Eases Anxiety • Using Silver Diamine Fluoride Patient Education Insert: Caries Risk Assessment for Kids/Stages of Caries

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HELPING MEMBERS SUCCEED VOL. 32, NO. 1 • January/February 2020

in every issue 3

Staff Roster

President's Message

Did You Know?

What About Dentistry for Youngsters with Disabilities in Florida?

11 Info Bytes 18 news@fda 40 Get Involved! 70 Compleat Dentistry

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

Using Silver Diamine Fluoride at Your Practice: An Overview

Shopping List for Kids

Ellie: A Furry Assistant Eases Patient Anxiety

73 Diagnostic Discussion 78 Career Center 82 Advertising Index 84 Off the Cusp

Medical Treatment of Minors

The FDA’s 2020 Legislative Agenda

Florida Board of Dentistry Meets in Jacksonville

Strategic Scheduling for a Productive Pediatric Specialist

FDA Helping Hands

MORE HEALTH Helps MORE Kids!

Why Cyber Criminals Want to Steal Your Data

Providing Dental Care for the Patient with Autism

Getting Back More Than You Give

Iceberg Ahead! Avoiding a HIPAA Shipwreck

Cover photo by Judy Stone, FDA Leadership Affairs Manager

TODAY'S FDA ONLINE: floridadental.org

On the Cover:

FLORIDA DENTAL ASSOCIATION JANUARY/FEBRUARY 2020 VOL. 32, NO. 1

EDITOR Dr. John Paul, Lakeland, editor

STAFF Jill Runyan, director of publications Jessica Lauria, publications and media coordinator Lynne Knight, graphic design coordinator

BOARD OF TRUSTEES Dr. Rudy Liddell, Brandon, president Dr. Andy Brown, Orange Park, president-elect Dr. Dave Boden, Port St. Lucie, first vice president Dr. Gerald Bird, Cocoa, second vice president Dr. Beatriz Terry, Miami, secretary Dr. Jolene Paramore, Panama City, immediate past president Drew Eason, CAE, Tallahassee, executive director

FDA member Dr. Ransey Boyd’s children explore their career options at their mom’s practice in Tallahassee. L to R: Peyton, 10; Everett, 8; and, Britton, 5.

American Sensor Tech

Dr. Dan Gesek, Jacksonville • Dr. Karen Glerum, Boynton Beach Dr. Jeannette Pena Hall, Miami • Dr. Bernard Kahn, Maitland Dr. Irene Marron-Tarrazzi, Miami Dade • Dr. Eddie Martin, Pensacola Dr. Rick Mullens, Jacksonville • Dr. Jeffrey Ottley, Milton • Dr. Paul Palo, Winter Haven Dr. Howard Pranikoff, Ormond Beach • Dr. Mike Starr, Wellington Dr. Stephen Zuknick, Brandon • Dr. Ethan Pansick, Delray Beach, speaker of the house Dr. Rodrigo Romano, Miami, treasurer • Dr. John Paul, Lakeland, editor

PUBLISHING INFORMATION Today’s FDA (ISSN 1048-5317/USPS 004-666) is published bimonthly, plus one special issue, by the Florida Dental Association, 545 John Knox Road, Ste. 200, Tallahassee, Fla. 32303 . 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 2020 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, 545 John Knox Road, Ste. 200, Tallahassee, Fla. 32303.

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, 545 John Knox Road, Ste 200, Tallahassee, Fla. 32303. FDA office numbers: 800.877.9922, 850. 681.3629; fax 850.561.0504; email address, fda@floridadental.org; website address, floridadental.org.

ADVERTISING INFORMATION For display advertising information, contact: Jill Runyan at jrunyan@floridadental.org or 800.877.9922, Ext. 7113. For career center advertising information, contact: Jessica Lauria at jlauria@floridadental.org or 800.977.9922, Ext. 7115.

Today’s FDA is is a member publication ofof the Today’s FDA a member publication the American Association ofof Dental Editors and the Florida Magazine Association. American Association Dental Editors and the Florida Magazine Association.

TODAY'S FDA

JANUARY/FEBRUARY 2020

FLORIDADENTAL.ORG

CONTACT THE FDA OFFICE 800.877.9922 OR 850.681.3629 545 John Knox Road, Ste. 200 • Tallahassee, FL 32303

EXECUTIVE OFFICE DREW EASON, Executive Director deason@floridadental.org 850.350.7109 GREG GRUBER, Chief Operating Officer/ Chief Financial Officer ggruber@floridadental.org 850.350.7111 CASEY STOUTAMIRE, Director of Third Party Payer and Professional Affairs cstoutamire@floridadental.org 850.350.7202 JUDY STONE, Leadership Affairs Manager jstone@floridadental.org 850.350.7123 LIANNE BELL, Leadership Concierge lbell@floridadental.org 850.350.7114

ACCOUNTING BREANA GIBLIN, Director of Accounting bgiblin@floridadental.org 850.350.7137 LEONA BOUTWELL, Finance Services Coordinator Accounts Receivable & Foundation lboutwell@floridadental.org 850.350.7138 DEANNE FOY, Finance Services Coordinator Dues, PAC & Special Projects dfoy@floridadental.org 850.350.7165 ALLEN JOHNSON, Accounting Manager allen.johnson@fdaservices.com 850.350.7140 MITZI RYE, Fiscal Services Coordinator mrye@floridadental.org 850.350.7139 STEPHANIE TAYLOR, Membership Dues Coordinator staylor@floridadental.org 850.350.7119 LESYA WILBUR, Commissions Coordinator lesya.wilbur@fdaservices.com 850.350.7142

FLORIDA DENTAL ASSOCIATION FOUNDATION (FDAF)

DEIRDRE RHODES, FDC Exhibits Coordinator drhodes@floridadental.org 850.350.7108 ANDREW SCHERER, FDC Meeting Assistant ascherer@floridadental.org 850.350.7162 EMILY SHIRLEY, FDC Program Coordinator eshirley@floridadental.org 850.350.7106

JOE ANNE HART Chief Legislative Officer jahart@floridadental.org 850.350.7205 ALEXANDRA ABBOUD Governmental Affairs Liaison aabboud@floridadental.org 850.350.7204 JAMIE SHEEHAN Governmental Affairs Legislative Assistant jsheehan@floridadental.org 850.350.7203

INFORMATION SYSTEMS LARRY DARNELL Director of Information Systems ldarnell@floridadental.org 850.350.7102 RACHEL STYS, Systems Administrator rstys@floridadental.org 850.350.7153

MEMBER RELATIONS KERRY GÓMEZ-RÍOS Director of Member Relations krios@floridadental.org 850.350.7121 MEGAN BAKAN Member Access Coordinator mbakan@floridadental.org 850.350.7100 JOSHUA BRASWELL Membership Coordinator jbraswell@floridadental.org 850.350.7110 CHRISTINE TROTTO Membership Concierge ctrotto@floridadental.org 850.350.7136

KRISTIN BADEAU, Foundation Coordinator kbadeau@floridadental.org 850.350.7161

PUBLICATIONS

KRISTEN RULE, Foundation Assistant krule@floridadental.org 850.350.7122

JILL RUNYAN, Director of Publications and e-Publications jrunyan@floridadental.org 850.350.7113

FLORIDA DENTAL CONVENTION (FDC)

LYNNE KNIGHT, Graphic Design Coordinator lknight@floridadental.org 850.350.7112

CRISSY TALLMAN Director of Conventions and Continuing Education ctallman@floridadental.org 850.350.7105

JESSICA LAURIA Publications and Media Coordinator jlauria@floridadental.org 850.350.7115

FLORIDADENTAL.ORG

Group & Individual Health • Medicare Supplement • Life Insurance Disability Income • Long-term Care • Annuities • Professional Liability Office Package • Workers’ Compensation • Auto • Boat

GOVERNMENTAL AFFAIRS

R. JAI GILLUM, Director of Foundation Affairs rjaigillum@floridadental.org 850.350.7117

BROOKE MARTIN, FDC Marketing Coordinator bmartin@floridadental.org 850.350.7103

FDA SERVICES 800.877.7597 or 850.681.2996 545 John Knox Road, Ste. 201 Tallahassee, FL 32303

The last four digits of the telephone number are the extension for that staff member.

SCOTT RUTHSTROM, Chief Operating Officer scott.ruthstrom@fdaservices.com 850.350.7146 CAROL GASKINS Commercial Accounts Manager carol.gaskins@fdaservices.com 850.350.7159 ALEX KLINE, FDAS Marketing Coordinator arey@fdaservices.com 850.350.7166 MARCIA DUTTON, Membership Services Assistant marcia.dutton@fdaservices.com 850.350.7145 PORSCHIE BIGGINS Central Florida Membership Commercial Account Advisor pbiggins@fdaservices.com 850-350-7149 MARIA BROOKS South Florida Membership Commercial Account Advisor maria.brooks@fdaservices.com 850.350.7144 KELLY DEE Atlantic Coast Membership Commercial Account Advisor kelly.dee@fdaservices.com 850.350.7157 MARRISA LEE North Florida Membership Commercial Account Advisor marrisa.lee@fdaservices.com 850.350.7122 MELISSA STAGGERS West Coast Membership Commercial Account Advisor melissa.staggers@fdaservices.com 850.350.7154 TESSA DANIELS Commercial Account Advisor tessa.daniels@fdaservices.com 850.350.7158 LIZ RICH Commercial Account Advisor liz.rich@fdaservices.com 850.350.7171

CARRIE MILLAR Director of Insurance Operations carrie.millar@fdaservices.com 850.350.7155

YOUR RISK EXPERTS DAN ZOTTOLI, SBCS Director of Sales — Atlantic Coast 561.791.7744 Cell: 561.601.5363 dan.zottoli@fdaservices.com DENNIS HEAD, CIC Director of Sales — Central Florida 877.843.0921 (toll free) Cell: 407.927.5472 dennis.head@fdaservices.com MIKE TROUT Director of Sales — North Florida 904.249.6985 Cell: 904.254.8927 mike.trout@fdaservices.com JOSEPH PERRETTI, SBCS Director of Sales — South Florida 305.665.0455 Cell: 305.721.9196 joe.perretti@fdaservices.com RICK D’ANGELO, CIC Director of Sales — West Coast 813.475.6948 Cell: 813.267.2572 rick.dangelo@fdaservices.com

ARIEL WORD Commercial Account Advisor a.word@fdaservices.com 850.350.7151

To contact an FDA Board member, use the first letter of their first name, then their last name, followed by @bot.floridadental.org. For example, Dr. John Paul: jpaul@bot.floridadental.org.

TODAY'S FDA JANUARY/FEBRUARY 2020

JACKSONVILLE 2020 FLA-MOM

CHILDHOOD CARIES AND WHAT WE CAN DO! February is Children’s Dental Health Month. Our members who work on children, whether in their private office, a federally qualified health center or at an event such as the Florida Mission of Mercy (FLA-MOM), understand the prevalence of childhood caries. Some key takeaways from the National Center for Health Statistics’ 2018 Data Brief found that from 2015-2016, caries is the most common disease among children, the prevalence of total caries (treated and untreated) was 45.8% and untreated caries was 13% among youth 2-19 years of age. Prevalence was lowest in the 2-5 years age group, but more than doubled in 6-11- and 12-19-year age group. For both total and untreated caries, prevalence decreased as family income level increased. Several studies indicate that between 35-51 million school hours are lost due to dental-related illness. Dental disease is a huge problem. The Florida Dental Association (FDA) is taking the lead when it comes to addressing these concerns. This past November, there was a vote to discontinue water fluoridation in Brevard county. With dedicated leaders like Drs. Johnny Johnson, Jim Antoon and Jerry Bird, the vote to remove fluoride failed, but the desire to remove it from public drinking water will not go away and we must defend the use of fluoride vigorously. Medicaid reimbursement has been on the FDA’s radar for as long as I can remember. We continually lobby the Florida Legislature to provide more money so that the providers of Medicaid services can be fairly reimbursed. Dr. Andy Brown, along with Dr. Jill Hearndon, is embarking upon an analysis of FLORIDADENTAL.ORG

Medicaid data to make sure that the allocated dollars are having the intended impact regarding treating the dental needs of Florida’s children. The data analysis is intended to track how much money is spent doing which specific procedures, and to determine if that money is being spent efficiently. The analysis will be partly funded by a grant from the FDA Foundation from their Dental Health and Education Fund. They’re also hoping to get a matching State Public Affairs grant from the American Dental Association. The 2020 Legislative Session is a little different than past years, as the FDA is not promoting legislation. The heavy lift was done last year getting our Dental Student Loan Repayment Plan, the Donated Dental Services program and water fluoridation passed. This year, we need to focus on the funding for these initiatives. Make plans to attend the 2020 Dentists’ Day on the Hill, Feb. 4th, with a briefing held Feb. 3 at the Aloft Hotel.

leadership

PRESIDENT’S MESSAGE RUDY LIDDELL, DMD FDA PRESIDENT

Dr. Liddell can be reached at rliddell@ bot.floridadental.org.

Mark your calendars for April 24-25, 2020. The sixth FLA-MOM will be hosted by the Northeast District Dental Association at the Jacksonville Prime F. Osborn III Convention Center. This is an excellent opportunity to use our God-given talents to help children and adults who are less fortunate. Visit floridadental.org/flamom to sign up as a provider/participant. You also can donate to the Foundation at dontate.floridadental.org.

TODAY'S FDA JANUARY/FEBRUARY 2020

human relations

MEDICAL TREATMENT OF MINORS

Providing medical treatment to minors poses an interesting and sometimes confusing mosaic of issues to consider. The first issue presented is whether the person is a minor. This may seem like a strange question with extremely young patients, but with teenage patients it’s not so clear-cut.

DEBORAH S. MINNIS

Ms. Minnis practices labor and employment law at Ausley McMullen, and she also represents various local government bodies. She can be reached at dminnis@ausley.com. 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.

A minor may become emancipated, i.e., be considered an adult. There are three ways this can happen: if the minor is no longer residing with his/her parent(s) (including legal guardians, etc.) and is financially independent; if the court has issued an order to emancipate the minor, which would apply to 16- and 17-year-olds only; and, if the minor is married. Emancipated minors can consent to their own medical treatment. In the event of an emancipated minor, the provider should ask for proof of emancipation, either the order of emancipation, a copy of the marriage license, or proof of financial independence and that they are no longer living with a parent. Examples of proof could be a copy of a lease agreement or a utility, cable or other bill in 2. the minor’s name. Pregnant minors are considered emancipated only as it relates to agreeing to treatment related to their pregnancy. They are not considered emancipated for other medical treatment. Pregnancy does not give a minor the right to consent to medical treatment unrelated to the pregnancy. Similarly, the fact that a minor has become a parent does not give that minor the right to consent to his/ her own medical treatment. Ironically, however, minor parents can consent to medical treatment for their own children.

TODAY'S FDA

JANUARY/FEBRUARY 2020

Where it’s clear that the patient is a minor, steps must be taken to determine who has the right to consent and to make sure proper consent has been obtained. Failure to do so could result in suits by the parent, charges of battery or may be considered grounds for discipline under Chapter 466, Florida Statutes, as a violation of the Florida Medical Consent Law.

General Rule and Exceptions As a general rule, either parent (including adoptive parents, legal guardians and legal custodians) of a minor child can consent to medical treatment. This includes wed and unwed parents. There are limited instances where this is not the case. Despite what may be customarily thought, the parent awarded custody (the parent with whom the child primarily resides) after a divorce does not, by merely being awarded custody, get the sole right to determine medical treatment. Unless there is a court order taking away the noncustodial parent’s rights to do so, the noncustodial parent still has the right to make decisions about the child’s medical care. Under this scenario, if the provider has consent from one parent, the provider cannot be sued by the other parent. Before refusing consent to a noncustodial parent based on representations by the custodial parent, you should ask for a copy of the court order. Though it’s not the provider’s obligation to mediate disputes between warring ex-spouses, mediating such differences may be considered necessary to make sure the child gets the care needed.

FLORIDADENTAL.ORG

Emergencies

legally designated health care surrogate

Providers can provide care in cases of emergency in the event of an accident or where the patient is suffering from an acute illness or condition, and within a reasonable degree, delayed treatment would put the patientâ&#x20AC;&#x2122;s health in danger. However, emergency treatment without consent is proper only where either (1) the minor is unable to tell the provider who his/her parents are, and this information is not known to the provider or (2) the provider has been unable to locate the parents by telephone at home or at work. Documentation of attempts to contact the parents should be maintained in the file.

stepparent

grandparent

adult sibling

adult aunt or uncle

A record of the attempts to contact the parents must be maintained in the providerâ&#x20AC;&#x2122;s file.

Who Else Has the Power to Consent? Under Florida law when, after a reasonable attempt, a parent cannot be contacted, the following persons can consent to treatment. They are listed in order of priority:

FLORIDADENTAL.ORG

TODAY'S FDA JANUARY/FEBRUARY 2020

DIDYOU

BOD

INFORMATION ABOUT THE FLORIDA BOARD OF DENTISTRY

STERILIZATION RULE UPDATE Did you know that the Florida Board of Dentistry recently updated its rule on sterilization? The updated rule can be found below. Please note, the new sections are underlined. 64B5-25.003 Required Sterilization and Disinfection Procedures. DR. DON ILKKA FDA LIASON TO THE FLORIDA BOARD OF DENTISTRY

(1) At least one of the following procedures must be used in order to provide proper sterilization:

CASEY STOUTAMIRE FDA DIRECTOR OF THIRD PARTY PAYER & PROFESSIONAL AFFAIRS

(a) Steam under pressure (e.g., autoclave); (b) Dry-heat; (c) Chemical vapor; (d) Ethylene oxide; (e) Devices used to achieve sterilization must be approved by the U.S. Food and Drug Administration (FDA) for sterilization. (f)(e) Disinfectant/sterilant. U.S. Environmental Protection Agency (EPA) approved disinfectant/sterilants or U.S. Food and Drug Administration (US-FDA) approved sterilant may be used but are only appropriate for sterilization when used in appropriate dilution and for the time periods set forth in the manufacturer’s instructions for use recommendation and only on non-heat tolerant instruments which do not penetrate soft tissue. (2)(a) Surgical and other instruments that normally penetrate soft tissue or bone, including, but not limited to, forceps, scalpels, bone chisels, scalers, and surgical burs, must be sterilized after each use.

If you have any questions, please contact Director of Third Party Payer and Professional Affairs Casey Stoutamire, Esq. at cstoutamire@ floridadental.org or 850.350.7202, or FDA Liaison to the Florida Board of Dentistry Dr. Don Ilkka at donjilkkadds@aol.com or 352.787.4748.

TODAY'S FDA

(b) Instruments that are not intended to penetrate oral soft tissue or bone, including, but not limited to, high speed dental handpieces, contra-angles, prophy angles, amalgam condensers, plastic instruments, and burs, but that may come into contact with oral tissues must be sterilized after each use according to

JANUARY/FEBRUARY 2020

the manufacturer’s instructions for use. (c) However, if heat, steam under pressure, or chemical vapor sterilization of an instrument is not technically feasible, due to its size or composition, the instrument must undergo sterilization with a disinfectant/sterilant that destroys viruses and spores. Disinfectants must be registered by the U.S. Environmental Protection Agency (EPA) as a disinfectant/ sterilant and must be used in accordance with the manufacturer’s recommendations and in accordance with CDC Guidelines as defined and incorporated by reference in Rule 64B525.002(4), F.A.C. the recommendations of the Centers for Disease Control (CDC). (d) High speed dental handpieces, slow speed dental sleeves and contra-angles and prophy angles must be sterilized after each use using a heat or heat with pressure or heat with chemical method. The method used must be capable of sterilization. (e) Heat-sensitive instruments may require up to 10 hours of exposure in a liquid chemical agent registered by the U.S. Environmental Protection Agency (EPA) as a disinfectant/ sterilant. (3) Before sterilization, instruments must be cleaned to remove debris. Cleaning must be accomplished by a thorough scrubbing with soap or a detergent and water or by using a US-FDA-approved mechanical device, such as an ultrasonic cleaner or a US-FDA-approved instrument washer following the manufacturer’s instructions for use recommendations. Metal or heat-stable dental instruments must be sterilized after each use by one of the procedures identified in paragraphs (a)-(d), of subsection (1), above. FLORIDADENTAL.ORG

(4) Oral prosthetic appliances received from a dental laboratory must be washed with soap or a detergent and water, rinsed well, appropriately disinfected and rinsed well again before the prosthetic appliance is placed in the patient’s mouth. (5) At the completion of dental treatment, all surfaces that may have become contaminated with blood, saliva or other bodily fluids must be disinfected in accordance with CDC Guidelines as defined and incorporated by reference in Rule 64B5-25.002(4), F.A.C. using a procedure recommended by the Centers for Disease Control (CDC). (6) Disinfectant/sterilants appropriate for use under paragraph (e), of subsection (1), above, are only those disinfectant/ sterilants that are registered by the EPA. Those disinfectant/ sterilants must be used in accordance with the manufacturer’s recommendations for correct use as a disinfectant/sterilant. (7) The sterilization and disinfection procedures required by this rule must be followed unless appropriate disposable items are used. Disposable items may only be used on a one time basis and may never be used on more than one dental patient. The use of disposable items is encouraged. (8) Surgical or examination gloves and surgical masks shall be worn by all dentists, dental hygienists, and dental assistants while performing or assisting in the performance of any intraoral dental procedure on a patient in which contact with blood and/or saliva is imminent. Surgical or examination gloves must be changed between patients. Hands shall be washed with soap and water and dried immediately after removing and prior to replacing gloves. A healthcare grade alcoholbased hand rub may also be used according to the most current CDC Guidelines as defined and incorporated by reference in Rule 64B5-25.002(4), F.A.C. Gloves are never to be washed and reused. Surgical or examination gloves that are punctured or torn must be removed and replaced immediately with new gloves following rewashing of provider’s hands with soap and water. It is recommended that Protective eyewear protection must be worn by all dentists, dental hygienists, and dental assistants while performing or assisting in the performance of any dental procedure on a patient in accordance with OSHA’s Bloodborne Pathogen Standard, as defined and incorporated by reference in Rule 64B5-25.002(5), F.A.C., and the CDC Guidelines as defined and incorporated by reference in Rule 64B5-25.002(4), F.A.C. recommendations (9) The procedures and equipment used for sterilization must have their efficacy tested periodically. Adequacy of steam under pressure (e.g., autoclave) or chemical vapor sterilizaFLORIDADENTAL.ORG

tion must have their efficacy verified by appropriate biological monitoring at least once every 40 hours (2,400 minutes) of use or at least once every 30 days, whichever comes first. Dry heat and ethylene oxide sterilizers must have their efficacy verified with appropriate biological monitoring every 120 hours of operation at sterilization parameters or every 30 days, whichever comes first. (Use time is determined by multiplying the number of cycles by the individual cycle time.) Disinfectant/ sterilants as set forth in paragraph (e), of subsection (1), above, when used instead of heat sterilization procedures, must be used according to the manufacturer’s recommended dilution and exposure time and must be changed according to the manufacturer’s recommendations. (10) All OSHA category 2 employees must be provided with and must use the barrier techniques required by this rule when they are in situations where they may be exposed to blood, saliva, or other bodily fluids from the patient during the treatment or examination process. 64B5-25.002 Definitions. (1) “Sterilization” is defined to mean the process by which all forms of microbial life within an environment are totally destroyed. (2) “Disinfection” is defined to mean the destruction or inhibition of most pathogenic bacteria while they are in their active growth phase and the inactivation of some viruses. Disinfection allows the potential for viable pathogens to remain (e.g., Tubercle bacilli and some viruses, including A, B and C hepatitis virus, and nonA-nonB (NANB) viruses which may survive depending upon the chemicals used). (3) For purposes of this rule, the term “infected with the Hepatitis B virus” means that the licensee is sero-positive for the Hepatitis B surface antigen and the Hepatitis B e-antigen. (4) “CDC Guidelines” are the Center for Disease Control’s Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008, adopted and incorporated by reference and available at cdc.gov/infectioncontrol/guidelines/disinfection/ index.html. (5) “OSHA’s Bloodborne Pathogen Standards” are the Occupational Safety and Health Standards, 29 CFR §1910 1030 (2012), adopted and incorporated by reference and available atosha. gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_ table=STANDARDS.

TODAY'S FDA JANUARY/FEBRUARY 2020

FDA Online Radiography Training Program

YOUR TECHNOLOGICAL LEGACY TO info bytes YOUR CHILDREN AND GRANDCHILDREN You might imagine since I am knowledgeable about technology that at least one of my three daughters might share that gift. Sadly, that is not so. It’s not because I didn’t try to make it so. I consistently provided them with above average technology (usually my hand-me-downs, but still). Often referred to as Techno Dad, I was available to answer any and all questions about technology they had. Once again, few questions arose. Perhaps technological ability skips a generation because two of my three granddaughters have picked up technology and have done things with it that I could never have dreamed about when I was 4 or 7 years old. Every year before school starts, many law enforcement agencies put out a list of 15 or so apps you should be concerned about that your kids might be using. Google it, it’s easy to find that list. I bet you may recognize five of those. The other 10 you’ve probably never heard of at all. The list probably scares you into checking their devices just to see. The real question is, how much are you paying attention to what your children and grandchildren are doing with the advanced technology they have at their disposal literally from birth? Do they have limits about when, where and how often they can use the technology? I’m no medical doctor, but I hear reputable people talk about the addictive effects this technology has on children. I see it with my own eyes, and I can’t help but wonder what that will mean for them as they grow older. We’ve had the opioid crisis and I’m afraid a techno crisis is coming soon. I’m convinced I bought my teenage daughters smartphones so they could text me from their rooms 10 feet away. I know technology is not evil unto itself. It’s a tool. But like any tool, it can be misused, so you need to keep tabs on FLORIDADENTAL.ORG

when, how and for what purpose it’s being used. I heard Simon Sinek in a video recently say, “They are children, you can take it away.” Talk about starting World War III. So, as parents or grandparents, what are we to do? Here are three things to consider. First, set limits when the phone can be used. There are technological solutions to this (setting up systems that permit use during certain time frames, etc.) or there is the Sinek method and just take the phone away. However, allowing children unfettered access to technology is not the best idea even if it seems to make your life easier now.

LARRY DARNELL, MBA, CAE FDA DIRECTOR OF INFORMATION SYSTEMS

Mr. Darnell can be reached at ldarnell@floridadental.org.

Secondly, determine where those devices can be used. At the dinner table? Never. School? Limited usage. In their rooms overnight? NO. Teach your children and grandchildren proper use etiquette, but realize you’ll have to adhere to that, too. No “do as I say not as I do” with this stuff. Lastly, see what they are doing on their devices. The best way I could do that was have all the devices funneled through one account. If my kids or grandkids wanted some app, they had to ask me to get it for them. Did I track their website usage? You bet I did. I knew when and where they went on the web. I know all the bad stuff out there. I know the horror stories of people trying to get to our kids through technology. Occasionally, I physically inspect all their devices. I pay for it, so I can have access at any time. They knew this when I entrusted them with it. I’m the parent and I have the responsibility to do my best to protect them. Our children are too precious to imagine that Google, Facebook, Snapchat or whatever is next will look out for their best interests. That’s our job, and it’s time we start doing it. TODAY'S FDA JANUARY/FEBRUARY 2020

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BOD meeting

FLORIDA BOARD OF DENTISTRY MEETS IN JACKSONVILLE The Florida Board of Dentistry (BOD) met in Jacksonville on Friday, Nov. 22, at 7:30 a.m. The Florida Dental Association (FDA) was represented by FDA BOD Liaison Dr. Don Ilkka and Director of Third Party Payer and Professional Affairs Casey Stoutamire. Other FDA members in attendance included Drs. Andy Brown and Jim Haddix.

CASEY STOUTAMIRE FDA DIRECTOR OF THIRD PARTY PAYER & PROFESSIONAL AFFAIRS

If you have any questions, please contact Director of Third Party Payer and Professional Affairs Casey Stoutamire, Esq. at cstoutamire@floridadental.org or 850.350.7202.

All the BOD members were present, which included: Dr. Claudio Miro, chair; Drs. Naved Fatmi, Matt Freedman, Nick Kavouklis, T.J. Tejera and Nick White; Ms. Cathy Cabanzon and Ms. Angie Sissine, hygiene members; and consumer member, Mr. Fabio Andrade. There is one dentist position and one consumer position open on the board that the governor has not yet filled. The BOD continued its discussion on the numerous revisions to 64B5-14, the Anesthesia Rules, which were first proposed in August. These revisions are not yet effective and will start moving through the administrative process. Please watch your inbox for notices from the FDA on this important topic. Again, some of the highlights of the proposed revisions include: n Requiring the team approach for all types of sedation, which includes the operating dentist, a person responsible for monitoring the patient and a person to assist the operating dentist. n Clarifying that a dentist using general anesthesia, deep sedation, moderate sedation or pediatric moderate sedation in the

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dental office may only have one patient at a time induced. A second patient shall not be induced until the first patient is awake, alert, conscious, spontaneously breathing, has stable vital signs, is under the care of a responsible adult and that portion of the procedure requiring the participation of the dentist is complete. In an office setting where two or more permit holders are present simultaneously, each may sedate one patient provided that the office has the necessary staff and equipment for each sedated patient. n Effective March 1, 2022: n General Anesthesia Permit Holder: If treating a patient under the age of 7, a dentist using any level of sedation must be currently trained in pediatric advanced life support (PALS). n Moderate Sedation Permit Holder: If treating a patient under the age of 7, a dentist using moderate sedation must be currently trained in PALS. n Routine inspections shall be conducted at a minimum of every three years, and any additional location shall be subject to a routine inspection no later than one year from the date the location was added. n All rooms where sedation is being performed must accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least three individuals to freely move

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The next BOD meeting is scheduled for Friday, Feb. 21, 2020 at 7:30 a.m. EST in Gainesville. about the patient. An operating table or chair which permits the patient to be positioned so the operating team can maintain the airway, quickly alter patient position in an emergency and provide a firm platform for the management of CPR. n The anesthesia record must include the duration of the procedure, including the start and finish time of the procedure. The BOD also approved changes recommended by the Council on Dental Hygiene at its August meeting. These include: n Rule 64B5-16.001(1) Definition of Remediable Tasks and Supervision Levels will now read:

n (1) Remediable tasks, also referred to as expanded functions of dental hygienists and dental assistants, which are enumerated in Rule 64B5-16.006, 16.0061, 16.005 and 16.0051, are those intra-oral tasks which do not create unalterable changes in the oral cavity or contiguous structures, are reversible and do not expose a patient to increased risks. The use of a laser or laser device of any type is not a remediable task, unless utilized as an assessment device by a dental hygienist.

n The licensure and renewal fees for dental hygienists were lowered to $75. n The remediable task of applying bleaching solution, activating light source, monitoring and removing in-office bleaching materials was moved from direct supervision to general supervision. The rationale was that because scaling and root planing can now be done under general supervision, these tasks are less invasive and thus, also should be under general supervision.

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n The tasks of: taking impressions for study casts which are not being made for the purpose of fabricating any intraoral appliances, restorations or orthodontic appliances; taking impressions to be used for creating opposing models or the fabrication of bleaching stents and surgical stents to be used for the purpose of providing palatal coverage as well as impressions used for fabrication of topical fluoride trays for home application; taking of impressions for and delivery of at-home bleaching trays; and, taking impressions for passive appliances, occlusal guards, space maintainers and protective mouth guards were moved from indirect supervision to general supervision. The rationale of the council and the board was that a hygienist can adjust these types of devices under general supervision, so they should be able to take impressions under the same level of supervision. Also, there is no danger to the public. n For all changes listed above, the dentist can still choose the supervision level under which he/she he wants his hygienist to practice. For example, the dentist can still require the impressions be taken under indirect supervision. Finally, Dr. Fatmi was elected chair and Dr. White was elected vice chair of the BOD for the upcoming year. The FDA congratulates them on their elections and looks forward to working with them as they serve in their new capacities! There were nine disciplinary cases, two informal hearings, two determination of waivers and two voluntary relinquishments dealing with failure to pay student loans, failing to keep adequate records and failing to meet the minimum standard of care. It is much better to be a spectator than a participant in BOD disciplinary cases.

TODAY'S FDA JANUARY/FEBRUARY 2020

updates for members *PLEASE NOTE THAT FDA MEMBERS HAVE THEIR NAMES LISTED IN BOLD.

Correction to the Nov/Dec issue An article in the Nov/Dec issue accidentally left out the author’s affiliation and contact information. “Selectively Equilibrating the Hard Occlusal Guard” by John R. Antonelli, DDS, MS was on pages 92-95. Dr. Antonelli is a professor and director of fixed prosthodontics courses at Nova Southeastern University College of Dental Medicine. He can be reached at antonell@nova.edu. We apologize for this oversight.

Renewal Deadline Reminder: Feb. 28, 2020! All Florida-licensed dentists must renew their license through CE Broker (CEBroker.com) for the 2018-2020 biennium by Feb. 28, 2020. You must have 30 hours of continuing education (CE) by the biennium deadline to renew your license. Go to floridasdentistry.gov/renewals/dentist to view the list of courses that must be taken to renew. The Florida Dental Association (FDA) offers seven hours of FREE online CE for member dentists to help you reach your 30-hour requirement. Go to floridadental.org/online-ce to access these free courses.

NEW! Mandatory CE — Opioid Prescribing and Human Trafficking All dentists, regardless of DEA licensing, must take a two-hour CE course on the safe and effective prescribing of controlled substances during licensure renewal by Feb. 28, 2020. You do not need to take another CE course on the prescribing of controlled substances for this licensure cycle if you already did so during this biennium. Go to floridadental.org/opioidlaw to learn more about this new legislation. The FDA offers a twohour Opioid Prescribing on-demand webinar for $50 for FDA members. Go to learning.floridadental.org to take the course. All dentists and dental hygienists must take a one-hour CE course on human trafficking by Jan. 1, 2021 and are required to place a sign in their office with specific language for human trafficking victims. Go to floridadental.org/humantrafficking

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to learn more about this new legislation and get your free copy of the Human Trafficking sign. The FDA offers a one-hour Human Trafficking on-demand webinar for $35 for FDA members. Go to learning.floridadental.org to take the course.

Email from DEA on Suspicious Orders Report System You may have received an email from the DEA about a new requirement to report to a recently launched centralized database called the Suspicious Orders Report System (SORS). Good news! If you only write prescriptions for and dispense controlled substances, you do not have to report anything to SORS. You would only need to report if you distribute controlled substances to other DEA registrants. For more information, please go to bit.ly/2SjQpqN to read an article in the ADANews.

The Future is Female — 7th Annual Lucy Hobbs Project Awards In 1866, Lucy Hobbs became the first American woman to earn a degree in dentistry, and practiced until her death in October 1910. In 2013, Benco Dental inaugurated the Lucy Hobbs Project in her honor, celebrating the achievements of women in dentistry and empowering them to drive further change. Dr. Deborah V. George won the Clinical Expertise Award this year. As executive vice president and chief dental officer at Jessie Trice Community Health Center in Miami, Dr. George has dedicated her career to underserved populations, leaving an indelible imprint on thousands of patients through her impeccable clinical expertise. She began her professional life in medicine as a triage nurse at George Washington University’s teaching hospital in the

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nation’s capital and at Jackson Memorial Hospital in Miami. In both places, she says, she encountered many children who complained of toothaches caused by untreated decay. Exposure to oralhealth disparities and other inequities made her want to do something to address them. Noticing how few African American women were health care professionals only reaffirmed her commitment, she says, to “serve and help people live healthier lives.” At Jessie Trice, Dr. George has created an Advanced Education in General Dentistry program, boosted the center’s number of practices from one to seven and established a dental office within a pediatric medical practice. She has likewise built her team steadily; it now includes an endodontist and two periodontists. She also has trained her staff to screen patients for HIV and diabetes.

A Legacy of Smiles For almost 40 years Dr. David Zabrocki deeply cared about providing top quality dentistry to his patients. He also cared about those who couldn’t afford to seek dental care. As March 2020 approached, the fourth anniversary of his death, friends and family gathered to celebrate establishing the Dr. David Zabrocki Memorial Dental Program. This program, in partnership with Ready for Life, provides dental care to young adults who have aged out of foster care — a population that has received little to no dental care their entire lives. FLORIDADENTAL.ORG

Through the generosity of practicing dentists in the community, these young adults’ lives are being greatly enhanced. Their first fundraiser was held on Sept. 24, 2019 and raised more than $19,000! Dr. Zabrocki is greatly missed by family, friends, his patients and his long-time Z Team!

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.

Atlantic Coast District Dental Association

The Dawson Academy Names Clinical Director of its Nationwide Study Club Program

Dr. Juan Cerrutti, Boca Raton Dr. Ariel Cross, West Palm Beach Dr. Rickie Ferguson, Davie

The Dawson Academy, which provides a pathway to clinical mastery for dental professionals, has enhanced its Study Club program with the appointment of Dr. Jeff Scott as clinical director of Dawson Study Clubs. The Study Clubs provide a supportive peer group for dentists who are learning to confidently solve complex dental problems. Dr. Scott owns and operates his dental practice, Jeff Scott Dentistry, in St. Petersburg, where he practices cosmetic and restorative dentistry fulltime. He has lectured on dentistry in 16 states, and in Japan and Poland. In this role, Dr. Scott will guide the clinical direction and oversee the educational content provided to Dawson Study Club participants. With his oversight, Study Clubs will align with The Dawson Academy’s curriculum and offer CE opportunities on topics that range from airway disorders and digital dentistry to dental insurance and practice management. For more information, please visit thedawsonacademy.com/dawsonacademy-study-clubs.

Welcome New FDA Members

Dr. Poorvi Gandhi, Sunrise Dr. Sandra Gomez-Trainor, Oakland Park Dr. Meyleen Izquierdo, Weston Dr. Joshua Jaffe, Fort Lauderdale Dr. Stephanie Jensen, Port St. Lucie Dr. Steven Kaltman, Davie Dr. John Karpinski, Fort Pierce Dr. Amelia Lindsey, Fort Lauderdale Dr. Anelisse Martinez, Lauderhill Dr. Sara Morgan, Fort Lauderdale Dr. Geoffrey Morris, Boca Raton Dr. Yudit Moya, Belle Glade Dr. Rosario Pinero Correa, Palm Beach Gardens Dr. Ankita Prabhakar, Plantation Dr. David Santana, Coral Springs Dr. Jesse Schwartz, Hollywood Dr. Ivan Vega, Boca Raton Dr. Jessica Wyatt, Palm Beach Gardens

Central Florida District Dental Association Dr. Mariana Al Nasser, Rockledge Dr. Ferhan Aziz, Port Orange Dr. Stuart Beauchamp, Ormond Beach Dr. Marielle Beauchamp, Ormond SEE PAGE 20

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updates for members FROM PAGE 19

Dr. Zachary Jin, Tallahassee

Dr. Anna Royzman, Lake Park

Dr. Elizabeth Pages, Panama City

Dr. Zarish Shaw, Miramar

Dr. Kinnari Patel, Inlet Beach

Dr. Edwin Smith, Hallandale

Dr. Lara Sackheim, Pensacola

Dr. Sarika Tamaskar, Miramar Beach

Dr. Kelly Seebaldt, Destin

Dr. Humberto Vazquez, Miami

South Florida District Dental Association

West Coast Dental Association

Beach Dr. Sheno Bennett, Leesburg Dr. Juliana Correal, Kissimmee Dr. Yesenia Fernandez-Riera, Miami Dr. Sanjay Ghetiya, Orlando Dr. Sakshi Gupta, Melbourne Dr. Anju Jain, Orlando

Dr. Dana Al-Hashimi, Pembroke Pines Dr. Juan Amundaray, Miami Beach Dr. Stephen Boss, Miami Beach

Dr. Xandria Johnson, Belle Isle Dr. Jayson Kirchhofer, Gainesville Dr. Cameron McMillin, Orlando

Dr. Alexandra Botero, Doral Dr. Grisel Castillo Fernandez, Miami Dr. Yohayra Chardon, Miami

Dr. Lauren Melendez, Gainesville Dr. Hiral Modi, Indian Harbour Beach Dr. Kim Nguyen, Melbourne Dr. Naila Ortega, Orlando Dr. Wendi Wardlaw, Winter Garden

Dr. Jose Chaviano Jr., Miami Dr. Laura De Pena, North Miami Beach Dr. Kristen Diaz, Miami Lakes Dr. Mehr Faisal, Pembroke Pines

Dr. Rabie Youssef, Orlando

Dr. Tommy Gaertner, Miami Beach

Northeast District Dental Association

Dr. Nils Gomez Perez, Hollywood

Dr. Cristina Garcia, Palmetto Bay Dr. Yordanka Gonzalez, Miami

Dr. Alan Antao, St. Augustine

Dr. Yaima Gonzalez Farinas,

Dr. Shahin Bayani, Jacksonville Beach

South Miami

Dr. Tania Cheema, Jacksonville Dr. Felipe Falcao, Jacksonville Dr. Brent Ford, Jacksonville

Dr. Jessica Junquera, Miami Dr. Arlet Lopez Neyra, Hollywood Dr. Nayade Morell, Miami

Dr. Karlie Kashat, Jacksonville

Dr. Dominic Morel-Maynard,

Dr. Justin Page, St. Johns

Boca Raton

Northwest District Dental Association

Dr. Eunice Perez, Miami Dr. Melissa Quintana, Miami

Dr. Ana Fernandez Rodriguez,

Dr. Yoaris Ramos Collazo, Miami

Tallahassee

Dr. Christina Robinson,

Dr. Amjad Heidami, Panama City

North Miami Beach

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Dr. Matthew Benson, Cape Coral Dr. Maria Bernal, Lakeland Dr. Yamilet Blanco, Venice Dr. Daryl Brito, Riverview Dr. Samuel Cancelliere, Naples Dr. Joshua Colvin, St. Petersburg Dr. Tracy Couillard, Naples Dr. Riham Diasti, Tampa Dr. Denise Gay, Naples Dr. Rose Gedeon, Naples Dr. Monica Ghattas, Palm Harbor Dr. Hanny Hamoui, Brooksville Dr. Anna Hill-Moses, Tampa Dr. Ahmed Jawad, Tampa Dr. Thao Latham, Bonita Springs Dr. Thinh Luong, Tampa Dr. Caitlin McLaughlin-Raiger, Naples Dr. Johanna Moorefield, Naples Dr. Thao Nguyen, Bradenton Dr. Joe Pinkston, Lakeland Dr. Austin Sampson, Clearwater Dr. Ai Streacker Jr., Sarasota Dr. Chinh Van, Clewiston Dr. Marina Vasilaros, Cooper City Dr. Vincent Veronick, Clearwater Dr. Kyle Yerton, Lakeland

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In Memoriam The FDA honors the memory and passing of the following members: Alfred Duda Hollywood, FL Died: 11/8/2019 Age: 88

Antonio Castro Lutz, FL Died: 12/1/2019 Age: 88

Conrad Hazen Ormond Beach, FL Died: 12/4/2019 Age: 86

Robert Moskovits Boca Raton, FL Died: 11/18/2019 Age: 67

Harold Friedman Boca Raton, FL Died: 12/3/2019 Age: 95

L. Linebaugh Tampa, FL Died: 12/6/2019 Age: 83

Carlton Henry Vilas, NC Died: 11/19/2019 Age: 74

Clayton Roth William Von Sick Boca Raton, FL New Port Richey, FL Died: 12/3/2019 Died: 12/20/2019 Age: 59 Age: 72 Alvin Krasne Parkland, FL Died: 12/26/2019 Age: 96

Aftco

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guest editorial

WHAT ABOUT DENTISTRY FOR YOUNGSTERS WITH DISABILITIES IN FLORIDA? We’re from the northeast. Yes, snow and all that! And, one of us is in his mid-70s; the other in his mid-80s. When we think of Florida, it’s usually about old folks and all their disabilities. Almost 532,000 residents (22.9%) between 65 and 74 years and 833,800 residents (45.8%) 75 years or older, have one or more disabilities (a total of 33.5% of the elderly population). In the northeast, we think that Florida is highest on the list of states with the largest percent of their senior citizen populations with disabilities. The reality is that there are seven states, ranging from 40.6% of all seniors in Louisiana to 43.1% in West Virginia (and 46.3% in Detroit) who have one or more disabilities.1,2

H. BARRY WALDMAN, DDS, MPH, PHD

STEVEN P. PERLMAN, DDS, MSCD, DHL (HON) 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 typically 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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Yes, many practitioners do provide oral health services for individuals with disabilities. They not only deal with the complexities of the delivery of services, but also are confronted with the impact of limited reimbursement for the added effort and time required for the care of individuals with disabilities. Note: In 2019, the American Dental Association (ADA) Code of Ethics was modified to include individuals with a disability in the list of individuals (e.g., race, gender and sexual orientation) for whom dentists may not deny services solely on the basis of a particular characteristic.3 Now, add the realities of securing dental care for individuals with disabilities who are living in poverty. In 2017, the poverty rate of working-age people with disabilities in Florida was 25.3%; compared to the poverty rate of 11.2% of those individuals without disabilities.1

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And Children with Disabilities in Florida? In 2017, there are more than 232,600 children with one or more disabilities, including 170,000 youngsters between 5 and 20 years with cognitive disabilities. n Age 4 years and under: 0.6% (6,700 youngsters) n Note: This number includes only young children with visual or hearing disabilities. Reports on the number of children less than 5 years originate from the U.S. Census Bureau annual surveys. The Bureau estimates that, nationally, there are 155,000 children with visual and/or hearing disabilities less than 5 years of age. The Global Burden of Disease Study reports almost 810,000 U.S. children, less than 5 years, had developmental disabilities in 2016.4 n 5-15 years: 6.0% (155,200 children) n 16-20 years: 5.7% (70,700 teenagers)1

Specifically, Dental Care In the past, children (and adults) with disabilities “did not exist.” They were schooled in separate classrooms, kept in institutions (often out of town) or in the back rooms of private homes. The Commission on Dental Accreditation (CODA) had not established standards for the required preparation of dental or dental hygiene students for the care of individuals with disabilities, and repeat-

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edly refused to bring about educational standards for care for this patient population. Eventually, in 2006, a new standard was implemented. “Graduates must (sic) be competent in assessing the treatment needs of patients with special needs.”5 (Note: While clinical requirements were not required, some dental schools added these experiences to their general curriculum.) In 2019, CODA modified standard 2-25 so that it now states: “Graduates must be competent in assessing and managing the treatment of patients with special needs.”5 (The single word “management” now requires the clinical component of the preparation of students to provide the needed care.) Over time, the profession will be filled with practitioners prepared in dental schools to provide care for patients with special needs. In the interim, the question remains: Should current practitioners who completed their dental education prior to these changes, be required to follow continuing education (CE) requirements regarding the care of individuals with disabilities at the time of their license renewals? Similarly, CE programs should include guidelines to assist practitioners in dealing with third parties to secure compensation for the care individuals with disabilities. Wouldn’t this approach be in line with the ADA Code of Ethics, which stipulates that dentists may not deny services to individuals with a disability? But, it’s not just dental care. “One of the most overlooked areas in the (Florida state) budget involves services for those with disabilities. The state’s 21,000-person waiting list (for services) would draw no new money in the state budget year …”6,7 “Florida lawmakers told state health officials earlier this year that a Medicaid program for people with disabilities has too often overspent its share of the state’s budget … may soon recommend rationing specialized care to some of the state’s most vulnerable people to meet the Legislature’s demands to curtail costs.”8

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Maybe the approach of the dental profession to “go it alone” to develop support for health services for individuals with disabilities should rather be to join the general effort to recognize and support the needs for individuals with disabilities! H. Barry Waldman, DDS, MPH, PhD, SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY. He can be reached at h.waldman@stonybrook.edu. Steven P. Perlman, DDS, MScD, DHL (Hon), Global Clinical Director, Special Olympics, Special Smiles; Clinical Professor of Pediatric Dentistry, Boston University Goldman School of Dental Medicine.

References 1. Cornell University. Disability Status Report – Florida, 2017. Available from: http://www.disabilitystatistics.org/StatusReports/2017-PDF/2017StatusReport_FL.pdf?CFID=20897598&CFTOKEN=519fa2c27b7776be2ABCB70A-AB7C-A54E-F5D7435500DC0B7A Accessed Nov. 20, 2019. 2. Center on Disability. Percent of people with disabilities age 65 years and above: 2016 Available from: http://centerondisability.org/ada_parc/ utils/indicators.php?id=45&palette=3 Accessed Nov. 20, 2019. 3. Commission on Ethics, Bylaws and Judicial Affairs. Education Standards for Dental Education Programs. Available from: https://www.ada. org/~/media/ADA/Member%20Center/Ethics/Code_Of_Ethics_Book_ With_Advisory_Opinions_Revised_to_November_2018.pdf?la=en Accessed Oct. 7, 2019. 4. Global Research on Developmental Disabilities. Developmental disabilities among children younger than 5 years in 195 countries and territories. 1990-2016; a systematic analysis for the Global Burden Disease Study 2016. Available from: https//the-lancet.com/journals/langlo/article/ PH11S2214-109X(18)30309-7/fulltext Accessed Sept. 1, 2018. 5. Commission on Dental Accreditation. CODA Standard 2-25 Available from: https://www.ada.org/~/media/CODA/Files/2019%20ADEA/Appendix3_predoc_standard_2-25.pdf?la=en Accessed Oct. 7, 2019. 6. Herald-Tribune. Little in $89 billion budget for state’s neediest residents. Available from: https://www.heraldtribune.com/news/20180318/ little-in-89-billion-budget-for-states-neediest-residents. Accessed Nov. 21, 2019 7. Maxwell S. 21,000 special needs families on wait list for help in Florida. Orlando Sentinel. Available from: https://www.orlandosentinel.com/ opinion/os-special-needs-wait-list-florida-scott-maxwell-20180330-story. html Accessed Nov. 21, 2019. 8. Koh E. Florida eyes cutting rates or services for disabled people. Tampa Bay Times. Available from: https://www.tampabay.com/florida-politics/ buzz/2019/09/13/florida-eyes-cutting-rates-or-services-for-disabledpeople Accessed Nov. 21, 2019.

TODAY'S FDA JANUARY/FEBRUARY 2020

PREVENT FDAS: Water Damage Claims

DAMAGE CLAIMS IN YOUR DENTAL OFFICE. FDA Services has seen a sharp increase in water damage claims for our dental offices recently. There are several easy steps you can take as a practice owner to reduce the risk of water damage and avoid costly claims.

On average, the claim process lasts ~130 days, many times with the business unable to operate.

800.877.7597 â&#x20AC;˘ insurance@fdaservices.com â&#x20AC;˘ fdaservices.com

OVER THE PAST 5 YEARS... WE HAVE SEEN ~$200K

~$1.3M in losses to carrier

80 dental office water damage claims

in deductibles paid by insureds

SOME SUGGESTIONS FOR AVOIDING WATER LOSSES ARE: 1. Establish a process to turn off water in your office at the end of the day. If you plan to leave your office for an extended period of time, or are just closing up for the day, you need to establish a water shut-off process. This will involve both your equipment and your staff.

2. Inspect and fix water valves regularly. You should have a working solenoid valve installed and check it regularly. This is especially important when you are going to be out for an extended period of time. Steps for Checking Your Valve: 1. Turn off the solenoid valve and turn on the water at a sink in your office. 2. Let the water run. 3. If the water stops after the water in the line has run out, the valve should be working. 4. If the water continue to flow, chances are your valve isnâ&#x20AC;&#x2122;t working.

5. Your staff should know how to shut off the water. With a working solenoid valve, shutting off the water each night should be a simple process. Choose a member of staff to flip the solenoid valve switch off each night and on again in the morning.

6. Check and repair water lines and valves on dental chairs regularly. Sources: 1. Bankers Insurance Group: Dental Office Claims 2013-2018 2. blog.smartpractice.com/prevent-water-damage/

strategic scheduling

Are you and your team in control of your schedule or does it control you? Do parents dictate when they want their children to be seen? Are you and your team exhausted at the end of your work day or constantly running behind? Have you been conditioned to just deal with the production highs and lows in your schedule?

“

Productivity is never an accident. It is always the result of a commitment to excellence, intelligent planning and focused effort.

— Paul J. Meyer

”

Poor scheduling practices cause stress and frustration. Following an organized, systematic approach every time an appointment is scheduled helps you control the schedule each day instead of the schedule controlling you. Scheduling more efficiently allows you to reach your goals while maintaining a consistent flow. Review the scheduling recommendations below to identify areas in your schedule that could be modified. Where do you see areas for improvement in your own schedule?

1. Understand the goals of block scheduling: Meet defined production goal for each provider. Increase production through efficient use of time. Reduce stress for team members and patients. Keep the day interesting by having a good mix of procedures. Office runs on time. Reduce or eliminate no-shows and cancellations. Eliminate doctor or team member scheduled in too many places at the same time. Place emergency patients on the schedule and still run on time. Provide quality time with the patient. Provide the correct amount of time for each procedure. Allow flexibility for complications.

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2. Identify the types and lengths of appointments: Hard Op: More productive and longer procedures. Schedule in the morning, in the doctor’s first column. Easy Op: Easier, less productive and shorter restorative procedures. Schedule in the doctor’s second column either in the morning or afternoon. Place easy ops in between hard ops. Short Op: Follow up or quick check. Schedule in the doctor’s second column. Schedule during anesthesia time beside hard op/easy op. Urgent Op: Patient who needs a procedure within a few days. Block one to two per week, or more if needed, in your schedule for 30-40 minutes in length. Emergency: Patient who must be seen that day. Place emergency appointments 20 minutes before easy op appointments. Consult: Consult in the conference room. Avoid scheduling next to hard ops. NP: New patient appointment. Do not put next to hard op or sedation appointment.

3. Input the block schedule into your software to ensure proper daily flow: A well-planned block schedule will better serve each patient and allow the dental team to work more productively with less stress. First, define your production goals. A block schedule must be created with the goals in mind to ensure that goals can be reached with the designated appointments. Review your production goals every year to adjust them based on your practice needs and objectives. Use your practice management software to create designated blocks in your schedule for each appointment type listed above. Set up your practice management software to view the schedule in 10-minute increments.

Most software scheduling systems will have their own provider symbols, codes or colors; however, all team members need to be aware of your specific provider codes. The colors/codes allow the scheduler to be aware of provider availability. When a patient is motivated and ready to complete their treatment, it is important to have an available and open appointment ready for them to schedule immediately.

4. Keeping the schedule filled: Schedule your most loyal patients during the first appointment in the morning and the first appointment right after lunch. This will help to minimize last-minute changes to your schedule during times that do not give you much time to fill. Keep a priority list of patients who need treatment and are flexible who can come in on short notice. Most practice management systems have an indicator to identify “ASAP” or “quick call” patients. Keep track of correspondence made using this list. Once you have called three times, take them off the list. Use the unscheduled treatment report to call patients that have treatment diagnosed but not yet scheduled. Call parents regarding siblings of patients already on the schedule.

5. Stop broken appointments: Give the patient a reason to return. Emphasize how important it is not to change or fail their next appointment because of the benefit they will receive at their next visit. Educate the patient about the treatment they will receive today and have the clinical team express the reason to return for their next appointment. The reason to return also should be communicated at the front desk upon checkout and again when they are scheduling and confirming. Use the route slips every time to ensure that the correct treatment is being walked out and the next appointment is being scheduled correctly. SEE PAGE 31

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Award

2020

RECIPIENTS



PRESIDENT’S AWARD



Dr. Rudy Liddell  DENTIST

OF THE YEAR

Dr. Michael Starr 

J. LEON SCHWARTZ LIFETIME SERVICE



LEADERSHIP

Dr. Drew Johnson Dr. Jessica Stilley

PUBLIC SERVICE

Dr. Diane Ede-Nichols Dr. Reese Harrison Dr. John Penny

Dr. Bill D’Aiuto 

DENTAL TEAM MEMBER

Ms. Heather Lewis

Dr. Don Ilkka



NEW DENTAL LEADER



HELPING MEMBERS SUCCEED TEAM IMPACT AWARD

Ms. Carol Gaskins

JOIN IN THE RECOGNITION OF YOUR COLLEAGUES AT THIS SPECIAL EVENT.

AWARDS DINNER Friday • June 12, 2020 • 6:30-10 PM Gaylord Palms Resort & Convention Center Orlando, Florida Cocktail Reception, Dinner & Dancing Single tickets are $80 or a table for 10 is $750. Available Spring 2020.

strategic scheduling

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Confirm appointments two to three days ahead of time and the day before. Use your patient communication software to confirm patients through email and text message. For especially long or sedation appointments, confirm verbally and directly with the parent. If this is not possible, leave a message with the parent and ask them to return your call to verbally confirm their child’s appointment. For patients with a history of no-shows or failed appointments, leave a message for them to call before a certain date or time and let them know if you do not hear from them by then, their appointment will be removed from the schedule. This can only be done if the parents have signed an appointment agreement and have been verbally reminded every time an appointment is scheduled.

6. Be proactive with the schedule and discuss challenges and successes: Productive scheduling only occurs when the block schedule is followed and adhered to. Be proactive with the schedule and remind your team that adhering to the block schedule will create a more productive and less stressful work day. The entire team must be committed to the block schedule in order to make effective scheduling a success. When you schedule, always consider how many places you are asking the doctor to be at one time. Change any appointment time or date if it will help result in a more productive day and will not inconvenience the patient.

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During your morning meeting, identify any openings in your schedule so your team can help to fill those with same-day appointments. Review your schedule for the next three days as well to identify potential problems with the schedule, conflicts or openings to be sure there is time to make those changes prior to the actual appointment day. Maintain consistent communication between the front office and the clinical team to inform of patient arrivals, schedule changes, etc. Come together at the end of the day for five minutes and discuss what made today’s schedule successful or stressful. What worked, what didn’t? What could be modified to create a better flow? Remember, the best days are the ones that have been carefully planned out with consistent communication between the doctor, team, and the patients and parents. Keeping a productive, steady schedule mutually benefits your practice and your patients. When you spend more time with your patients and they avoid waiting, the value of the appointment increases. Managing the schedule and your time effectively reduces frustration, increases team morale and boosts productivity in your practice. Take the first step and identify which areas in your schedule are bogging you down. Making changes to your scheduling practices can get you on your way toward working smarter, not harder. Copyright © 2019 by the American Academy of Pediatric Dentistry and reproduced with their permission. This article first appeared in the September 2019 issue of Pediatric Dentistry Today.

TODAY'S FDA JANUARY/FEBRUARY 2020

classroom dental lessons

MORE HEALTH MORE

HELPS

KIDS!

Did you know that dental pain is one of the most common reasons students miss school? Dental pain can lead to poor academics, eating problems, low self-esteem and speech delay in children. MORE HEALTH Inc., a nonprofit organization based in the Tampa Bay area, teaches interactive dental lessons to more than 25,000 elementary school children each year, one classroom at a time. Students have a great time learning about dental hygiene, healthy nutrition and the importance of visiting the dentist. They also receive a toothbrush – sometimes it’s their very first toothbrush. Perhaps that is why dental education is MORE HEALTH’s most requested lesson by elementary school teachers.

KAREN BUCKENHEIMER, MORE HEALTH, INC. EXECUTIVE DIRECTOR

Ms. Buckenheimer can be reached at kpesce@morehealthinc.org.

TODAY'S FDA

MORE HEALTH has been filling the gap for school-based health and safety education for 30 years, this year celebrating teaching more than 4 million students in the Tampa Bay area. Twenty-five lessons, such as dental health, nutrition, heart, brain, firearm safety, bike and pedestrian safety, skin cancer prevention and distracted driving, empower students and parents with the knowledge to make healthy and safe decisions. The lessons are scripted, approved and taught in four school districts to more than 200,000 students in grades K-12 each year. The Florida Dental Association (FDA) Foundation, the S.L. Gimbel Foundation, George C. Forsythe Family Foundation, Johns Hopkins All Children’s Hospital, Tampa General Hospital, West Coast District Dental Association, Hillsborough County Dental Association, Upper Pinellas County Dental Association, Pinellas County Dental Association and Drs. Edward Hopwood and Terry Buckenheimer provided funding to MORE HEALTH to teach the dental lessons, at no cost to schools.

JANUARY/FEBRUARY 2020

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Using a kinesthetic style of learning, the MORE HEALTH lessons are interactive, fun and engaging. MORE HEALTH incorporates songs, puppets and hands-on activities as young students learn how to protect their teeth and mouth from oral disease: brushing, flossing, using fluoride, choosing nutritious foods and drinks, and visiting the dentist two times a year. Students receive a toothbrush at the end of the lesson. Additionally, parents receive oral health information and links to resources available in their community. Teachers are grateful to have dental education taught to their students — especially during Children’s Dental Health Month. MORE HEALTH has developed a video, educational materials and dental kits to help dentists and others teach oral health to children and parents. The “Magi the Magnificent Dragon” video teaches children the importance of oral health, dental checkups and sealants. This free short video is available on our website at morehealthinc.org/shop and can be shown in dental offices, school sites, after-school programs, community centers, clinics and hospitals. MORE HEALTH is passionate about teaching health and injury prevention education in the classroom and in community settings such as the FDA Foundation’s Florida Mission of Mercy. Research shows that by increasing oral health literacy, children and adults understand the value and importance of preventive oral health care, leading to reduced incidents of decay and costly treatment. No one is ever too young or too old to learn, especially if you make it fun and keep the messages simple and meaningful. Be mouthwise — your teeth will last a lifetime!

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A joint meeting of the American Dental Association and Florida Dental Association

ADA/FDC Annual Meeting

Harness the Power of Connection.

Save the Date

for the ADA FDC Annual Meeting in Orlando! Continuing Education Oct. 14-18 • Exhibit Hall Oct. 15-17 • ADA House of Delegates Oct. 16-19 Registration opens April 22, 2020 at ADA.org/meeting

The Doctors Company

autism

Providing Dental Care for the Patient with Autism The reality: Many individuals with autism spectrum disorders (ASDs) are members of families currently being treated by dentists in your community â&#x20AC;&#x201D; probably in your practice, too! 36

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Autism spectrum disorders (ASDs) are a group of developmental disorders defined by a significant impairment in social interaction and communication and the presence of unusual behaviors and interests. Many individuals with ASDs have atypical ways of learning, paying attention or reacting to different sensations and stimuli. The assessment and learning abilities of youngsters and adults with ASDs can vary from gifted to severely challenged. ASDs begin before the age of 3 and last throughout a personâ&#x20AC;&#x2122;s life. It occurs in all racial, ethnic and socioeconomic groups. The Centers for Disease Control and Prevention (CDC) estimated in 2018 that one in 37 boys and one in 51 girls have some form of autism. It is unclear if the increase is due to changes in how one identifies people with ASDs or whether it is an increase in prevalence.

General Symptoms People with ASDs differ greatly in the way they act and their capabilities. Social skills: They have limited or no interaction with other people, might not make eye contact and just want to be alone. They may have difficulty understanding other peopleâ&#x20AC;&#x2122;s feelings or talking about their own feelings. Children might not like to be held or cuddled. They may not know how to talk, play or relate to other people. Speech, language and communication: About 40% of ASD children do not talk at all. Others repeat words or questions directed to them, rather than responding. They may not understand gestures. Some can speak well, but have a hard time listening to others. Repeated behaviors and routines: Individuals with ASDs may repeat FLORIDADENTAL.ORG

actions. They may want to maintain routines and have trouble with changes. Children with ASDs may have significant delays in language, social and cognitive skills, but may be great at solving puzzles or computer problems.

Causes and Treatment It is suspected that there are numerous causes for ASDs due to complex interactions of genetic and environmental factors. Studies of twins have shown that in identical twins, there is about a 75% rate of both twins having autism, while in fraternal twins this occurs about 3% of the time. The cause of ASDs in most people is unknown, however, it tends to occur more frequently than expected among individuals who have other particular medical conditions, including Fragile X syndrome, tuberous sclerosis, congenital rubella syndrome and untreated phenylketonuria. Although there is no known cure for ASDs, early and intensive education can help children develop and learn new skills. The goal of these efforts is to help the child to talk, interact, plan, learn and care for his/her needs. While some medications can relieve some of the symptoms, structured teaching of skills (often called behavioral intervention) is currently the most effective treatment.

H. BARRY WALDMAN, DDS, MPH, PHD

STEVEN P. PERLMAN, DDS, MSCD, DHL (HON)

Associated Oral Conditions The complex neuro/developmental disabilities compound and exacerbate the all too frequent oral health disorders in the general child and adult populations, including: poor oral hygiene, increased risk for caries, generalized periodontal problems, oral-facial pain, xerostomia, poor nutrition and poor diet.

KAREN A. RAPOSA, RDH, MBA

Dental Services in a Private Practice The actual technical aspects of care are similar to the delivery of services for the general SEE PAGE 39 TODAY'S FDA

JANUARY/FEBRUARY 2020

Easyrefine

FROM PAGE 37

autism population of patients. Modifications in practitioner-patientstaff-parent or guardian interactions, however, may be necessary. Providing dental care and ensuring follow-up home care for individuals with ASDs will vary by patient age, type and level of the particular disorder, as well as an appreciation of family/living arrangements. An underlying understanding of patients with ASDs will facilitate the actual provision of care.

Keep wait times to a minimum to help reduce anxiety.

With proper consent, medical immobilization/ protective stabilization may be a necessary behavioral guidance technique. Use simple verbal and nonverbal communication.

Not all patients with ASDs are alike.

They may be hypo- or hypersensitive to sight, sounds and smells.

Nonverbal patients may carry out self-abusive behavioral acts as their only means of expression for pain.

You may need to attempt different modalities of behavioral guidance. Additional time may be necessary.

Schedule appointments in line with behavioral medication.

FLORIDADENTAL.ORG

Use adequate pain control for both restorative and surgical procedures.

H. Barry Waldman, DDS, MPH, PhD, SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY. He can be reached at h.waldman@stonybrook.edu. Steven P. Perlman, DDS, MScD, DHL (Hon), Global Clinical Director, Special Olympics, Special Smiles; Clinical Professor of Pediatric Dentistry, Boston University Goldman School of Dental Medicine. Karen A. Raposa, RDH, MBA, Published Author and International Speaker, Clinical Education Manager, Hu-Friedy Mfg. Co., Raynham, Massachusetts.

TODAY'S FDA JANUARY/FEBRUARY 2020

C C

MITTME OM

C C

MITTME OM

special needs

GETTING BACK MORE THAN YOU GIVE

“

Early in my experience treating patients with special needs, I realized that most of the challenges of treating this population lie in working outside of my own comfort level.

”

TODAY'S FDA

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I never pictured myself working in special needs dentistry. I love big, cosmetic cases. I enjoy collaborating with specialists for interdisciplinary full-mouth rehabilitations. Like most of us, I don’t especially look forward to a day full of class II composites. But when I was looking for an associateship and a friend was leaving this position, I decided to give it a chance. I’ll admit I was nervous at first. I didn’t have extensive experience with either pediatrics or patients with special needs. Those I had seen in the past were either extremely cooperative or, during my AEGD, under IV sedation. But over the last couple of years, I’ve come to love the population of patients with special needs more than any other. While my days now can be more physically challenging, they are extremely rewarding. One of my patients is 23 years old and has cerebral palsy. She’s in an automated wheelchair that she moves with a joystick but has very little controlled movement of her body. Her mouth is small with limited opening and she cannot transfer from her wheelchair into our dental chair. When I first met her, she was embarrassed to smile because of the visible anterior decay. She lives in a group home and, while mentally she is very capable, physically she is unable to brush her own teeth. She relies on overworked caregivers and unfortunately, oral hygiene often falls to the bottom of the priority list. By the time I met her, she had wrap-around decay on most of her anterior teeth and needed endodontic treatment on tooth No. 5. Because she was unable to transfer into the dental chair and her automated chair didn’t recline more than about 30°, I did most of the root canal sitting below her and looking up. I was pregnant at the time, so this was additionally challenging, but the final radiograph looked textbook.

FLORIDADENTAL.ORG

Early in my experience treating patients with special needs, I realized that most of the challenges of treating this population lie in working outside of my own comfort level. These patients typically want to make their caregivers and their health care providers happy. I hear “I love you” and “Did I do good?” so many more times a day than I hear “I hate the dentist.” Nobody complains about a stiff neck or post nasal drip, even while wearing helmets to protect them from seizure injuries or while having uncontrollable muscle spasms. With such a willing and eager group of patients, the only thing standing in the way of providing good dentistry is learning to work around the different physical demands. Sometimes this means contorting into awkward positions, learning to work on moving targets, or doing heroics in order to save as many teeth as possible. I rely on “tell, show, do,” as I was taught in dental school for pediatric patients, but even more than that I rely on my assistants. I am lucky to be working with two women who have been doing this much longer than me, and the behavior management skills they have learned through experience allow me to focus on the work.

DR. JESSICA KROLL

Dr. Kroll practices in Tampa and can be reached at jekroll@gmail. com.

If I were to give another dentist advice about how to treat patients with special needs, it would be to treat them just as any other patient. I regularly use comfortable rubber mouth props that dental floss can be tied to and SonicFill or other bulk fill composites to keep procedures as short as possible. I have training in oral sedation and, because we often use medication to help with behavior management, I would recommend continuing education on this topic for anyone who plans to treat patients with special needs frequently. But mostly, I would encourage others to understand that while the dentistry itself may be challenging, the rewards are well worth the effort.

TODAY'S FDA JANUARY/FEBRUARY 2020

silver diamine fluoride

USING SILVER DIAMINE FLUORIDE AT YOUR PRACTICE: AN OVERVIEW

LOGAN WILSON

Class of 2021 DMD Candidates at University of New England College of Dental Medicine and can be reached at lwilson10@ une.edu.

ZACHARIAH WULLBRANDT

Class of 2022 DMD Candidates at University of New England College of Dental Medicine and can be reached at zwullbrandt@une.edu.

TODAY'S FDA

Silver diamine fluoride (SDF) is a nonsurgical and non-invasive approach for caries control and arrest. SDF is available in the United States as 38% aqueous solution with fluoride ion concentration of 44,800 ppm. The solution provides a bactericidal and net cariostatic effect to infected dentin, along with the subsequent promotion of tooth hard tissue remineralization. Although SDF received approval from the Food and Drug Administration in 2014, the evidence supporting its effectiveness in caries prevention has been accumulated since the 1960s. Eleven systematic reviews, examining a total of 30 primary studies, have been conducted evaluating the evidence supporting the effectiveness of SDF in caries prevention.1 Four focused on root caries in adults, while seven focused on coronal caries in children. These reviews support SDF’s effectiveness for arresting coronal caries in the primary dentition and arresting and preventing root caries in older adults. However, there is currently limited evidence to draw conclusions on the effectiveness of SDF for prevention and caries arrest in permanent teeth in children.1 When using SDF as a caries management approach, case selection is key. Potential indications for SDF include patients with a high risk for caries due to salivary dysfunction secondary to cancer treatment, SjÖrgen’s syndrome, polypharmacy, aging or methamphetamine abuse. Other indications for SDF include those with severe early childhood caries, patients who cannot tolerate standard treatment for medical or psychologi-

JANUARY/FEBRUARY 2020

cal reasons, uncooperative children, frail elderly, individuals with severe cognitive or physical challenges, dental phobias and the immunocompromised.2 SDF stops disease progression, which can be useful for patients requiring multiple visits to complete care, those with limited access to care or those with extensive wait times for treatment.3 The SDF procedure is relatively simple, with SDF application completed via microbrushes to occlusal surfaces and super floss to interproximal regions. A single drop of SDF provides therapeutic treatment to multiple teeth, and at a less than $2 per drop, is a cost-effective treatment with the potential for high impact on populations where achieving disease control through traditional restorative approaches may be challenging. SDF application can be coded per tooth as D1354 – Interim caries arresting medicament application-per tooth. Adverse reactions related to SDF, although infrequent, include small, mildly painful white lesions on the oral mucosa that heal within 48 hours and a metallic taste or burning sensation in the mouth at the time of treatment. The main concern is black staining of the carious lesions, which may have negative aesthetic value and deter some patients.1 It is highly recommended to obtain separate consent from patients for the use of SDF, incorporating photographs of treated teeth. It is important to note that SDF does not stain sound enamel or dentin. The American Academy of Pediatric Dentistry (AAPD) issued a policy recommendaFLORIDADENTAL.ORG

tion that â&#x20AC;&#x153;supports the use of SDF as part of an ongoing caries management plan with the aim of optimizing individualized patient care consistent with the goals of a dental home.â&#x20AC;?4 After taking into consideration the low cost of treatment and the disease burden of caries, AAPD panel members reported confidence that the benefits of SDF application in the target populations outweigh its possible undesirable effects.4

Acknowledgments: This article has been reviewed by Dr. Mohamed ElSalhy, BMS, BDM, MSc, MPH, Ph.D., FRCD(C); and Dr. Rachel King, DDS, MPH, MBA, MS.

SILVER DIAMINE FLUORIDE (SDF)

DR. MOHAMED ELSALHY

DR. RACHEL KING

Silver ions kill bacteria that promote decay

Fluoride ions promote hydroxyapatite and fluorapatite formations

AgF(NH3)2

References:

Cavity

1. Seifo N, Cassie H, Radford JR, Innes NPT. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral Health. 2019;19(1):145. 2. Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, et al. Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. Pediatr Dent. 2017;39(5):135-45. 3. AAPD Council on Clinical Affairs. Chairside Guide: Silver Diamine Fluoride in the Management of Dental Caries Lesions. Pediatr Dent. 2017;39(6):478-9. 4. AAPD Council on Clinical Affairs. Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients. Pediatr Dent. 2017;39(6):51-3.

FLORIDADENTAL.ORG

TODAY'S FDA JANUARY/FEBRUARY 2020

therapy dog

ELLIE: A FURRY ASSISTANT EASES PATIENT ANXIETY 50

Dr. Erin Taylor and Ellie

There’s something remarkable about the patients who visit Dr. Erin Taylor’s pediatric practice — they’re excited to go to their appointments. Normally, most children are fearful and anxious when going to the dentist. But visiting this dentist means a visit with their favorite Pediatric Dentistry employee: Ellie the therapy dog.

Ellie has the important job of comforting anxious children during their dental visits. For almost two years, the fluffy 2-year-old goldendoodle has been an exemplary employee. Her primary responsibilities include providing comfort, offering snuggles and easing fear. However, incorporating this little pup into the practice was no easy task. It took a lot of time, money and work. Several patients bring in service dogs for various reasons — from diabetes to emotional disorders. Dr. Taylor and her staff noticed the effect these dogs had on their other patients. They talked about how great it would be to have a dog in the office to provide this same comfort to any nervous patients. When she lost her family pet several years ago, Dr. Taylor decided that if she was going to have another dog, it was going to be a working dog to help her patients. Many children are scared or anxious when visiting the dentist. Any way to provide a calming environment and ease their fears leads to a positive experience, which makes maintaining good oral health that much easier. Incorporating a sweet therapy dog does just the trick — even more so than other methods of distraction. Studies have confirmed that animal-assisted interventions, such as therapy dogs, cause a relaxing effect in people that allows them to divert their attention to the dog and therefore, reduce their anxiety.1 There’s also a decrease in pain perception during animal-assisted therapy, especially with children, and physically touching an animal decreases blood pressure, heart

rate, anxiety and stress.2 Even those patients who aren’t afraid love the fact that Ellie is a part of the pediatric dental team. Originally, Dr. Taylor went to her local animal shelter to find a suitable dog to be a part of her practice, but it was tough to find the right match. She knew she wanted a specific size, one that didn’t shed and most importantly, had a calm demeanor. She researched breeders who specifically bred service/therapy dogs and tested for temperament. It took six months to find the right breeder, but that was only the beginning. The right pup with the right temperament was selected and promptly named Ellie. For the first four months, Ellie spent time with a trainer learning the basics, like sit and stay, and to make sure she was well-behaved and potty trained. After Ellie had the basics down, the trainer frequently brought her around special needs schools to become accustomed to the different sounds and behaviors that children with special needs exhibit. By the time Dr. Taylor brought Ellie home, she was ready for her on-the-job training in the office to learn how to sit with the patients and get used to the sights and sounds that come along with a dental office. While her partner, Dr. Miguel Argumosa, and office managers knew about their new canine team member, Ellie’s introduction to the dental team was a delightful surprise for the rest of the staff. They were excited to welcome their new team member, and everyone was a part of the training process. The first six months were a lot of work — in addition to training Ellie to respond to various commands, including to sit and stay in the dental chair, the staff also needed to learn what Ellie could and couldn’t do. Patients are required to follow certain rules, too. They aren’t allowed to play with Ellie, but she does have some tricks up her fluffy proverbial sleeve: she plays dead and gives high fives. At the end of their visit, Dr. Taylor allows the patients to give Ellie a Cheerio for her helpful efforts.

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Synovus

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Dr. Taylor was adamant that Ellie was a working dog, so after greeting all the staff and getting some belly rubs first thing in the morning, Ellie knows when it’s time to work. Dr. Taylor is her handler, and she’ll simply say the cue phrase, “Ok, Ellie, it’s time to work.” The little dog will folJESSICA LAURIA low her into an operatory and put her paws up on the chair, FDA PUBLICATIONS AND ready to be picked up and put MEDIA COORDINATOR into position. Ellie also knows Ms. Lauria and can be reached when her job is done; in true at jlauria@floridadental.org or Pavlovian fashion, the snap 850.350.7115. of Dr. Taylor’s gloves coming off signals it’s time to stand up, jump off the chair and head back to Dr. Taylor’s office. Since she doesn’t freely roam, Ellie stays in Dr. Taylor’s office whenever she isn’t working. It’s just as important to know when Ellie shouldn’t be working. If a child is too unruly and kicking, it’s time for Ellie to retreat to the office. While a great tool, she is not the fix-all for every patient. If there is any type of safety issue, she is removed from the room. Since Ellie is always with Dr. Taylor, she works every day and has been in all three of Pediatric Dentistry’s locations in Bonita Springs, Cape Coral and Port Charlotte. Wherever she’s working, there’s a sign prominently displayed to let everyone who enters the office know there’s a therapy dog available. If anyone has an aversion to or fears dogs, Ellie stays in Dr. Taylor’s office. Her “schedule” varies — every patient is always asked if they would like Ellie to sit with them. Some days she’s with every patient; other days, just a few. While Pediatric Dentistry has an array of patients with anxiety or special needs, not every patient is fearful. However, every patient has the same opportunity to benefit from the

therapeutic and calming effects that Ellie provides. Having Ellie on the dental team makes a difference, and patients who previously could not get through appointments or even sit in the chair are now able to relax with Ellie snuggled next to them. Dr. Taylor credits the little dog with improving her patients’ experience and outlook on visiting the dentist. “My favorite thing is watching a child who has never been able to sit or do anything in the chair have their whole experience changed. And then watch that child be so happy and change their whole outlook about what coming to the dentist involves. It’s the most fulfilling thing in my career.” Working with children can be tough. Ellie’s also a supportive and encouraging companion to the staff when they just need a minute to decompress and take a break. They’ll sit with her in Dr. Taylor’s office and stroke her fur for a quick pick-me-up that would be sure to do wonders for anyone’s mood. Animals can change our perspective on many things, and dogs especially have a profound effect on us. One of the best things about dogs is their ability to love and comfort. Even so, not all dogs are suitable to be therapy dogs. Temperament is the most important characteristic to look for. For a therapy dog to be successful and beneficial, it needs to have a calm, gentle demeanor and be well-behaved and socialized. Children often are unpredictable, especially those with special needs, so it’s crucial that the therapy dog be at ease in all situations. After that, breed, size and age can vary based on your preferences and your patients’ needs. There’s a lot of factors to consider if you’re thinking about adding a therapy dog to your team. For more information on incorporating a therapy dog into your practice, please go to bit. ly/2ZHb606 to read “The Dogtor Will See You Now” from the Sept/Oct 2018 issue of Today’s FDA.

References: 1. Friedmann, E.; Tsai, C. The Animal-human Bond: Health and Wellness. Handbook on Animal-Assisted Therapy; Fine, A., Ed.; Elsevier: San Diego, CA, 2015; 95-117. 2. Netting, F. Ellen; Wilson, Cindy C.; and, New, John C. “The HumanAnimal Bond: Implications for Practice.” Social Work, 1987;32(1):6064.

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WHY CYBER CRIMINALS WANT TO YOUR DATA

STEAL

TODAY'S FDA

JANUARY/FEBRUARY 2020

FLORIDADENTAL.ORG

cyber criminals scans of driver’s licenses, insurance cards, health history forms, 2D and 3D images, lab reports, etc. To the average hacker, this information is a treasure trove of data and easily allows a hacker to perform identity theft on your patients or sell the data on the Dark Web (the black market of hackers). In addition, we’re now seeing scenarios where dental practices are targeted because their IT company or even their accountant’s office was hacked, and the criminals then use this data to attack or target their practices. In the past few months, approximately 700 dental practices became victims of ransomware attacks which were a direct result of their IT partner or managed service provider (MSP) being targeted by cyber criminals. IT companies and MSPs in the health care space should be engaging with cybersecurity specialists to protect their own businesses and they should be recommending that their clients engage with cybersecurity experts. A dental practice’s security protocols and procedures that were in place three to four years ago are no longer sufficient in today’s world.

GARY SALMAN, CEO, BLACK TALON SECURITY

It seems that you can’t turn on the TV or visit your favorite news website without reading about how cyberattacks and ransomware are crippling businesses and health care entities across the United States. Unfortunately, dental practices are now becoming the victims of similar attacks. We often hear dentists say, “Why would they want to come after my practice?” Your practice is being targeted because of the vast amount of data you store. Dental practices store a wealth of important information that can be used for identity theft and blackmail purposes. They often store data such as: name, address, birthdate, social security number, family members, FLORIDADENTAL.ORG

Cybercriminals are targeting practices through phishing or spear phishing campaigns. The hackers will send blanket or targeted emails to you and your staff with the intent of getting someone to either click on something or give up the credentials to your network or email system. We have seen many instances where a practice’s email system gets hacked and the hackers then send out emails to the practice’s patients with malware attached to them. Hackers are getting creative to “trick” you into opening emails and/or attachments (aka “hacking the human”). For example, they will send an email that appears to be from someone you know but change the letter “l” to the number “1” or use a “0” instead of an “O,” or send attachments with a “.exe” attachment instead of a “.doc” attachment. They will even steal your username and password by sending you a password reset email that appears to be legitimate. When an office is busy, the doctor or staff member may not pick up on these small changes, click on the emails and open attachments, which can lead to a disastrous result. The debilitating effects of a cyberattack include loss of productivity and business continuity, lack of trust by your patients and referrals, and negative PR in the community where you worked so hard to build your reputation. Imagine opening an email and clicking on what appears to be an invoice and then SEE PAGE 59 TODAY'S FDA

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Henry Schein

cyber criminals

FROM PAGE 57

getting hit with ransomware or malware. Ransomware is malicious software designed to block access to a computer system until a sum of money is paid and malware is software specifically designed to disrupt, damage or gain unauthorized access to a computer system. Hackers also are breaking into your network through vulnerabilities (“unlocked doors and windows”). They can gain access to your data through any type of device with an IP address (i.e., workstations, laptops, servers, printers, digital picture frames in your office, VoIP phone systems, smart TVs, digital thermostats, etc.) — or, even worse, through your IT vendor. You can no longer rely solely on your IT company to protect your network. IT companies are not cybersecurity companies. You need the knowledge and expertise of a specialist in cybersecurity to help ensure the security of your network. Hackers can scan your network for vulnerabilities in a matter of minutes and then identify and exploit these vulnerabilities in order to gain access. This approach in the dental space is much more common than you may imagine. The FBI and Department of Homeland Security posted a bulletin in fall 2018 warning IT vendors that advanced persistent threat actors (APTs) are targeting IT firms in order to exploit their information to attack their clients. Since your IT vendor typically stores your IP address, username and password in their database, a breach will give the cybercriminal the “keys to your castle.” Make sure to take defensive measures to help protect your network and critical patient data. It’s important to work with a qualified cybersecurity company who can: (1) perform an audit of your existing policies and procedures; (2) provide you with quarterly vulnerability scans of your network; (3) conduct live employee training to educate your staff on the latest threats and learn how to prevent them; and, (4) have penetration testing conducted on your network.

“

The debilitating effects of a cyberattack include loss of productivity and business continuity, lack of trust by your patients and referrals, and negative PR in the community where you worked so hard to build your reputation.

”

You don’t have to be the next victim of a cyberattack if you act NOW.

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For information on how to protect your practice against cyber attacks, contact FDA Services at 800.877.7957 or insurance@ fdaservices.com. FLORIDADENTAL.ORG

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Like the Titanic, not taking precautionary steps before an incident will most certainly end in doom and gloom.

ICEBERG AHEAD! 62

AVOIDING A HIPAA SHIPWRECK TODAY'S FDA

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Thanks to Leonardo DiCaprio and Kate Winslet, we all know how the story goes. On April 14, 1912, under a moonless night with calm seas, the unthinkable happened. The Titanic collided with an iceberg creating a gaping 300-foot hole in the bottom of the boat and dooming its maiden voyage. The 2,000+ passengers would have easily been saved had the ship carried the proper number of lifeboats onboard, but their overconfidence in their “unsinkable” ship meant only half of the required lifeboats were loaded. Don’t let this happen to your practice! “Easy,” you say. “I’m a dentist and I most certainly haven’t built an ocean liner.” Oh, but you have. All health care professionals, not just dentists, can take away a great lesson from that fateful journey almost 108 years ago. While your practice powers forward, there’s a lurking (HIPAA) iceberg right ahead! You’d better have those lifeboats ready. You may feel like most dentists: Your small craft would hardly cause such a fuss in a marina full of cruise ships — but the Office for Civil Rights (OCR) has proven all health care organizations are treated the same when it comes to HIPAA. OCR’s enforcement actions have shown that even a few affected patients can elicit a boat-sinking penalty. In 2017, the OCR announced a settlement agreement of $400,000 with a health center in Denver due to a breach of only 3,200 patients. Ironically, it wasn’t the breach itself that lead to the heavy fine. According to OCR’s press release,

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the health center had not conducted an organization-wide security risk analysis until after the breach occurred. Sure, your practice is likely doing everything in its power to keep sensitive patient information safe, but let’s be real for a second — it’s not unsinkable. In today’s world, we can all appreciate there’s not an organization or person out there who is immune to a breach. Which is why, with a 25% increase in health care hacking incidents last year, many experts agree the question isn’t if your practice will be breached, but when will your practice be breached. So, what’s the best way to surround your practice with lifeboats and avoid potential fines in the case of a breach? Well, you must first document ... then document again ... and then document some more before a breach occurs.

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Like the Titanic, not taking precautionary steps before an incident will most certainly end in doom and gloom. HIPAA-compliance programs that adhere with government regulations must include proactive comprehensive security risk analyses, documented policies and procedures, a formal HIPAAtraining program and completed business associate agreements, among others. Even though the seas may seem calm now, without heeding warnings, disaster almost certainly awaits many practices like yours when — not if — a data breach occurs.

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now you know INFORMATION FROM THE FDA GO TO SUMMARY All health care providers must include non-opioid alternatives for pain and pain management in their discussions with patients before providing anesthesia, or prescribing, ordering, dispensing or administering a schedule II controlled substance for the treatment of pain. Effective July 1, 2019.

 OPIOIDS

Non-opioid Alternatives Law bit.ly/2KXvZ2h

HEALTH CARE PROVIDER CHECKLIST INFORM

 Non-opioid alternatives for pain treatment, which may include non-opioid medicinal drugs or drug products are available.

 Non-opioid interventional procedures or

treatments, which may include: acupuncture, chiropractic treatments, massage, physical or occupational therapy, or other appropriate therapy are available.

DISCUSS

 Advantages and disadvantages of non-opioid alternatives.

 Patient’s risk or history of controlled

substance abuse or misuse, and patient’s personal preferences.

DOCUMENT IN PATIENT’S RECORD

 Non-opioid alternatives considered.

Your

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PROVIDE

 “Alternatives to Opioids,” an educational

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ur FDA YoEXCLUSIVE

information pamphlet created by the Florida Department of Health (required, available at bit.ly/2KXvZ2h) Also, a checklist and poster.

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Re: Dental supply savings for your practice Dear FDA Members, There is no denying that the business challenges for dentists across the nation continue to grow as the dental marketplace becomes more complex and competitive. Like many of our peers, we became members of organized dentistry because we believe that our profession should be shaped by those who practice it. And we value being part of a community that supports and advocates for each other. Together, we have a louder voice and more negotiating power. So, weâ&#x20AC;&#x2122;re writing to share great news, both as peers and as volunteer leaders in organized dentistry: a better way to shop for dental supplies is here. The Dentists Supply Company (TDSC) was launched in California in 2017 as a new business dedicated to leveraging association membersâ&#x20AC;&#x2122; buying power to deliver dental supply savings. With our shared strength, TDSC negotiates pricing with major manufacturers and distributors, which helps stabilize prices and drive down supply costs for practices of every size. Through an online shopping site, TDSC. com, many member dentists have already started to save more than they pay in annual tripartite dues. This early success has caught the attention of your peers and other leaders in dentistry. Now, TDSC is responding to the demand by partnering with the Florida Dental Association to bring the same level of savings to association members in Florida. As a member, you will be able to benefit from exceptional savings and free shipping on the expansive online catalog of supplies from authorized sources. You can start shopping TDSC.com in December. We encourage you to gather your current invoices today and submit them at TDSC.com/pricecompare to let the TDSC team do the work of comparing prices for you. Your custom price comparison will show product-by-product savings and streamline your shopping. Please know that these supply savings are a free benefit of your association membership. Thank you for supporting our community and your peers as we work to change the business side of dentistry for the better. Sincerely,

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Rudy Liddell, DMD President, Florida Dental Association

compleat dentistry

EXCUSES, EXCUSES

DR. EDWARD HOPWOOD

Dr. Hopwood is a restorative dentist in Clearwater and can be reached at edwardhopwood@gmail.com.

Compleat dentistry is a slower-paced, deliberate style of dentistry, espoused by Pankey, Dawson and so many others, in which the dentist knows the patient well, knows the work, knows their own abilities and limitations, and uses this knowledge to take care of the patients who trust them with their care. The world will change, but the principles of compleat dentistry will remain the foundation of an exceptional practice. The spelling is an homage to Isaak Walton, whose book, “The Compleat Angler,” was about so much more than fishing.

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Sometimes when we’re faced with a daunting task, we make up excuses why we can’t complete that task. Often, it’s much easier to make excuses than to complete the task or to embark on a difficult journey. When we speak about compleat dentistry, there often are several misconceptions that arise. I think it’s worthwhile to group these misconceptions into two categories: resistance misconceptions and philosophical misconceptions. Resistance misconceptions are so named because I think they really speak to the part of the soul that Steven Pressfield so appropriately calls the resistance. In his wonderful book, “The War of Art,” Pressfield defines the resistance as a repulsive force that works against any act that seeks long-term growth, health or integrity. In fact, the resistance is so predictable that the more important the act, the more resistance we will feel. And we can use the resistance to guide us to move in the appropriate direction. Three examples of resistance misconceptions are insurance, location and money. The insurance misconception is that our patients will only do treatments that their insurance company will pay. In reality, dental insurance is working its way out of business because it has held its annual maximum so low for so long, that it will no longer pay for much at all. If a patient needs one root canal, one buildup and one crown, most of them will find themselves over their annual maximum. If we’re truly interested in preserving our patients’ health, we’ll need to find a way to provide treatment beyond what their insurance company will pay.

JANUARY/FEBRUARY 2020

Location is another misconception. You don’t need to practice in an affluent area to provide people with great dentistry. I practice in the middle-class neighborhood where I grew up. My patients range from wealthy to working class to destitute. I have plenty of teachers and police officers as patients. One of my favorite cases was completed on a maintenance man — he has one of the best restorations I’ve done. Another patient didn’t have a car and rode his bike to my office to have his implants restored. The common denominator of my patients is not affluence, it’s that they value their dental health. My favorite misconception is money: Patients just don’t have the money to have great dentistry. Well, that’s where compleat dentistry is so helpful. Often, a compleat dental treatment plan can be staged to be completed over many years (my record is 12 years, but I have a couple in the works that may take longer). But the real kicker is that I can honestly swear that a patient seen for a lifetime at a compleat dentist’s office will spend less money than a patient who spends a lifetime reacting to problems and maximizing their insurance company’s $1,500 per year limit. Once you get on top of the treatment and control the causes of breakdown, then you spend very little on maintenance. Over the past 20 years, I’ve spent less on my own dental care (even adding back in the discounts from colleagues) than on my cellphone. The first philosophical misconception is that compleat dentistry is about full-mouth rehabs. Initially, I was concerned when I took my first Dawson course because I was

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worried that every patient would require a full-mouth reconstruction. The reality is that very few of my patients require a full-mouth reconstruction. This is especially true now because of the conservative restorative materials that we have at our disposal. I agree that young dentists go to continuing education courses to learn full-mouth rehabs, but the reality is that the great institutes teach us so much more that we can apply daily. Every patient deserves to understand that dental health involves infection control and occlusal stability, and these two goals usually don’t require a full-mouth reconstruction. But make no mistake, each patient deserves the autonomy to decide which goals they wish to pursue. The biggest philosophical misconception is when we ask the question, “What can compleat dentistry do for me?” This is a completely backward way of thinking. Compleat dentistry is not for the dentist, it’s for the patient. If we are diligent and apply the teachings and work hard at it, then we can use compleat dentistry for our patients. Instead of helping ourselves to financial rewards, our attitude needs to shift toward helping our patients achieve health. Certainly, the dentist is ultimately rewarded, but all the rewards come from helping the patient. Now, the journey is difficult and there are many hurdles along the way. We’re constantly challenged by the resistance. Not many will overcome the resistance, and most will make excuses why they can’t. Working hard to approach that great asymptote that we call mastery is a worthwhile endeavor. But, it’s worthwhile not because of what we’ll get; rather, because of what we can give. To be sure, I am no master and I work hard to overcome the resistance every day. When I can overcome it, I’m able to reveal a fire inside of me that has inspired me to spend the past 20 years teaching our residents at the University of Florida AEGD program, the past five years writing this column and to spend my career providing for my patients.

“

Compleat dentistry is not for the dentist, it’s for the patient.

”

“Whatsoever ye want o’ discontented man, step up, pay the price, and take it.” This quote is attributed to L.D. Pankey, a man who dedicated his life to helping his fellow professionals pursue mastery. I love the quote because it empowers us to get what we want if we are willing to pay the price. Sometimes, the price we pay is overcoming a resistance that is entirely internal.

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Your

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Superior DDS

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DRS. LAUREN RUDDOCKS*, SUMITA SAM*, SAJA ALRAMADHAN*, NEEL BHATTACHARYYA, DONALD M. COHEN AND NADIM M. ISLAM

Question:

A 7-year-old Hispanic male presented to Dr. Pat Ricalde, an oral and maxillofacial surgeon at the Florida Craniofacial Institute in Tampa, with the chief complaint of a swelling of the right mandible. The patientâ&#x20AC;&#x2122;s father first noted the swelling around eight months prior to the appointment. He reported that it had increased in size since then. Clinical examination revealed an approximately 3 cm expansion of the right mandibular vestibule (premolar region) with a smooth, non-ulcerated and erythematous surface (Fig. 1). The area was tender upon palpation. The patientâ&#x20AC;&#x2122;s medical history was non-contributory, and his only complaint was difficulty eating due to the pain. The radiograph (Figs. 2-3) revealed a large illdefined radiopaque mass fused to the root of tooth #S, causing expansion of the right mandibular premolar region. The radiopaque area appeared to extend from the apex of tooth #R to the mesial aspect of tooth #T and apically to the coronal aspects of unerupted teeth Nos. 27, 28 and 29.

A. Osteosarcoma B. Calcifying epithelial odontogenic tumor C. Focal cemento-osseous dysplasia D. Complex odontoma E. Cementoblastoma

Based on the above history, clinical photograph and radiograph, what is the most likely diagnosis?

Fig. 1: Swelling of the right mandibular vestibule

An excisional biopsy was performed along with extraction of the associated tooth. The specimen was then submitted to the University of Florida Oral Pathology Laboratory Biopsy Service for histopathologic examination. The tissue was decalcified and sectioned for fixation and processing. Histopathologic examination revealed well-vascularized cellular fibrous connective tissue along with numerous variably sized and mineralized trabeculae of bone and cementum-like material. In some areas, there was evidence of bone being replaced by fibro-osseous material. The periphery of the lesion showed radiating columns of cemento-osseous tissue with cementocytes and osteocytes within lacunae. These cells appeared to be producing bone and osteoid.

SEE PAGE 74 FLORIDADENTAL.ORG

Fig 2. Ill-defined radiopaque mass fused to root of tooth #S

Fig. 3. CT imaging shows a well-defined opacity with a radiolucent rim in association with root of tooth #S TODAY'S FDA JANUARY/FEBRUARY 2020

diagnostics FROM PAGE 73

Diagnostic Discussion A. Osteosarcoma Incorrect. Although this case and osteosarcoma share some radiographic and clinical features, there are important differences. Osteosarcoma of the jaws is usually seen in older individuals with a mean age of 30 years, which is about a decade or so older than the mean age for osteosarcomas of the long bones (extragnathic). Osteosarcoma is the most common type of bone malignancy. Gnathic osteosarcomas are uncommon, accounting for around 6% of all osteosarcomas. These lesions often are associated with symptoms such as numbness, paresthesia, swelling and pain. Unlike the present case, osteosarcomas are destructive lesions. An early radiographic finding is symmetric widening of the periodontal ligament space around involved teeth. The classic appearance of osteosarcoma is a mixed radiolucent and radiopaque lesion with ill-defined “moth-eaten” borders. In around 25% of cases, there is a “sunburst” appearance caused by osteophytic bone production on the periphery of the lesion. Other common findings include “spiking” root resorption and cortical destruction. These features are not seen in the present case. The histologic finding is osteoid production by malignant mesenchymal cells. The tumor cells may appear pleomorphic with bizarre nuclei. Overall, the radiographic findings when combined with the clinical symptoms are important in the early diagnosis of osteosarcoma. Osteosarcomas are treated by radical surgical excision. Gnathic osteosarcomas have a lower tendency to metastasize and have a better prognosis than extragnathic. The literature reports approximately 30-50% five-year survival rate.

B. Calcifying epithelial odontogenic tumor (Pindborg Tumor) Incorrect. There are several key differences between the case presented here and calcifying epithelial odontogenic tumor (CEOT). These include the age of the patient, the radiographic presentation and the histologic findings. CEOT is an uncommon odontogenic tumor with a prevalence 10-15 times lower

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than ameloblastoma. It is thought to arise from either the dental lamina in peripheral (gingival) cases, or the stratum intermedium of the enamel organ in intrabony cases. This lesion is most often encountered in patients between the ages of 30 and 50. Two-thirds of all cases are found in the posterior mandible, and almost 50% of the cases are associated with an impacted tooth. CEOT usually demonstrates evidence of expansion. Radiographically, CEOT often appears as a mixed radiolucent/ radiopaque lesion with well-defined scalloped margins. In contrast, the present case demonstrates an ill-defined radiopaque mass. In addition, the lesion may be multilocular or have a honeycomb appearance. Histologic features include sheets or islands of atypical polygonal epithelial cells with significant amorphous, pink material (amyloid-like, which stains positive with a Congo red stain). Numerous small mineralized deposits with concentric rings (Liesegang ring calcifications) also may be noted. Treatment consists of conservative local excision including a narrow rim of surrounding bone. Maxillary lesions tend to grow rapidly and are not usually circumscribed, meaning they often require more aggressive surgery. A recurrence rate of 15% has been noted, with simple enucleation associated with the highest rate of recurrence. For lesions that demonstrate radiolucent and radiopaque areas, CEOT should be included in the differential diagnosis.

C. Focal cemento-osseous dysplasia Incorrect. Distinguishing features between the present case and focal cemento-osseous dysplasia (FCOD) are the age at presentation and the radiographic and histologic findings. FCOD is the most common benign fibro-osseous lesion encountered in the oral pathology laboratory. Ninety percent of these lesions occur in females with an average age of 40 years. These lesions are almost invariably asymptomatic and are regularly discovered on routine radiographic examination. The posterior mandible apical to the first or second permanent molar is the most common site for this lesion. Patients may present with multiple lesions. Radiographically, the lesion varies from completely radiolucent to densely radiopaque, with the most common presentation being a mixed radiolucent and radiopaque pattern. Lesions occur either in dentulous or edentulous areas, but always in the alveolar process. On surgical exploration, the tissue occupying the bone defect consists of fragmented gritty or “sand-like” tissue. There is FLORIDADENTAL.ORG

little to no tendency for progression or enlargement, unlike the present case. No treatment is indicated for asymptomatic cases. Optimal management consists of regular recall appointments for prophylaxis and oral hygiene reinforcement to avoid the need for tooth removal. This is because symptoms usually begin after the lesions are either manipulated or irritated. This may occur following extractions or as a result of alveolar atrophy beneath a denture.

Radiographically, the tumor appears as a radiopaque mass that is fused with the root(s) of the involved tooth. A thin radiolucent rim often surrounds the opaque mass in the periphery. Microscopically, the lesion may be fused to the tooth root, which helps differentiate it from osteoblastoma. Mineralized tissue compatible with cementum containing numerous cementoblasts may be seen (Fig. 4).

D. Complex odontoma Incorrect, but a logical entity to be included in the differential diagnosis of any opacity of the jaws seen in a pediatric patient. Radiographic and histologic findings are the main distinguishing features between odontoma and the presenting case. The odontoma is the most common odontogenic tumor whose prevalence exceeds all other odontogenic tumors combined. It is considered to be a developmental anomaly (hamartoma) rather than a true neoplasm. It is a disorganized mass of enamel and dentin with variable amounts of cementum and pulp and it often causes disturbances in tooth eruption. However, these lesions are typically asymptomatic and usually discovered on routine radiographic examination. These lesions most often present in tooth bearing areas associated with the crowns of unerupted teeth, and they are more common in the molar regions of either jaw. Large odontomas may cause jaw expansion. Radiographically, complex odontomas appear as irregularly shaped calcified masses with the radiodensity of tooth structure, associated with a radiolucent rim. The treatment of choice is usually surgical removal. Microscopically, complex odontomas display mature tubular dentin, enclosing pools of enamel matrix. Importantly, odontomas are not fused to the tooth root(s) as in the present case.

E. Cementoblastoma Correct â&#x20AC;&#x201D; well done! Cementoblastoma is a rare benign tumor of cementoblasts. This lesion is most common in young patients, with 75% of cases diagnosed before the age of 30. There is no sex predilection. The most frequent site of involvement is the posterior mandible, with the mandibular first molar being involved in 50% of cases. In rare cases, this lesion may involve primary and impacted teeth. Cementoblastoma may cause jaw expansion, with pain and swelling as reported symptoms in two-thirds of cases. Locally aggressive lesions may show cortical destruction, tooth displacement, infiltration into the pulp chamber and root canals and occasional involvement of the maxillary sinus.

Fig. 4: Microscopic presentation showing variably mineralized cementoosseous material with osteocytes and cementocytes

Fig. 5: Post-operative radiograph taken eight months after surgical removal of the lesion. Treatment involves surgical extraction of the tooth along with the attached lesion. This may be followed by osseous curettage to reduce the risk of recurrence. In addition, amputation of the affected root and endodontic treatment of the remaining tooth may be considered. Estimates of recurrence vary, and complete removal is usually associated with a good outcome. The present case showed no clinical or radiographic evidence of recurrence at the eight-month follow-up appointment.

SEE PAGE 76 FLORIDADENTAL.ORG

TODAY'S FDA JANUARY/FEBRUARY 2020

diagnostics

FROM PAGE 75

12,000 specimens the service receives every year from all over the United States.

References: Arora A, Donald PM. Complex odontomas hindering eruption of maxillary permanent teeth: a radiological perspective, Case Reports 2016;2016:bcr2016216797. Bereket C, Çakir-Özkan N, Şener İ, Bulut E, Tek M. Complex and compound odontomas: Analysis of 69 cases and a rare case of erupted compound odontoma. Nigerian Journal of Clinical Practice. 2015: 18(6):726-730. Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck 2nd Ed Philadelphia W.B. Saunders Co. (Elsevier) 2009 p. 810-12. Neville B, Damm D Allen C and Chi A. Oral and Maxillofacial Pathology ed.4. Elsevier, 2016. Regezi J, Sciubba J, and Jordan R. Oral Pathology Clinical Pathologic Correlations ed. 5 Philadelphia: W.B. Saunders CO. 2008 p. 268-9.

Diagnostic Discussion is contributed by UFCD professors, Drs. Indraneel Bhattacharyya, Don Cohen and Nadim Islam who provide insight and feedback on common, important, new and challenging oral diseases.

Clinicians are invited to submit cases from their own practices. Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter. DR. COHEN

Drs. Bhattacharyya, Cohen and Islam, can be reached at oralpath@dental.ufl.edu. Conflict of Interest Disclosure: None reported for Drs. Bhattacharyya, Cohen and Islam.

The Florida Dental Association is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals DR. ISLAM in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp. *Residents in oral and maxillofacial pathology at the University of Florida College of Dentistry.

The dental professors operate a large, DR. BHATTACHARYYA multi-state biopsy service. The column’s

case studies originate from the more than

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Card Connect

career center The FDA’s online Career Center allows you to conveniently browse, 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! Post an ad on the FDA Career Center and it will be published in our journal, Today’s FDA, at no additional cost! Today’s FDA is bimonthly; therefore the basic text of all active ads will be extracted from the Career Center on roughly the 10th of every other month (e.g., Jan. 10 for the Jan/Feb issue, March 10 for the March/April issue, etc). Please note: Ads for the Nov/Dec issue must be received no later than Nov. 1. Please visit the FDA’s Career Center at careers.floridadental.org. Seeking General Dentist for Busy, Well-Established 25 y/o Practice in Boca. Associate DDS wanted for busy, well-established 25-year-old dental practice in prime location of Boca Raton. Dentist must be highly proficient in all forms of dentistry, including cosmetics and implant restorations. Two days to start, eventually leading to full time, with eventual partnership/buyout. Great opportunity for the right individual. Go to careers. floridadental.org/jobs/13206144 to apply. General Dentist — Kendall. Description: Now is the time to join a fast-growing organization. You will have opportunities to learn new skills from our team of experienced professionals. If you’re ready to take your career to the next level and gain valuable experience, apply today! Overview: Let us allow you to do what you do best by doing the dentistry that you diagnose while exploring future partnership opportunities. We follow through on our promise to clinicians with our culture of patient centric care, our ability to deliver comprehensive integrated care, and our ability to support modern dentistry. PDS supported owner dentists know that being backed by the country’s leading dental support organization allows them to focus on providing patient centric and clinically excellent care. Benefits: Competitive Compensation and Benefit Package; Modern offices equipped with the latest dental technology; Malpractice Insurance; Healthcare Benefits (Medical, Prescription Drugs, Dental and Vision); 401(k) Savings Plan. The average full-time PDS-supported Dentist earns $160,000 - $390,000. Testimonial from Dr. Callaway-Nelson: “Partnering with PDS has given me the opportunity to realize my dream of practice ownership. I am able to do the dentistry that I love.” Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2sA1skT. Dental Assistant — Port Charlotte. Overview: Responsibilities: Perform functions in accordance with the applicable state’s Dental Auxiliaries Table of Permitted Duties; Actively participate in the Perfect Patient Experience by striving to keep your patients focused on optimal treatment while attending to their individual needs and concerns; Escort patients to/from the front desk and introduce them to other team members as appropriate;

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Maintain a clean, sterile, and cheerful environment; Record patient charting and all of the dentist’s notes in the digital patient chart as directed by the dentist; Maintain strict compliance with State, Federal, and other regulations, (e.g., OSHA, WC, Dental Board, HIPAA, ADA, DOL, HR policies and practices). Qualifications: Necessary industry certifications and education; Possess outstanding time management, communication, and technical skills; Can-do attitude, a proactive nature, a strong sense of ownership and integrity and a desire to continue to learn and grow; Demonstrate knowledge of dental terminology, instruments and equipment. Benefits: Medical, dental and vision insurance; Continuing Education (CE Units); Paid time off; Tuition Reimbursement; Child care assistance; 401K; Paid time to volunteer in your local community. Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/37jtaBl. Dental Assistant — Doral. Overview: Responsibilities: Perform functions in accordance with the applicable state’s Dental Auxiliaries Table of Permitted Duties; Actively participate in the Perfect Patient Experience by striving to keep your patients focused on optimal treatment while attending to their individual needs and concerns; Escort patients to/from the front desk and introduce them to other team members as appropriate; Maintain a clean, sterile, and cheerful environment; Record patient charting and all of the dentist’s notes in the digital patient chart as directed by the dentist; Maintain strict compliance with State, Federal, and other regulations, (e.g., OSHA, WC, Dental Board, HIPAA, ADA, DOL, HR policies and practices). Qualifications: Necessary industry certifications and education; Possess outstanding time management, communication, and technical skills; Can-do attitude, a proactive nature, a strong sense of ownership and integrity and a desire to continue to learn and grow; Demonstrate knowledge of dental terminology, instruments and equipment. Benefits: Medical, dental and vision insurance; Continuing Education (CE Units); Paid time off; Tuition Reimbursement; Child care assistance; 401K; Paid time to volunteer in your local community. Pacific Dental Services is an equal opportunity employer and does not discriminate against

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any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2SFKzAa. Treatment Coordinator — Doral. Overview: Do you love working with patients to make sure they can get the treatment they need within their financial means? Are you great at helping patients understand their options and why the treatment is important to their health and well-being? Are you looking for a challenge and the chance to be part of a true team environment where you can constantly learn and grow? If so, now is the time to join us as a benefits coordinator. Responsibilities: Gain a financial commitment from the patient; Understanding of general dental operations and patient flow issues; Utilize tools, skills, and talents to assist patients in making the best possible decision for their unique wants and needs, remembering that the most important choice the patient will make is getting started with treatment; Coordinate fees and insurance benefits for patients visiting general practitioners; Utilize available financial options to give patients choices for how they can pay; Professionally overcome the common patient objections/rejections; Maintain accurate patient financial paperwork and adherence to the office manager’s financial arrangement parameters; Properly use patient account software and maintain accuracy in records related to patient financials. Obtain necessary insurance approvals in a timely manner; Partner with the Specialty BC, when appropriate, to complete patient care; Help in exceeding patient expectations in order to achieve the Perfect Patient Experience®. Qualifications: High school diploma or general education degree (GED) and one or more years of previous experience as a treatment coordinator in a dental practice is preferred; Ability to understand insurance plans is preferred; Knowledge of Microsoft and QSI software applications is preferred. Benefits: Medical, dental and vision insurance; Paid time off; Tuition Reimbursement; Child care assistance; 401K; Paid time to volunteer in your local community. Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here:

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bit.ly/36aWud7. Dental Assistant — Miami. Overview: Responsibilities: Perform functions in accordance with the applicable state’s Dental Auxiliaries Table of Permitted Duties; Actively participate in the Perfect Patient Experience by striving to keep your patients focused on optimal treatment while attending to their individual needs and concerns; Escort patients to/from the front desk and introduce them to other team members as appropriate; Maintain a clean, sterile, and cheerful environment; Record patient charting and all of the dentist’s notes in the digital patient chart as directed by the dentist; Maintain strict compliance with State, Federal, and other regulations, (e.g., OSHA, WC, Dental Board, HIPAA, ADA, DOL, HR policies and practices). Qualifications: Necessary industry certifications and education; Possess outstanding time management, communication, and technical skills; Can-do attitude, a proactive nature, a strong sense of ownership and integrity and a desire to continue to learn and grow; Demonstrate knowledge of dental terminology, instruments and equipment. Benefits: Medical, dental and vision insurance; Continuing Education (CE Units); Paid time off; Tuition Reimbursement; Child care assistance; 401K; Paid time to volunteer in your local community. Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2Q9nSlX. Miami, FL Area OMS Practice for Sale. This dental practice in northwest Miami, Florida is on the market and it is hot! This specialty oral surgery and implant practice is well-established in the community. Located in an upscale office building with over 1,700 square feet. The current doctor has practiced in the community for over three decades. As such, they are willing to stay on for a number of years to ensure a smooth transition. The practice is in a suburb of Miami, FL and is a short drive to downtown or only ten miles from the airport! Enjoy a lower cost of living while having easy access to all Miami is famous for. The area is known for its tree lined streets and low crime rate in addition to its well-regarded public school system. With a vibrant community and international roots, there is a thriving arts scene as well. Visit Oleta River State Park- a haven for mountain bikers, paddlers, anglers and families just thirty minutes from downtown Miami. To learn more about this outstanding practice in the Sunshine state, read below: 4 fully equipped operatories; Collections nearly $690,000; Adjusted EBITDA nearly $120,000; Current doctor willing to stay on for smooth transition; Great growth opportunity with extended hours, offering more services in house and additional marketing efforts. To receive a copy of the prospectus and learn more about this practice opportunity in Miami-Dade County, please reach out to Kaile with Professional Transition Strategies. Email anytime: kaile@professionaltransition. com or by phone: 719.694.8320. General Dentist — Winter Haven. Overview: Let us allow you to do what you do best by doing the dentistry that you diagnose while exploring future partnership opportunities. We follow through on our promise to clinicians with our culture of patient centric care, our ability to deliver comprehensive integrated care, and our ability to support modern dentistry. PDS supported

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owner dentists know that being backed by the country’s leading dental support organization allows them to focus on providing patient centric and clinically excellent care. Benefits: Competitive Compensation and Benefit Package; Modern offices equipped with the latest dental technology; Malpractice Insurance; Healthcare Benefits (Medical, Prescription Drugs, Dental and Vision); 401(k) Savings Plan. The average full-time PDS-supported Dentist earns $160,000 - $390,000. Apply now or contact a recruiter anytime. We’d love to chat, get to know you and share more about us. Testimonial from Dr. Callaway-Nelson: “Partnering with PDS has given me the opportunity to realize my dream of practice ownership. I am able to do the dentistry that I love.” Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/36cDVVI. Dentist — Arcadia, FL. Overview: Our Dentist provides dental assessments and dental care of patients and supervises the Dental Assistant. Additional Details: *Flexible scheduling, 30 hours per week* Paid Malpractice. Qualifications: Education for Dentist: Graduated from an accredited school of dental medicine. Experience for Dentist: One (1) or more years’ experience in general dentistry preferred. Licenses/Certifications for Dentist: Current licensure as a Dentist within the State; Current CPR Certification. Responsibilities: 1) Documents treatment. Provides direct supervision of Dental Assistant. Routine cleaning, drilling, filling, extractions, root canals, impressions, prosthetic and replacement of teeth. Repair of teeth (crowns, bridges). Cuttage, gingivectomy I&D of infections, local nerve blocks, dental referrals, consultations to psychiatric staff, provides education about dental diagnoses and treatment as well as oral hygiene to patients and their families. 2) Supervises dental services received by the patient, supervision of appropriate staff in the dental clinic. 3) Participates in performance improvement activities. MSO, hospital wide committees and Task Forces. Collaborates and communicates with staff in other disciplines in an effective and professional manner. Participation in Peer review, Quality Improvement, and in the development of policies and procedures. 4) Demonstrates understanding of, and complies with special precautions, disaster and fire safety procedures, and knowledge of abuse reporting. 5) Is sensitive to cultural diversity issues, treats patients as an individual, and considers the culture of the patients when providing care and treatment. Wellpath is an EOE/ Minorities/Females/Vet/Disability Employer. Contact Rankin Holloway at rholloway@wellpath.us. General Dentist — Palm Beach County. Overview: Let us allow you to do what you do best by doing the dentistry that you diagnose while exploring future partnership opportunities. We follow through on our promise to clinicians with our culture of patient centric care, our ability to deliver comprehensive integrated care, and our ability to support modern dentistry. PDS supported owner dentists know that being backed by the country’s leading dental support organization allows them to focus on providing patient centric and clinically excellent care. Benefits: Competitive Compensation and Benefit Package; Modern offices equipped with the latest dental technology; Malpractice Insurance; Healthcare Benefits

(Medical, Prescription Drugs, Dental and Vision); 401(k) Savings Plan. The average full-time PDS-supported Dentist earns $160,000 - $390,000. Apply now or contact a recruiter anytime. We’d love to chat, get to know you and share more about us. Testimonial from Dr. Callaway-Nelson: “Partnering with PDS has given me the opportunity to realize my dream of practice ownership. I am able to do the dentistry that I love.” Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/357dq2D. General Dentist — Royal Palm Beach. Overview: Let us allow you to do what you do best by doing the dentistry that you diagnose while exploring future partnership opportunities. We follow through on our promise to clinicians with our culture of patient centric care, our ability to deliver comprehensive integrated care, and our ability to support modern dentistry. PDS supported owner dentists know that being backed by the country’s leading dental support organization allows them to focus on providing patient centric and clinically excellent care. Benefits: Competitive Compensation and Benefit Package; Modern offices equipped with the latest dental technology; Malpractice Insurance; Healthcare Benefits (Medical, Prescription Drugs, Dental and Vision); 401(k) Savings Plan. The average full-time PDS-supported Dentist earns $160,000 - $390,000. Apply now or contact a recruiter anytime. We’d love to chat, get to know you and share more about us. Testimonial from Dr. Callaway-Nelson: “Partnering with PDS has given me the opportunity to realize my dream of practice ownership. I am able to do the dentistry that I love.” Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2ZBRonH. Associate Dentist. Our patients love us, and you will, too! Thriving fast-growing practice located in Bushnell, FL is currently seeking a full time Associate Dentist. Bushnell is a friendly small town that is conveniently located within commuting distance of Ocala, The Villages, Brooksville, as well as parts of both Tampa and Orlando. We are a Private Practice that is non-corporate owned with a 1/3 FFS and 2/3 PPO mix. No DMO’s or capitation. Paperless office (Dentrix) with all Digital Radiography (Dexis). Fun team! Excellent productionbased compensation with guaranteed minimum pay plus benefits package. Successful candidate will be people oriented and motivated. A minimum of 1 year experience is desired. For more information, please contact Tearsa Smith at tearsasmith@bushnelldental. com. NOTES: Additional Salary Information: Guaranteed Minimum pay plus benefits package. Operations Manager — Port Charlotte. Overview: As an Operations Manager at Pacific Dental Services, you’ll have the opportunity to build a promising career—and a bright future. At Pacific Dental Services, we’ll help you take your drive and dedication as far as you want to go.

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career center FROM PAGE 79 When you join us as an Operations Manager/Trainee, you’ll have the tools and resources you need to build a rewarding career. That support starts with a carefully designed training program including unique online components and valuable mentorship. And as you build your future with us, you’ll discover additional opportunities for continued education and training, helping you attain your professional goals. In this entrepreneurial role, you’ll use your team-building skills to help us establish a new, state-of-the-art office. If you’re looking for an opportunity to enjoy both professional excellence and a balanced lifestyle, join us at Pacific Dental Services. Responsibilities: Achieve financial performance and revenue growth goals while supporting our culture and mission; Act as an expert in the local market, employing best practices for patient acquisition and retention; Provide direct individual and team leadership to achieve success in an entrepreneurial environment. Preferred background: Bachelor’s degree; 5 years of relevant work experience, or equivalent; Coursework or on-the-job training in the fields of dentistry, business or training; Strong retail management and leadership skills; Experience leading a team, mentoring and coaching subordinates. A life of service is the highest calling, and we live it every day. Join us as an Operations Manager/ Trainee at Pacific Dental Services and help us improve the quality of life for millions of people. Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2QwZidN. Registered Dental Hygienist — Orlando. Overview: Are you ready to take your career as a hygienist further than you ever thought possible? Do you get excited about working closely with dentists and dental staff to provide the best care that will keep your patients healthy and happy? If the answer is yes, then joining our practice as a hygienist is for you. This collaborative and well-supported office will help you grow your skills as a hygienist while providing a rewarding and exciting career. About the opportunity: If you care about your career as much as you care about your patients, join our practice, an office supported by Pacific Dental Services®, and build relationships that will keep patients coming back for years to come. As a hygienist, you are a vital part of patient care. As such, you deserve to work for a practice that cares about their employees as much as they care about their patients. You will receive ongoing technical training, have access to the latest technology, and have a balanced lifestyle that leaves you feeling ready to greet each new opportunity with a smile. Add on competitive compensation and benefits, including healthcare, dental and vision insurance, paid time off, retirement savings plans, child care assistance, and the fact that PDS® is one of the fastest growing companies in the US, and you’ll wonder why you didn’t find us sooner! About you: As a registered dental hygienist with our team, you need

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to have a current state license. You will have a desire to always be learning and want to stay on top of the latest technology. You should also have outstanding time management and communication skills. To excel, you’ll bring a can-do attitude, a strong desire to treat and educate your patients, and a strong sense of ownership and integrity. Ready to get started? We are too! Apply today! Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2F4wa8n. Registered Dental Hygienist — Naples. Overview: Are you ready to take your career as a hygienist further than you ever thought possible? Do you get excited about working closely with dentists and dental staff to provide the best care that will keep your patients healthy and happy? If the answer is yes, then joining our practice as a hygienist is for you. This collaborative and well-supported office will help you grow your skills as a hygienist while providing a rewarding and exciting career. About the opportunity: If you care about your career as much as you care about your patients, join our practice, an office supported by Pacific Dental Services®, and build relationships that will keep patients coming back for years to come. As a hygienist, you are a vital part of patient care. As such, you deserve to work for a practice that cares about their employees as much as they care about their patients. You will receive ongoing technical training, have access to the latest technology, and have a balanced lifestyle that leaves you feeling ready to greet each new opportunity with a smile. Add on competitive compensation and benefits, including healthcare, dental and vision insurance, paid time off, retirement savings plans, child care assistance, and the fact that PDS® is one of the fastest growing companies in the US, and you’ll wonder why you didn’t find us sooner! About you: As a registered dental hygienist with our team, you need to have a current state license. You will have a desire to always be learning and want to stay on top of the latest technology. You should also have outstanding time management and communication skills. To excel, you’ll bring a can-do attitude, a strong desire to treat and educate your patients, and a strong sense of ownership and integrity. Ready to get started? We are too! Apply today! Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/39ooSdG. Registered Dental Hygienist — South Naples. Overview: Are you ready to take your career as a hygienist further than you ever thought possible? Do you get excited about working closely with dentists and dental staff to provide the best care that will keep your patients healthy and happy? If the answer is yes, then joining our practice as a hygienist is for you. This collaborative and wellsupported office will help you grow your skills as a hygienist while providing a rewarding and exciting career. About the opportunity: If you care about your career as much as you care about your patients, join our practice, an office supported by Pacific Dental Services®, and build relationships that will keep patients coming back

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for years to come. As a hygienist, you are a vital part of patient care. As such, you deserve to work for a practice that cares about their employees as much as they care about their patients. You will receive ongoing technical training, have access to the latest technology, and have a balanced lifestyle that leaves you feeling ready to greet each new opportunity with a smile. Add on competitive compensation and benefits, including healthcare, dental and vision insurance, paid time off, retirement savings plans, child care assistance, and the fact that PDS® is one of the fastest growing companies in the US, and you’ll wonder why you didn’t find us sooner! About you: As a registered dental hygienist with our team, you need to have a current state license. You will have a desire to always be learning and want to stay on top of the latest technology. You should also have outstanding time management and communication skills. To excel, you’ll bring a can-do attitude, a strong desire to treat and educate your patients, and a strong sense of ownership and integrity. Ready to get started? We are too! Apply today! Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Go to careers.floridadental.org/jobs/13133147 to apply. Dentist Associate — Spring Hill. We are a privatelyowned practice, looking for an extremely motivated and talented General Dentist to join our growing dental team! We work with patients of all ages. Please send your resumes to: lakesidefamilydentalcare@yahoo.com. Needed in Tampa - Pediatric dentist in Summer 2020. Private Pediatric dental practice - Two owners, with 3 privately owned pediatric dental office locations in the Tampa area. The ideal candidate we are seeking is full time, 4 days per week and will work at 2 different office locations. PPO insurance and fee-for-service patients in all practices. No government plans or HMO plans. Highincome potential, guaranteed $225K+ in the first year with our compensation structure and patient volume. All offices have digital radiographs and digital charting. In office IV-sedation provided on a regular basis with a certified Pediatric Anesthesiologist group. Fully trained and certified pediatric dental staff in place. Orthodontic treatment is provided in all locations by our in-house orthodontist. Full autonomy over treatment plans. Must have a current Florida dental license, previous experience in private practice is preferred but not necessary. Must be a certified pediatric dentist. Candidate should have excellent communication skills and enjoy a fast pace, fun work environment. We are now interviewing qualified candidates, if interested please email current CV to: sugarbugdude@gmail.com. We look forward to speaking with you. Kind Regards, CV to – sugarbugdude@gmail.com. Must have completed a certified pediatric dental residency. General dentists need not apply. NOTES: Additional Salary Information: Discussed on interview. GENERAL DENTIST - PRIVATE FFS/PPO, Trinity Florida. Associate Dentist, Immediate Full-Time Opening. PRIVATELY OWNED, Well-established, Growing Dental Practice. Progressive Career Opportunity & Competitive Compensation Package. Trinity FL (North Clearwater Area). Are you an experienced Associate who is ready to join a well-established private dental practice that seeks

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your general dentistry talents? We are looking for a full time, Monday – Friday, highly productive dentist who is proficient in all aspects of general dentistry. We seek an Associate who also possesses a positive and cooperative nature, keen sense of business, self-directed motivation, exceptionally smart, eager to learn, and an easy-going personality. About Our Practice: At New Port Richey Dental; soon to be Trinity Dental Excellence, we boast a team of dental professionals dedicated to creating and maintaining healthy, beautiful smiles. We will be moving into a brand-new office building that is currently under construction in Trinity FL. In a safe, comforting environment, we provide meticulous, uncompromising, state-of-the-art dentistry to each and every patient. We are a private PPO/FFS dental office. We do not accept HMO/Medicaid. We have a wonderful team dedicated to the success of our patients, dentist, and our office. I cannot speak highly enough of the front business team, the two assistants and our hygienist. We are looking for someone to join our already strong team. Perks of being a dentist at our Practice: Paid CE, 3 weeks paid time off. Guaranteed salary of $150,000 plus 30% of collections. No Lab bill, office pays Labs 100%. Targeted compensation of $150,000 - $300,000 in year 1 with room to grow in years 2-5. POSITIVE WORK CULTURE of learning, growth, and positivity. HIGH CLINICAL CARE STANDARDS where proper patient treatment is the #1 priority. CLINICAL FREEDOM to expand your procedure expertise as you grow or to use your expanded skills. Essential Job Responsibilities: Diagnose and treat oral health conditions in accordance with the Office Treatment & Diagnosis Policy in the H/R Manual; Examine patients, review medical history, develop and present a preventive and restorative treatment plan; Prescribe medications appropriately; Address clinical issues promptly and accurately; Provide treatment for fillings, broken teeth, replacement of teeth, root canals, extractions and other treatments as necessary; Perform daily Post Op calls to any patients that received surgery or root canals; Available by phone for after hour emergencies; Ensure compliance with OSHA and dental board procedures. Required Job Qualifications: Must have 1-2 years of general dentistry experience; Ability to work evening hours 2 days/week; we offer patient centered business hours; Degree from an accredited U.S. Dental School; Must have and maintain a current dental license in FL; Must have and maintain malpractice insurance; Possess strong communication skills with the ability to build positive and trusted relationships with both staff and patients; Dedicated to provide consistent quality dental care and service to patients; Strong desire to grow and learn new skills and responsibilities; Enjoy working with all generations of patients. Go to careers. floridadental.org/jobs/13047651 to apply. General Dentist — Davenport. Description: Now is the time to join Davenport Modern Dentistry. You will have opportunities to learn new skills from our team of experienced professionals. If you’re ready to take your career to the next level and gain valuable experience, apply today! Overview: Let us allow you to do what you do best by doing the dentistry that you diagnose while exploring future partnership opportunities. We follow through on our promise to clinicians with our culture of patient centric care, our ability to deliver comprehensive integrated care, and our ability to support modern dentistry. PDS supported owner dentists know that being backed by the country’s leading dental support organization allows them to focus on providing patient

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centric and clinically excellent care. Benefits: Competitive Compensation and Benefit Package; Modern offices equipped with the latest dental technology; Malpractice Insurance; Healthcare Benefits (Medical, Prescription Drugs, Dental and Vision); 401(k) Savings Plan. The average full-time PDS-supported Dentist earns $160,000 - $390,000. Apply now or contact a recruiter anytime. We’d love to chat, get to know you and share more about us. Testimonial from Dr. Callaway-Nelson: “Partnering with PDS has given me the opportunity to realize my dream of practice ownership. I am able to do the dentistry that I love.” Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2udl7HZ. Registered Dental Hygienist — Wildwood. Description: Now is the time to join Wildwood Dentists. You will have opportunities to learn new skills from our team of experienced professionals. If you’re ready to take your career to the next level and gain valuable experience, apply today! Overview: Are you ready to take your career as a hygienist further than you ever thought possible? Do you get excited about working closely with dentists and dental staff to provide the best care that will keep your patients healthy and happy? If the answer is yes, then joining our practice as a hygienist is for you. This collaborative and well-supported office will help you grow your skills as a hygienist while providing a rewarding and exciting career. About the opportunity: If you care about your career as much as you care about your patients, join our practice, an office supported by Pacific Dental Services®, and build relationships that will keep patients coming back for years to come. As a hygienist, you are a vital part of patient care. As such, you deserve to work for a practice that cares about their employees as much as they care about their patients. You will receive ongoing technical training, have access to the latest technology, and have a balanced lifestyle that leaves you feeling ready to greet each new opportunity with a smile. Add on competitive compensation and benefits, including healthcare, dental and vision insurance, paid time off, retirement savings plans, child care assistance, and the fact that PDS® is one of the fastest growing companies in the US, and you’ll wonder why you didn’t find us sooner! About you: As a registered dental hygienist with our team, you need to have a current state license. You will have a desire to always be learning and want to stay on top of the latest technology. You should also have outstanding time management and communication skills. To excel, you’ll bring a can-do attitude, a strong desire to treat and educate your patients, and a strong sense of ownership and integrity. Ready to get started? We are too! Apply today! Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/2MOUsHU. Healthcare Network of Southwest Florida | Pediatric Dentist. HCN is seeking a Pediatric Dentist to join our family. This position will provide comprehensive Pediatric Dental care in a primary health care delivery

system. Provide preventive and restorative treatments for problems affecting the mouth and teeth. Graduation from an accredited school of dentistry. Board Certification in Pediatric Dentistry. Experience with nitrous oxide, oral sedation, IV sedation/general anesthesia preferred. NOTES: 3 openings. Additional Salary Information: Competitive Salary and Benefit Package. Go to careers. floridadental.org/jobs/13217706 to apply. Healthcare Network of Southwest Florida | Dental Hygienist. HCN is seeking a Dental Hygienist to join our family! Hygienists are committed to improving the oral health of patients through delivery of periodontal therapies and promotion of dental health. Candidates must be enthusiastic about their work, and willing to provide the highest level of care at all times. Education/Training Level: Graduation from an accredited dental hygiene school. Licenses and Certifications: A current Florida license to practice dental hygiene; CPR certification; Local anesthesia certification. Communication Skills: Able to communicate with patients, all staff, and others clearly and effectively; Bilingual skills are required. Technology Skills: Understanding of and ability to use the Electronic Dental Record (Denticon/Dentrix). NOTES: 2 openings. Go to careers.floridadental.org/ jobs/13217733 to apply. Registered Dental Hygienist — Mount Dora. Overview: Are you ready to take your career as a hygienist further than you ever thought possible? Do you get excited about working closely with dentists and dental staff to provide the best care that will keep your patients healthy and happy? If the answer is yes, then joining our practice as a hygienist is for you. This collaborative and wellsupported office will help you grow your skills as a hygienist while providing a rewarding and exciting career. About the opportunity: If you care about your career as much as you care about your patients, join our practice, an office supported by Pacific Dental Services®, and build relationships that will keep patients coming back for years to come. As a hygienist, you are a vital part of patient care. As such, you deserve to work for a practice that cares about their employees as much as they care about their patients. You will receive ongoing technical training, have access to the latest technology, and have a balanced lifestyle that leaves you feeling ready to greet each new opportunity with a smile. Add on competitive compensation and benefits, including healthcare, dental and vision insurance, paid time off, retirement savings plans, child care assistance, and the fact that PDS® is one of the fastest growing companies in the US, and you'll wonder why you didn't find us sooner! About you: As a registered dental hygienist with our team, you need to have a current state license. You will have a desire to always be learning and want to stay on top of the latest technology. You should also have outstanding time management and communication skills. To excel, you'll bring a can-do attitude, a strong desire to treat and educate your patients, and a strong sense of ownership and integrity. Ready to get started? We are too! Apply today! Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status. Apply here: bit.ly/35FYNnk.

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FROM PAGE 84

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Unless you started reading this edition from the back (and if you did, thank you for reading me first) you have already seen several stories of dentists who are a little creative and who do their best to make their patients’ lives better. People are people and we all have special needs, some of us also have a formal diagnosis. If there is a change that needs to be made, it’s not in our minds, but in our hearts. I challenge you to keep your doors open to those who need your help. Anyone who walks in your door may need skills different than you practice or be the person who makes your day when they visit. Meet them as a person before you accept or decline them as a patient.

JOHN PAUL, DMD, EDITOR, TODAY'S FDA

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TODAY'S FDA JANUARY/FEBRUARY 2020

off the cusp

HEARTS AND MINDS

JOHN PAUL, DMD FDA EDITOR

Dr. Paul can be reached at jpaul@bot.floridadental.org.

My father did not have a college degree, but he was a wise man. We had a tradition of debating topics (arguing) just as a matter of sharpening our skills. Often, neither of us was particularly invested in the viewpoints we were discussing; it was just a way to figure out what we believed in a verbal sparring match. Given this, I was proud when he’d ask my thoughts about something, seeking to get some return on his investment in my education. I’d give him a wellthought out answer and he’d reply, “That can’t be right.” Generally, I’d respond, “I realize that I am burdened by nine years of post-secondary education and 20 years of hands-on experience, but yes, I really think that is so.” All of us spent at least seven — and some as many as 12 years — in study topped off by national and state examinations before we began to practice our profession for the general public. There is a crazy amount of stuff packed into our heads on topics necessary to the profession that most who aren’t directly involved can’t imagine. That’s why it always depresses me when some well-intentioned but likely incompetent individual thinks the problem they perceive with our profession can be solved with some mandatory continuing education (CE). I’ll stipulate that there are times this is the correct course of action. The opioid CE we recently had to take wasn’t really about teaching the proper use of pain medications as it was about following new laws governing our right to prescribe. I’m still not convinced we are part of the problem, but we are responsible professionals and willing to be part of the solution. I follow social media because I’m your editor. I’m also plugged into a few special interest (special needs) communities because of my patients and my family. At least once a week, someone shares a story or wants to know where they find dental treatment for their child. The stories are heartbreaking, and the perception seems to be that dental educations are lacking in their ability to help. Some truly believe that requiring you to take a course about how to treat individuals with special needs will solve the access-to-care issue for this population. When I was in dental school, I was taught all the basic skills I needed to treat people with special needs because first off, they are people. There are people with significant illnesses and disorders that are beyond my skill set. Some of them simply have periodontal disease and should see a periodontist, not a general dentist. Some need general sedation because they cannot control their movements long enough to receive treatment in a typical setting. For the vast majority, the special needs are merely part of who they are, not the definition of what they can be. The CE suggested doesn’t cover any magical new techniques and certainly doesn’t cover sedation. I’m sure there are a few members who can school me in how to be a Medicaid provider and still have a thriving business, but this also won’t be covered in the mandatory course. SEE PAGE 83

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