Treating Special Children Disability Insurance Claims Wheelchair Transfer Practical Oral Care
VOL. 27, NO. 6 • SEPTEMBER/OCTOBER 2015
HEALTH CARE ENROLLMENT CENTER
The FDA Services Health Care Enrollment Center will be your expert guide for the 2016 Health Insurance Open Enrollment Period.
CALL US AT 800.877.7597 TO TALK TO AN AGENT ABOUT YOUR PLAN OPTIONS
IMPORTANT DATES TO REMEMBER OCTOBER 2015
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contents
5-76
Special Needs
news
literary
18
news@fda
12
24
Board of Dentistry
f e at u r e s
Letters to the Editor
columns 3
Staff Roster President’s Message: @Ralph New: Video link for President’s Message
26
I’m Just a Regular Guy Treating Special Children
32
You Can Change the Lives of People Like Sandy
5
35
Can Your Landlord Relocate Your Dental Practice?
6
Legal Notes
40 Corporations and the Future of Dentistry
11
Information Bytes
42 A Successful Disability Insurance Claim Begins with the Application for Benefits
56
Diagnostic Discussion
76
Off the Cusp
44 Organized Dentistry Can Take You Places You Never Expected 50 Wheelchair Transfer 53
Familial Dysautonomia
54 Five Important Steps to Purchasing Disability Insurance 64
Practical Oral Care for People with an Intellectual Disability
69
Dental Staff: Embracing Variety
classifieds 72 Listings
Cover photo: From left to right: Dr. Ralph Attanasi, FDA President; Tirzah Woolf, RDH; Laura Pinelo, Dental Assistant and Jacqueline Warne (patient).
Read this issue on our website at:
www.floridadental.org.
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Today’s FDA is a member publication of the American Association of Dental Editors and the Florida Magazine Association.
September/October 2015
Today's FDA
1
L A C O L Y L E V I &L GATHER FOR FUN & CONTINUING EDUCATION IN YOUR DISTRICT. SFDDA STATE MANDATED COURSES
WEDNESDAY, OCT. 21, 2015 Tropical Acres, Fort Lauderdale
www.sfdda.org • 305.667.3647 • sfdda@sfdda.org
NEDDA CONTINUING EDUCATION FRIDAY, OCT. 30, 2015 Sheraton Jacksonville Hotel
Speaker: Dr. Henry Gemillion: Triaging the Orofacial Pain Patient www.nedda.org • 904.737.7545 • ddeville@nedda.org
NWDDA 2016 ANNUAL MEETING
FRIDAY & SATURDAY, JAN. 29-30, 2016 The Grand Sandestin
www.nwdda.org • 850.391.9310 • nwdda@nwdda.org
WCDDA ANNUAL MEETING 2016
FRIDAY, FEB. 19, 2016 USF Center for Advanced Medical Learning & Simulation in Downtown Tampa Speakers: Drs. Jeff Brucia and Rhonda R. Savage www.wcdental.org • 813.654.2500 • wc.dental@gte.net
ACDDA ANNUAL CONFERENCE
FRIDAY, APRIL 1, 2016 Embassy Suites Hotel, West Palm Beach
Speaker: Dr. Paul Homoly Register at www.acdda.org www.acdda.org • 561.968.7714 • acdda@aol.com
CFDDA ANNUAL MEETING
FRIDAY & SATURDAY, APRIL 15-16, 2016 Marriott Orlando World Center
www.cfdda.org • 407.898.3481 centraldistrictdental@yahoo.com
SFDDA ANNUAL BUSINESS MEETING
WEDNESDAY, APRIL 20, 2016 • Location TBD www.sfdda.org • 305.667.3647 • sfdda@sfdda.org
For a complete listing: www.trumba.com/calendars/fda-member.
FLORIDA DENTAL ASSOCIATION SEPTEMBER/OCTOBER 2015 VOL. 27, NO. 6
EDITOR Dr. John Paul, Lakeland, editor
STAFF Jill Runyan, director of communications Jessica Lauria, communications and media coordinator Lynne Knight, marketing coordinator
BOARD OF TRUSTEES Dr. Ralph Attanasi, Delray Beach, president Dr. William D’Aiuto, Longwood, president-elect Dr. Michael D. Eggnatz, Weston, first vice president Dr. Jolene Paramore, Panama City, second vice president Dr. Rudy Liddell, Brandon, secretary Dr. Richard Stevenson, Jacksonville, immediate past president Drew Eason, Tallahassee, executive director Dr. James Antoon, Rockledge • Dr. Andrew Brown, Orange Park Dr. Jorge Centurion, Miami • Dr. Robert Churney, Clearwater Dr. Richard Huot, Vero Beach • Dr. George Kolos, Fort Lauderdale Dr. Jeffrey Ottley, Milton • Dr. Howard Pranikoff, Ormond Beach Dr. Barry Setzer, Jacksonville • Dr. Beatriz Terry, Miami Dr. Stephen Zuknick, Brandon Dr. Ethan Pansick, Delray Beach, speaker of the house Dr. Tim Marshall, Weekiwachee, 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, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. FDA membership dues include a $10 subscription to Today’s FDA. Non-member subscriptions are $150 per year; foreign, $188. Periodical postage paid at Tallahassee, Fla. and additional entry offices. Copyright 2015 Florida Dental Association. All rights reserved. Today’s FDA is a refereed publication. POSTMASTER: Please send form 3579 for returns and changes of address to Today’s FDA, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.
EDITORIAL AND ADVERTISING POLICIES Editorial and advertising copy are carefully reviewed, but publication in this journal does not necessarily imply that the Florida Dental Association endorses any products or services that are advertised, unless the advertisement specifically says so. Similarly, views and conclusions expressed in editorials, commentaries and/or news columns or articles that are published in the journal are those of the authors and not necessarily those of the editors, staff, officials, Board of Trustees or members of the Florida Dental Association.
EDITORIAL CONTACT INFORMATION All Today’s FDA editorial correspondence should be sent to Dr. John Paul, Today’s FDA Editor, Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. FDA office numbers: 800.877.9922, 850. 681.3629; fax 850.681.0116; email address, fda@floridadental.org; website address, www.floridadental.org.
ADVERTISING INFORMATION For display advertising information, contact: Jill Runyan at jrunyan@floridadental.org or 800.877.9922, Ext. 7113. Advertising must be paid in advance. For classified advertising information, contact: Jessica Lauria at jlauria@floridadental.org or 800.977.9922, Ext. 7115.
CONTACT THE FDA OFFICE 800.877.9922 or 850.681.3629 1111 E. Tennessee St. • Tallahassee, FL 32308 The last four digits of the telephone number are the extension for that staff member.
FLORIDA DENTAL ASSOCIATION FOUNDATION
EXECUTIVE OFFICE Drew Eason, Executive Director deason@floridadental.org 850.350.7109 Greg Gruber, Chief Financial Officer ggruber@floridadental.org 850.350.7111 Graham Nicol, Chief Legal Officer gnicol@floridadental.org 850.350.7118 Judy Stone, Leadership Affairs Manager jstone@floridadental.org 850.350.7123 Blair Fowler, Leadership Concierge bfowler@floridadental.org 850.350.7114
ACCOUNTING Jack Moore, Director of Accounting jmoore@floridadental.org 850.350.7137 Leona Boutwell, Finance Services Coordinator Accounts Receivable & Foundation lboutwell@floridadental.org 850.350.7138 Joyce Defibaugh, FDA Membership Dues Assistant jdefibaugh@floridadental.org 850.350.7116 Deanne Foy, Finance Services Coordinator Dues, PAC & Special Projects dfoy@floridadental.org 850.350.7165 Tammy McGhin, Payroll & Property Coordinator tmcghin@floridadental.org 850.350.7139
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Meghan Murphy, Program Coordinator mmurphy@floridadental.org 850.350.7161
FLORIDA DENTAL CONVENTION (FDC) Crissy Tallman, Director of Conventions and Continuing Education ctallman@floridadental.org 850.350.7105 Elizabeth Bassett, FDC Exhibits Planner ebassett@floridadental.org 850.350.7108 Brooke Mills, FDC Meeting Coordinator bmills@floridadental.org 850.350.7103
GOVERNMENTAL AFFAIRS Joe Anne Hart, Director of Governmental Affairs jahart@floridadental.org 850.350.7205 Alexandra Abboud, Governmental Affairs Coordinator aabboud@floridadental.org 850.350.7204
FDA SERVICES 800.877.7597 or 850.681.2996 1113 E. Tennessee St., Ste. 200 Tallahassee, FL 32308 Group & Individual Health • Medicare Supplement • Life Insurance Disability Income • Long-term Care • Annuities • Professional Liability Office Package • Workers’ Compensation • Auto • Boat Scott Ruthstrom, Chief Operating Officer scott.ruthstrom@fdaservices.com 850.350.7146 Carrie Millar, Agency Manager carrie.millar@fdaservices.com 850.350.7155 Carol Gaskins, Assistant Membership Manager carol.gaskins@fdaservices.com 850.350.7159 Debbie Lane, Assistant Membership Services Manager debbie.lane@fdaservices.com 850.350.7157 Allen Johnson, Support Services Supervisor allen.johnson@fdaservices.com 850.350.7140 Alex del Rey, FDAS Marketing Coordinator arey@fdaservices.com 850.350.7166
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INFORMATION SYSTEMS
Jamie Idol, Commissions Coordinator jamie.idol@fdaservices.com 850.350.7142
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COMMUNICATIONS AND MARKETING Jill Runyan, Director of Communications jrunyan@floridadental.org 850.350.7113 Lynne Knight, Marketing Coordinator lknight@floridadental.org 850.350.7112 Jessica Lauria, Communications and Media Coordinator jlauria@floridadental.org 850.350.7115
Will Lewis, Information Systems Helpdesk Technician/ Database Administrator wlewis@floridadental.org 850.350.7153
Marcia Dutton, Administrative Assistant marcia.dutton@fdaservices.com 850.350.7145 Sarah Beall, Membership Services Representative sarah.beall@fdaservices.com 850.350.7171 Maria Brooks, Membership Services Representative maria.brooks@fdaservices.com 850.350.7144 Melissa Staggers, West Coast District Membership Services Representative melissa.staggers@fdaservices.com 850.350.7154
Nicole White, Membership Services Representative nicole.white@fdaservices.com 850.350.7151 Pamela Monahan, Commissions Coordinator pamela.monahan@fdaservices.com 850.350.7141 Porschie Biggins, North Florida Membership Services Representative pbiggins@fdaservices.com 850-350-7149
RISK EXPERTS Dan Zottoli Director of Sales Atlantic Coast 561.791.7744 Cell: 561.601.5363 dan.zottoli@fdaservices.com
Dennis Head Director of Sales Central Florida 877.843.0921 (toll free) Cell: 407.927.5472 dennis.head@fdaservices.com
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Joseph Perretti Director of Sales South Florida 305.665.0455 Cell: 305.721.9196 joe.perretti@fdaservices.com
Rick D’Angelo Director of Sales West Coast 813.475.6948 Cell: 813.267.2572 rick.dangelo@fdaservices.com
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. www.floridadental.org
September/October 2015
Today's FDA
3
CAPITOL VISITS Tuesday, Feb. 2, 2016
LEGISLATIVE BRIEFING Monday, Feb. 1 • 6:30 p.m. Aloft Hotel • Tallahassee
HOTEL ROOM BLOCK ALOFT HOTEL ONLINE REGISTRATION 850.513.0313 • Room floridadental.org/ddoh rate: $189 (free parking)
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For more information, please contact the FDA Governmental Affairs Office at 800.325.0051 or gao@floridadental.org.
@Ralph RALPH C. ATTANASI JR., DDS, MS
#Robandme We were born in the same year. Our mothers cooed: same full heads of hair, same almond eyes and same smile. We were the first-born sons with the same names as our fathers’. We were the next generation with the promise of an optimistic future. Rob and me — first cousins, best friends.
I learned so much from him — how to look at problems, how to laugh at absurdity, how to be strong and recognize your true weakness. When he passed away, I remember thinking that his life was brief yet so full. Educated, married and the father of twins — a wonderful life by all definitions.
We were inseparable. We spent our summers on the beach running, catching waves and chasing our shadows. Then, the diagnosis came: MS. What did this mean? How could everything change? When would Rob be able to play with me again?
Rob taught me that perception, limitations and special needs are often just illusions, stereotypes and preconceived notions that need to change. A full life is possible for all of us. When presented with the challenges of care for patients with special needs, the best advice that I can offer is the most basic; one that you already use every day. Provide compassionate, loving service with unbiased dignity and respect. By offering dental services to those who need special care, you are participating in one of the most rewarding parts of oral health care — yet another benefit of our profession. What an honor and privilege! But you don’t need to be reminded of that; most of us do this every day without fanfare.
Never. I quickly learned that Rob had special needs and that I needed to change. Yet, even though everyone told me that Rob would never have the same life as everyone else, that was not the case. You see, Rob never was “handicapped” nor had a “disadvantage.” If there was a party, sporting event or concert — Rob was there. If a teacher, coach or director told Rob that he couldn’t participate, he would laugh and then prove them wrong. When mobility became tough, he motorized his wheelchair. When eating became difficult, he joked about it. When breathing became a challenge, he used oxygen.
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Many of us have similar experiences, whether they are with family members or the patients we treat in our offices. These stories are critical to our collective dental experience and need to be shared. So, I thank you for all that you do and I ask that you share your experiences with us by send-
“
By offering dental services to those who need special care, you are participating in one of the most rewarding parts of oral health care — yet another benefit of our profession.
”
ing them to communications@floridadental.org for future posts to the FDA’s blog. Check out a video on special needs on Beyond the Bite, which can be found at floridadental.org/members/fda-blog. Help us tell your story…
Dr. Attanasi is the FDA President. He can be reached at rattanasi@bot.floridadental.org. Please folow us on Facebook and Twitter.
September/October 2015
Today's FDA
5
Legal Notes
Special Needs Patients on the 25th Anniversary of the Americans with Disabilities Act: 10 Things Florida Dentists Need to Know Graham Nicol, Esq., HEALTH CARE RISK MANAGER, BOARD CERTIFIED SPECIALIST (HEALTH LAW)
Florida dentists are at risk for civil liability under the federal Americans with Disability Act (AwDA) when refusing to treat special needs patients. Also, Florida dentists face civil liability in connection with improper discrimination against special needs employees or job applicants. This year marks the federal law’s 25th anniversary, which gives us an opportunity to review the case law involving dentistry and what it teaches us. As a doctor, you might see a patient or employee as having special needs. As a lawyer, I will see that patient or employee as a potential victim of discrimination by a place of public accommodation based on a disability that substantially limits major life activities. Here are 10 things both professions have learned after 25 years of case law under the AwDA: 1. The AwDA prohibits discrimination against any individual “on the basis of disability in the ... enjoyment of the ... services ... of any place of public accommodation by any person who ... operates [such] a place.” See, 42 U.S.C. §12182(a). Most, but not all, dental offices are “places of public accom-
6
Today's FDA
September/October 2015
modation” subject to AwDA because they offer their services to the public. The size of the practice or the number of employees it has makes no difference with regard to discrimination against prospective or actual patients with disabilities. However, a specialist who does not advertise or have signage, and accepts patients only through referral by another dentist may factually not be a place of public accommodation. But if that’s your best defense, expect it to go to a jury. 2. The AwDA applies even though a patient’s or an employee’s HIV infection has not progressed to the symptomatic phase because it is nevertheless a disability under §12102(2)(A). The AwDA defines disability as “a physical ... impairment that substantially limits one or more of (an individual’s) major life activities.” See, Bragdon v. Abbot, 524 U.S. 624, 118 S.Ct. 2196, 141 L.Ed.2d 540 (1998). In that case, the special needs patient went to the office for a dental examination and disclosed her HIV infection. The dentist discovered a cavity and informed the patient of his policy against filling cavities of HIV-infected patients in his office. He offered to perform the work at a hospital at no extra charge but the patient would have to pay for use of the hospital’s facilities. The dentist was sued under the AwDA and lost. The court specifically ruled that from the moment of infection and throughout every stage of the disease, HIV infection satisfies the statutory and regulatory definition of a physical impairment because it affects the “body’s ... hemic and lymphatic (systems).”
It causes immediate abnormalities in a person’s blood and affects the white cell count. The point is, the legal definition of disability is probably much broader than most doctors think. For example, it will almost certainly include chronic diseases (e.g., diabetes, chronic obstructive pulmonary disease, schizophrenia and hypertension). What you see as special needs, lawyers and judges will see as disabilities, and juries may hold you civilly liable if you discriminated on that basis with regard to provision of care or hiring practices. 3. The ability to reproduce and to bear children, obviously impacted with HIV as well as other chronic illnesses and genetically transmissible diseases, constitutes a major life activity under the AwDA. The plain meaning of the word “major” denotes comparative importance to the individual affected and suggests that the touchstone is an activity’s significance to the plaintiff. According to the Bragdon court, reproduction and the sexual dynamics surrounding it are central to the life process itself. It is irrelevant when treating special needs patients or hiring special needs employees, that their disabilities may not affect them every single day of their life in ways you, in a dental setting, consider to be important. The list of major life activities used by the AwDA is broad and non-exhaustive. It includes activities such as caring for one’s self, performing manual tasks, working and learning. 4. A substantial limitation of a major life activity has a similarly broad meaning in
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Legal Notes the context of the AwDA. For example, the Bragdon court’s evaluation of the medical evidence demonstrated that an HIV-infected woman’s ability to reproduce is substantially limited in two independent ways: If she tries to conceive a child, (1) she imposes on her male partner a statistically significant risk of becoming infected; and (2) she risks infecting her child during gestation and childbirth, i.e., perinatal transmission. In that case, the evidence showed that antiretroviral therapy lowered the risk of perinatal transmission to about 8 percent; it may be even lower with advanced medicine. But courts consider the percentage of risk irrelevant when considering damages against the defendant. It can be said as a matter of law that even a .001 percent risk of transmitting a disease to one’s child represents a substantial limitation on reproduction. The decision to reproduce carries economic and legal consequences as well. There are added costs for antiretroviral therapy, supplemental insurance and longterm health care for the child who must be examined and treated. Some state laws, moreover, forbid HIV-infected persons from having sex with others, regardless of consent. The point is, if you get sued for discrimination, then the court is likely to consider as true the plaintiff ’s admittedly self-serving testimony that their disability controlled their decision regarding a major life activity. 5. The direct threat defense is unlikely to prevail. In Bragdon, the dentist argued under §12182(b)(3) of the AwDA, that discrimination against a special needs patient was justified because “(n)othing (in the AwDA) shall require an entity to permit an individual to participate in or benefit from the ... accommodations of such entity where such individual poses a direct threat to the health or safety of others.” In ruling against the direct threat defense, the Supreme
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Court relied on the Centers for Disease Control and Prevention (CDC) guidelines for dentistry as well as the 1991 American Dental Association Policy on HIV, both of which emphasized that universal precautions and OSHA’s Bloodborne Pathogens Standard reduce the risk of cross-contamination. The AwDA’s direct threat exception comes from the Supreme Court’s decision in School Board of Nassau County v. Arline. The Arline decision is significant for Florida dentists in two ways: (1) it makes it clear that the existence of a significant risk is determined from the standpoint of the health care professional who refuses treatment or accommodation; but 2) the risk assessment must be based on medical or other objective, scientific evidence available to the professional, not simply on a good faith belief that a significant risk existed. 6. In the context of employment discrimination under the AwDA, a qualified individual is someone with a disability who, with or without reasonable accommodation, can perform the essential functions of the job. See, 42 U.S.C. § 12111(8). If a qualified individual with a disability can perform the essential functions of the job with a requested reasonable accommodation, then the employer is required to provide the accommodation unless doing so would constitute an undue hardship for the employer. See, 42 U.S.C.A. § 12112(b)(5)(A). Reasonable accommodations to the employee may include, but are not limited to, additional unpaid leave, job restructuring, a modified work schedule or reassignment. 7. Doctors need to be aware that if they have AwDA employment liability risk, then they also have liability risk under the Florida Civil Rights Act of 1992 (FCRA). See, §§ 760.01–760.11 and 509.092, Fla. Stats. In other words, if you get sued for not
providing reasonable accommodations for potential or actual workers with disabilities, you will be sued on both federal and state counts. The FCRA provides that it is unlawful for an employer to “discharge or fail or refuse to hire any individual, or otherwise to discriminate against any individual with respect to compensation, terms, conditions or privileges of employment, because of such individual’s race, color, religion, sex, national origin, age, handicap or marital status.” 8. Although the FCRA does not mention HIV specifically, Florida courts, just like federal ones, will recognize HIV positive status as a handicap within the meaning of the statute. See, McCaw Cellular Communications of Fla. v. Kwiatek, 763 So.2d 1063 (Fla. 4th DCA 1999). In fact, nowhere in the FCRA is the term handicap defined. Therefore, Florida courts rely on the AwDA’s broad definition of disability. See, Ross v. Jim Adams Ford Inc., 871 So.2d 312 (Fla. 2d DCA 2004). 9. If you get sued under the AwDA or the FCRA, then you probably also will get sued for intentional infliction of emotional distress, an independent cause of action under Florida law that allows punitive damages to be assessed against the defendant. To prove intentional infliction of emotional distress, the plaintiff must show “conduct so outrageous in character, and so extreme in degree, as to go beyond all possible bounds of decency, and to be regarded as atrocious, and utterly intolerable in a civilized community.” See, Allen v. Walker, 810 So.2d 1090, 1091 (Fla. 4th DCA 2002). Discriminating against someone as to medical care or employment terms and conditions may well rise to the level of intentional infliction in today’s politically correct world. Please see LEGAL, 9
September/October 2015
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7
Legal Notes
LEGAL from 7
Technically, whether alleged conduct is outrageous enough to support a claim of intentional infliction of emotional distress is a matter of law, not a question of fact (see, Gandy v. Trans World Computer Tech. Group, 787 So.2d 116 [Fla. 2d DCA 2001]) — but I wouldn’t bet on a Florida court dismissing the intentional infliction count in connection with discriminatory conduct against special needs patients or workers. I can hear the plaintiff ’s lawyer arguing to the judge the lack of compassion and callousness shown by the “good doctor” who is supposed to “first, do no harm!”
10. Because your potential liability risk is so great when people with disabilities are involved, evaluate your insurance needs in light of the AwDA, the FCRA and Floridaspecific causes of action. Specifically, with regard to employment discrimination based on handicap or disability status, look at your business owner coverage and evaluate whether you have adequate insurance. Many business owner policies provide coverage for employment practices liability but the policy limit is $10,000 and the risk retention (deductible) is $1,000. When dealing with high wage earners, such as dentists, hygienists and office managers, $9,000 of coverage in Florida’s current legal environment is dangerously low.
Take warning — the patient or employee you view as having special needs will be viewed by Florida lawyers as a potential victim of unlawful discrimination based on handicap or disability. That’s what we’ve learned after 25 years of case law under the AwDA. This article is for informational purposes only and is not intended to be a substitute for professional legal advice. If you have a specific concern or need legal advice regarding your dental practice, you should contact a qualified attorney. Graham Nicol is the FDA’s Chief Legal Counsel.
Patient Abandonment (LC02) At some time in their practice, all dentists will need to terminate a doctor/patient relationship. This Legal CE explains how to do so without violating Florida’s patient abandonment law.
What Florida Dentists Need to Know about Prescription, Controlled Substance and Pain Management Laws (LC01)
This FAQ helps dentists understand Florida law, recently changed, and what requirements they must meet to prescribe, dispense and administer drugs.
Take these courses online to earn free CE credit. For links, go to floridadental.org/members. FDA Members Only!
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Expires 4/1/2016
September/October 2015
Today's FDA
9
benefit
Helping Members Succeed
NUMBER
14
How are you managing your managed-care contracts? Banish the confusion with this definitive reference for Florida dentists.
A FREE BENEFIT AVAILABLE ONLY TO FDA MEMBERS A thoroughly researched and referenced handbook written clearly in an easy-to-follow format. Written by Graham Nicol, Esq., Health Care Risk Manager, Board Certified Specialist (Health Law) and the FDA’s Chief Legal Counsel
o t e M t n a W ? t You a h Sign W k ndboots a H ’s t c tis Contra da Den A Florianaged-care on M Law) (Health ol, Esq., ham Nic fied Specialist By Gra ti er C oard ager, B isk Man H LAW Care R HEALT Health N ON IO T A UBLIC ICIAL P ’S OFF IATION C O S S A ENTAL RIDA D
O THE FL
INSIDE: Chapter 1: The Basics: Types of Health Care Delivery Systems
Go to floridadental.org/signwhat
Questions? Call 800.877.9922
Chapter 2: The Basics: Types of MCO Models Chapter 3: The Basics: Types of Reimbursement Methods Chapter 4: MCOs & Other Types of Risk Chapter 5: How to Negotiate with MCOs Step by Step Chapter 6: Your Rights under Florida DMPO Contracts Chapter 7: Your Rights under Florida Health Insurance & PPO Contracts Chapter 8: Your Rights under Florida HMO Contracts Chapter 9: Your Rights under PLHSO Contracts Chapter 10: Fighting Back
Information Bytes
Beam Me Up, Scotty! What Can Technology Help You with Today? By Larry Darnell DIRECTOR OF INFORMATION SYSTEMS
I remember watching “Star Trek” episodes when I was a boy and thinking, “How cool would it be to talk to a computer and have it respond or do tasks for me?” In fact, that (and video games) was part of the reason I went into the computer field. Today, we have no problem asking our tablet or phone questions (to Siri, Cortana or even Alexa), using technology to find places via GPS, or performing simple or even complex calculations by speaking to a computer. Technology has come a long way. Technology continually is developing modifications to help those with special needs or impairments: visual, auditory, dexterity, mobility, cognitive, language or communication. Most computer operating systems (including Microsoft Windows and Apple OS X) offer built-in assistance for those with special needs or impairments, such as a magnifying tool, a narrator that reads the screen to you, interfacing tools besides a mouse or a keyboard, and all sorts of other assistive technologies. For some, it is more than just making the screen font larger or changing the sound levels. There are so few limitations to technology today. Things thought impossible 10 years ago are commonplace now. Envision where technology will be in 10 years. Clearly we are boldly going where no one has gone before. To find specifics about the accessibility options available
“
Technology continually is developing modifications to help those with special needs or impairments: visual, auditory, dexterity, mobility, cognitive, language or communication.
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for you to use today on your computer, visit the following websites, depending on which type you own: https://www.microsoft.com/enable/guides/default.aspx or https://www.apple. com/accessibility/osx/. You’ll be amazed at what your computer can do. Now, where did I put my tricorder and my Starfleet PADD? Mr. Darnell can be reached at ldarnell@floridadental.org or 850.350.7102.
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September/October 2015
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Members‘ Opinion
Letters to the Editor The Florida Dental Association (FDA) welcomes letters from readers on articles that have recently appeared in Today’s FDA (TFDA) and matters of general concern to Florida dentists. The FDA reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and may cite no more than five references. Brevity is appreciated. No illustrations will be accepted. You may submit your letter via email to fda@floridadental.org, by fax to 850.561.0504 or by mail to Florida Dental Association, Attn: TFDA Editor, 1111. E Tennessee St., Tallahassee, FL 323086914. By sending a “Letter to the Editor,” the author acknowledges and agrees that the letter and all rights of the author in the letter become the property of the FDA. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the editor, staff, officials, Board of Trustees or members of the FDA.
Letter to the Editor A LECOM Student’s Perspective in Reply to “Is Dentistry Already Succumbing to the “New Normal”? By Jenna Weldon Pascoli As an inaugural member of the LECOM School of Dental Medicine’s class of 2016, the founding president of LECOM’s American Student Dental Association (ASDA) chapter and an active pre-doctoral student in the Florida Dental Association’s (FDA) House of Delegates (HOD) for the past three years, I disagree with my soon to be colleague, Dr. Carlos Sanchez. I attended the HOD meeting this past June where Dr. Anton Gotlieb addressed the house attendees. Although there was no time set aside for formal questioning for any of the three dental school deans in attendance, I would like to formally address your concerns as a student leader at LECOM, who is directly affected by the questions in your letter. I would like to reiterate what Dr. Gotlieb mentioned at the HOD meeting regarding the background of the LECOM program. My first two years at LECOM consisted of core science classes, dental sciences and countless hours spent in the simulation lab. In the first two years, I completed two sets of dentures. In my third year, I continued my advanced dental sciences education, while
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Dr. Sanchez’s letter mentioned that my first- and second-year denture experience is only mere “denturism.” I would like to point out that much is learned from a denture — namely occlusion, patient management and anatomy. As a new pre-doctoral student, the experience fabricating the denture allowed me to get comfortable with patient care and learn how to treat a patient. The experience performing a reversible, harmless procedure provides confidence and a stepping stone in the learning environment.
In speaking with other students at several ASDA conferences, LECOM’s third- and fourth-year dedication to clinical experience far outweighs traditional dental programs. The amount of time spent with live patients greatly enhances LECOM’s overall education beyond the mannequin experience referenced in Dr. Sanchez’s letter. Although the mannequin is used heavily for pre-clinical techniques and learning in the first two years, LECOM dental students are fortunate to receive a high level of training daily in the patient clinic.
The letter mentioned that my fellow classmates and I are being “farmed” out to various locations throughout Florida. As the mission of LECOM states, students are prepared “to provide highquality, ethical and empathetic patient-centered care to serve the needs of a diverse population.” There are two outreach clinics in my program, one in DeFuniak Springs and the other in Erie, Pa. As I learned while advocating last year at the FDA’s Dentists’ Day on the Hill, the panhandle of Florida is greatly underserved and in need of dental care. As a student of a Florida dental school, I feel that it is our duty and mission to address this need. Would it be more beneficial for me to be serving patients full time in Bradenton, where dentists are plentiful? I think otherwise. LECOM was founded in Erie and the fourth-year dental students located in Erie are on LECOM’s main campus serving the needs of the local community.
For the record, at no time did Dr. Gotlieb insist that LECOM dental students do not have specialists teaching the dental school curriculum — pathology is taught by an oral pathologist; oral surgery is taught by an oral surgeon; and, pediatrics is taught by a pediatric dentist. In the outreach clinics, dental specialists oversee the procedures and services provided to the patients. I am finding the outreach clinical experience extremely beneficial to my clinical dental skills, while meeting a real need in rural Florida and providing an enriching experience as a pre-doctoral candidate.
LECOM’s primary mission is not to “train students to become employees of Medicaid or corporate masters” as Dr. Sanchez notes in his letter. LECOM’s mission is to train dental students to be forward-thinking and patient-focused practitioners. Each student can decide his or her role and career in dentistry. My three closest dental student friends are taking different career paths: one is going into the Army, one is becoming an associate and another is considering the public heath system. LECOM is training a diverse group of students with varied aspirations in the dental field to practice in Florida.
working in a directed patient clinic from 9 a.m. to 5 p.m. I now am in my fourth year at LECOM, and I am working as a student dentist in the DeFuniak Springs, Fla. outreach clinic treating underserved patients Monday through Friday from 1-7 p.m.
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Members‘ Opinion
Letters to the Editor As an inaugural student, I did not assume things would flow perfectly. Moreover, I did not assume that all class rubrics would be perfect. I am thankful, however, to be given the opportunity to be a part of the wonderful dental profession and to provide care to those in need in Florida. I am a proud member of the inaugural class of 2016 and supporter of the FDA. Comments made without facts, based upon rumors and without further research into our program, do not follow the principles of “evidence-based dentistry.” The unwritten code of dentistry is to not criticize your fellow practitioner if you were not there at the time of the procedure. I encourage all Florida dentists, including Dr. Sanchez, to visit our campus and outreach clinics and to speak with our preceptors and the specialists overseeing our clinical work. My successes as the founding ASDA president, being awarded ASDA National Delegate of the Year and serving as an FDA Services student board member are just some of the accomplishments I’ve achieved as a LECOM dental student. I am one of 100 students who will do great things in the dental field with LECOM on my diploma. Thank you for your time. Ms. Pascoli can be reached at Jenna.weldon@dmd. lecom.edu.
Letter to the Editor
LECOM: A Breath of Fresh Air By Dr. Dan Henry I was dismayed to read the “Letter to the Editor” in Today’s FDA, Vol. 27, No. 5, “Is Dentistry Already Succumbing to the ‘New Normal?’ ” I would like to take this opportunity to address the concerns of my friend, Dr. Carlos Sanchez. First and foremost, I would like to address the criticism of allowing first-year dental students to construct dentures on a patient. There was concern that this was tantamount to allowing denturism. Not only is this line of thought incorrect, it is
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not consistent with a good learning experience for first-year dental students. It is likely a conclusion made without thinking about the benefits for the dental student to construct a denture early in his/ her dental education. I remember constructing my first denture for a patient during my freshman year at the University of Maryland School of Dentistry. The process was a profound learning experience on multiple levels and in multiple disciplines that benefited me later in my dental school experience. To begin with, it was my first venture in understanding occlusion beyond a text book and the connection between centric relation, vertical dimension, balancing contacts, aesthetic balance and the myriad variations encountered in designing a balanced occlusal table in a compromised environment. The experience also allowed me to understand the anatomy and interactions of the head and neck muscles, jaw relationships and the neuromuscular complex, which up until that point were only names. In addition to being one of my first patient encounters, the experience helped me understand how to deal with the emotional and psychological problems a patient may present when in crisis. I’ve been practicing dentistry for more than 35 years, and I believe one of a student’s first patients should be a denture patient. I also would like to address the concerns about the “structure” of the dental education experience LECOM has designed for their students. Dental students spend their first three years in Bradenton, Fla., while their last year is spent at one of two outreach clinics in DeFuniak Springs, Fla. or Erie, Pa. under numerous general dentists’ and specialists’ guidance. The first dental school in the world in was established in 1840 in Baltimore, Md., and ever since then, formal dental education has continuously changed. From the beginning, the general dentist’s role was paramount — they were taught reproducible restorative techniques based in science and
medicine, which lead to delivering a high degree of excellence in dental care that influenced dental education around the world. The one common denominator was general dentists performing all techniques, including specialty procedures, within a framework of excellence and precision. Specialty procedures were taught within a general dental program. However, with the development of specialty disciplines, as separate fields of study and combined with dental schools becoming associated with universities, specialty certificates were elevated to postgraduate degrees within a framework of dental education. Over the years, specialty departments gained more influence in dental schools’ curricula, and general/ operative dentistry’s skill set — which once was considered foundational — became less apparent. Many dental schools limited their operative departments; absorbing them into various specialty departments. The net result was that the undergraduate student lost the direction that had been established by years’ of efforts by such men as G. V. Black, W. I. Ferrier and George M. Hollenback , to name a few. LECOM is attempting to establish a dental school to teach general dentistry, where specialty skills are taught to undergraduate dental students in a balanced program of foundational operative and specialty training. There are specialists teaching endo, surgery, basic ortho and perio; there simply are no “specialty departments” within the school teaching procedures for advanced degrees. Students who may want to go on to residencies or specialty training must apply to these programs elsewhere. In addition, an observation I’ve made over the years is ethically based competent private practicing dentists aren’t mentoring dental students as much. Again, I remember the “part timers” who came to my dental school to teach the practical Please see LETTERS, 14
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Members‘ Opinion LETTERS from 13 side of dentistry and the influence they had on me. What’s needed is for both the academic community and the private practicing community to become involved in a dental education program. With this type of program, the student benefits from being mentored and taught by ethical private-practicing dentists, both general and specialist, while still in training. This time also offers the student an opportunity to transition from an academic setting to the world of private practice in an ethically sheltered environment. Through mentoring and teaching, many part-time private-practicing dentists — both general and specialist — have given LECOM’s dental students the opportunity to transition into private practice with a better understanding of what they will face in a new world. Furthermore, they will have a broader skill set, based on the general dentist being in control. This should enable them to practice within our profession in a manner they choose, not one chosen by someone else! In short, these students are not “farmed out” to unrestricted chaos. On the contrary, they are given an experience that allows them to organize what they have learned and apply their knowledge in an environment that more closely simulates private practice. Finally, I’ve noticed that having one of the outreach clinics in the Panhandle has resulted in a group of patients receiving treatment that previously hadn’t for various reasons. Therefore, access to care is being directly addressed. In conclusion, the LECOM model’s new direction for dental education is creating opportunities for the academic community and the privatepracticing community to work together to teach and mentor our students to be better prepared to treat their patients with competence and ethics in a changing world. Other dental schools should consider this model to enhance their own teaching models and take advantage of the resources that are available.
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On a personal note, I have been more than pleased with our students. They are bright, energetic, eager to learn and easy to teach. It is an honor to be a part of this. They deserve our best — not our criticism! Dr. Henry is a past president of the FDA and can be reached at golddoc@bellsouth.net.
Letter to the Editor By Dr. Frank Catalanotto I’d like to comment on Dr. Sanchez’s recent “Letter to the Editor” in the July/August 2015 Today’s FDA. My response should in no way imply endorsement of his comments about LECOM dental school — I do not know enough about LECOM to agree or disagree with his comments. However, I do question his equating the LECOM dental student’s statement, “She had no aspirations of ever having her own practice, was fine with being an employee and readily accepted dental therapists as part of the dental team,” with the conclusion, “The (dental) schools should aim high, not for the lowest common denominator.” That disparaging comment makes no sense to me and is unkind to dental schools and students who think that way. Maybe Dr. Sanchez has not read the reports from the ADA Policy Center showing the increasing trend of dentists becoming employees rather than practice owners. Just because these dentists choose to practice their profession that way, as opposed to what Dr. Sanchez has chosen, does not mean they are “the lowest common denominator.” Does Dr. Sanchez have any evidence that being an employee dentist actually equates with poor quality? If he does, please share it with us. Career choices are personal, professional and financial decisions that have nothing to do with quality. What also bothered me was the implication that dental therapists are equated with “the lowest common denominator.” Maybe this student read the extensive literature about dental therapists being safe, high quality and cost-effective members of the dental team? Maybe this student attended the “day of learning” organized by the University of Florida College of Dentistry’s American Student Dental Association this past spring about alternative dental workforce models including dental therapists and found the arguments of the proponents intellectually honest and convincing. Maybe this student found out that Minnesota
dentists are employing these therapists, increasing the numbers of Medicaid-enrolled patients in their practices, and at the same time, allowing the dentists to practice at the top of their professional skill set and make more money. Dr. Sanchez’s statement implies that dental therapists are not good members of the dental team; if he has any evidence to support his opinion, I would love to see such evidence. I will be happy to point him to factual evidence supporting this student’s (and my) opinions. The most offensive statement in Dr. Sanchez’s letter was in point No. 5, implying (but not actually stating) that encouraging dental students to become Medicaid providers was somehow reaching for the “lowest common denominator.” That is truly offensive to both the dentists who treat Medicaid patients and to the Medicaid patients themselves. That kind of statement correlates with our team’s recent finding of a “social stigma” associated with being a Medicaid provider in Florida (Logan, HL, Guo, Y, Marks, J, Dharamsi, S, and Catalanotto, FA, Barriers to Medicaid Participation among Florida Dentists. Journal of Health Care for the Poor and Underserved. 2015; 26(1):154-67. PMID25792734). Dr. Catalanotto is a professor at the University of Florida College of Dentistry. His statements are his own and in no way associated with any policies of the university. He can be reached at fcatalanotto@ dental.ufl.edu.
Letter to the Editor By Dr. Neil Stringer Quite frankly, I was glad to read his letter. Finally, someone is saying something that we “old timers” have pondered over the years. Was all that stress and suffering we went through actually for a reason? I believe it taught me to handle and function under the stress that comes with patient care and running a small business. If that letter caused some comments and discussion— so much the better. Sometimes newsletters need some stimulation. Dr. Stringer can be reached at stringerdds@gmail. com.
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Members‘ Opinion
Letter to the Editor By Dr. Charles W. Elwell Jr.
I need to respond to Dr. Carlos Sanchez’s comments regarding LECOM, the newest dental school in Florida. Perhaps I can present a more measured opinion of the school based on fact and my personal experiences with the school. I am a private practitioner in oral and maxillofacial surgery (OMS) in the panhandle. I was curious as well when I first heard about LECOM and the “progressive” nature of the training. Problembased Learning (PBL)? What’s that? Digitalized anatomy class — wait, no cadavers? Simulation clinic? These are all foreign concepts to most of us who were trained in the classic traditions of dental education. But what do you really want to know? Of course, that would be the quality of the final product — the fourth-year dental student. Is he or she academically sound? Can they present a welldeveloped treatment plan in an articulate manner? Have the manual dexterity and procedural tasks been adequately developed? Have the students shown an appreciation for professional development? Do they know what it takes to be competent and ethical doctors? I can answer with a resounding “Yes” on all counts. You see, I teach the fourth-year students OMS and oral medicine along with a wonderful faculty of general dentists and specialists. We work in a new, first-class $8 million clinic in DeFuniak Springs specially designed to accommodate the students and patients of LECOM. Patients from all socio-economic groups receive care in every area of dentistry: surgery, perio, ortho, pediatrics, implant prosthetics, restorative, etc. The clinic also provides care to the underserved of northwest Florida. Rather than talk about the problems of access to care, LECOM has decided to act upon their convictions, which I think is admirable. These are excellent students and good people being well-trained at a fine facility. This is quite a different picture than what Dr. Sanchez tried to paint. Dr. Elwell is a private practitioner in the Florida panhandle and can be reached at cwelwell@yahoo. com.
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Letter to the Editor
An Unfortunate Step Backwards By Dr. Wilbur M. Davis Jr. In October 2014, medical and dental care for children with special needs or from low-income families in the central Florida region was significantly reduced and, for all practical purposes, discontinued by the Florida Agency for Health Care Administration (AHCA). These special needs services had been in existence for at least 50 years, beginning as the Crippled Children’s Program, which originally provided orthopedic care, and evolving in the late 90s into the Children’s Medical Services Network (CMS). The recent clinics met once a month to provide care for 30-40 patients each month. It was staffed by a plastic surgeon, oral and maxillofacial surgeon, otolaryngologist, pediatrician, pediatric dentist, orthodontist, physical therapist and speech-language pathologist. The system became a Mediapath provider, which also encompassed the care of Medicaid-recipient children as well as other low-income patients. A few private pay patients were seen by the clinic, as it was the only fully staffed group in the central Florida region to serve patients with craniofacial abnormalities, cleft lip and palate, and other special needs. Reimbursement “carve-outs” were established in order to retain the services of competent providers trained in caring for special needs patients, as well as the many needy low-income patients. It should be noted that specialized training and experience is necessary for the proper care of these patients. Before its demise, the Central Florida Region CMS Clinic was able to provide services in an outpatient and hospital setting, and direct patients to other specialized medical providers. Dental care included moderately comprehensive cleft surgery, maxillofacial and oral surgery, pediatric dentistry and orthodontics. Additional services were available or referred by the clinic. In January 2015, clinic providers received a letter from Dr. Ayodeji Otegbeye, CMS Regional Director, stating, “The CMS Cleft Lip and Palate Clinics in Orlando and Viera will end as of Jan. 1, 2015 due to lack of key providers in our area.” He later
corrected his statement: “The discontinuation of the clinics was based on the health care providers’ unwillingness to accept Medicaid fees as payment in full for services …” This decision by the providers was almost unanimous due to the fact that it is not possible to provide these services at 20-30 percent of a negotiated “carve-out” reimbursement, thus reimbursements were significantly below the overhead figure of most practices. In August 2014, the CMS Program was contracted by AHCA to convert the CMS network to a riskbearing program without additional appropriated funds and with a mandate to pay no more than the schedule of payments provided by Florida Medicaid. The entire system of care has undergone change with the rollout of the Managed Medical Assistance Program (MMA) by the AHCA under legislative direction of a medical managed-care model with about 20 vendors now responsible for the provision of care and payment for services of most Medicaid recipients in Florida under a waiver program approved by the federal government. Under this change, patients of the Cleft Lip and Palate Clinics in Orlando and Viera, as well as others in the state, were to seek alternative arrangements for patient care in facilities such as the University of Florida or University of Tampa. This proved to be unrealistic due to difficulties in obtaining appointments and competent specialized providers, as well as the significant transportation difficulty to distant facilities. Both federal and state funds are distributed within the state budget under the direction of the state Legislature. It is interesting that Florida’s Medicaid budget is $23 billion and seems to be enough to fund continued bureaucratic functions, but inadequate to provide the necessary care for children with special needs and from low-income families. With the above changes, we have regressed to a point where we were many years ago. There must be a strong public and professional appeal to those who are in control of systems and funds, i.e., the Legislature, if there is to be any hope for improvement. Only with proper funding for fair reimbursements for services rendered can there be adequate care for the children with special needs and from low-income families in our state. Dr. Davis can be reached at cfoms@cul.com.
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*Please note that FDA members have their names listed in bold.
Call for Award Nominees Nominate a deserving individual for recognition by the Florida Dental Association (FDA). It’s simple! You now can go online and recognize any FDA member, a dental team member, someone in the general public who is advancing the oral health of Floridians, and more! Let’s give those who are helping the public and the profession some well-deserved recognition. Oct. 23 is the deadline for applications. Go to http:// bit.ly/1EVPOAc for more information on how to nominate someone.
Bundling of Procedure Codes When a procedure is “disallowed” by the payer, it is a frustrating experience for contracted dentists. When a procedure is “denied,” the dentist’s fee for a procedure is not benefitted, but the dentist is allowed to charge the patient for that procedure. However, when a procedure is “disallowed,” the dentist’s fee for a procedure is not benefited by the payer AND is not collectible from the patient by a participating dentist. Examples of procedures that have been reported to the ADA as being commonly disallowed include the restorative foundation (D2949) for an indirect restoration or pulp capping (D3120) below a restoration. The ADA strongly opposes such practices. Each unique procedure is identified by a distinct CDT Code. Existence of a code allows the dentist to accurately record the unique services provided. Some would infer that by “disallowing” a service, payers are taking the stance that
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the procedure is not “medically necessary.” How can payers deem a distinct dental procedure (evidenced by a unique CDT Code) as “not medically necessary?” Medical necessity is established by the treating dentist responsible for diagnosing and planning treatment for a patient. It is the prerogative of a plan, in the spirit of serving as the administrator for the patients’ dental benefit, to seek documentation from contracted dentists to support the treatment rendered. However, the ADA believes that this function should not extend to determining “medical necessity” under the pretext of cost containment for the patient. Further, if a payer’s dental consultant makes a determination that a service can be “denied” for a non-contracted dentist, but the same service would be “disallowed” for a contracted dentist, it may place the plan and consultant in an ethical bind by applying different standards of care for the same service simply based on network status of a dentist. The ADA argues that this is inappropriate. A dental benefit plan that is meant only to cover some of the patients’ dental care costs, should limit its decisions to how that benefit is appropriately disbursed. Dentists should watch for these situations and coach their patients to approach their employers to identify solutions that would benefit plan designs. Further, language within the explanation of benefits (EOB) should be appropriate and not imply that the treatment was unnecessary or that the dentist was in error. The ADA encourages member dentists to bring forward issues with EOB language to our attention by calling us at 800.621.8099. For more informa-
tion on bundling and other third-party issues, please visit http://success.ada.org/ en/practice/dental-benefits/. When communicating with patients, dentists may want to use language similar to the following: “The maintenance of the CDT Code is through a multi-stakeholder process that includes payer and provider groups. The existence of a code allows for recording and reporting of that service and recognizes the unique nature of that care. Your benefit plan is only intended to pay for a portion of your dental care costs.”
Florida Academy of General Dentistry Welcomes New Executive Director The Florida Academy of General Dentistry (AGD) welcomes their new executive director, Judy Nichols. In addition to her new role, she also is the president of JN Management Solutions Inc., a boutique association management company. Ms. Nichols is an association management professional, and has been in the business for more than 20 years. Prior to joining the Florida AGD, she was involved with many of Palm Beach County’s finest nonprofits, including the Gold Coast Builders Association, Norton Museum of Art and the Executive Women’s Golf Association. She is a proud Gator graduate with a degree in Public Relations.
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UFCD and Nova White Coat Ceremonies The White Coat Ceremony is a time-honored tradition — students are ceremonially “cloaked” with their white coats by the dental faculty and officially welcomed into the dental profession. This ceremony marks a significant milestone in their educational journey. The Florida Dental Association (FDA) had the privilege of participating in the University of Florida College of Dentistry’s (UFCD) and Nova Southeastern University College of Dental Medicine’s annual White Coat Ceremonies. This year, the FDA was represented by FDA President Dr. Ralph Attanasi. On Friday, June 19, UFCD Dean Isabel Garcia presided over her first White Coat Ceremony. The students were pinned with their FDA member pin as they were welcomed into the profession by Dr. Attansai and Dr. Craig Oldham, president of the UFCD Academy of Alumni & Friends and chair of the FDA Council on Membership. At Nova’s White Coat Ceremony, Dr. Attanasi had the honor of pinning 150 first-year dental students with their official FDA member pins on Aug. 9 at the Don Taft University Arena on campus. Welcome new students!
Golden Image Award On 3 Public Relations (On3PR), the firm FDA Services (FDAS) hired to rebrand the endorsed programs, was recognized by the Florida Public Relations Association (FPRA) with an Award of Distinction for the FDAS’ rebranding project. Formerly the Corporate Affiliation Program, On3PR
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came up with Crown Savings, the new branding now used to market the program’s merchants to our members. The award was presented at the Golden Image Awards banquet during the FPRA’s annual conference in August.
Dental Society of Greater Orlando Participates in Back-to-school Bash The Dental Society of Greater Orlando participated in an annual back-to-school expo that provided free health services and school supplies to children. Thanks to the coordinated efforts of the 100+ dental volunteers in the central Florida area, it was a huge success! The event went smoothly, and 401 children received dental care. In addition to the dental area, the children had the opportunity to visit the other health fair booths and even get haircuts. Backto-school backpacks were given to 11,000 children courtesy of Sam’s Club. The event also included bounce houses, clowns and magicians. All in all, it was a great event.
Nova’s College of Dental Medicine Founding Dean Dies It is with great sadness we announce the death of Dr. Seymour Oliet, the founding dean of Nova Southeastern University College of Dental Medicine. Dr. Oliet began his involvement with Nova in 1994, when he was cajoled out of retirement to chair a committee to discuss the feasibility of starting a new dental school at Nova. Dr. Oliet immediately went to work setting up committees, identifying benchmarks, and learning much about the dental capacity and oral health needs in South Florida. Dr. Oliet impressed everyone with his spirit,
dedication, unbridled energy and knowledge. When the Nova Board of Trustees voted in March 1996 to approve a College of Dental Medicine, Dr. Oliet was appointed as dean. Opening the first new dental school in the U.S. in 25 years offered many special challenges, and Dr. Oliet’s vision was to make it the best it could be and provide the students with a collegial environment in which to learn to become a dentist. Mrs. Oliet has approved the establishment of a scholarship fund to honor Dr. Oliet. Donations can be made to the Dr. Seymour Oliet Scholarship Fund at the Nova Southeastern University College of Dental Medicine. Please keep the Oliet family in your thoughts and prayers during this difficult time.
Op-ed: Special Needs Dentistry Requires More Funding In an op-ed for Newsday, a dentist in Flushing, New York states that providing dental care for patients with special needs “costs more than the same care for non-disabled people” because of the additional time, specialized equipment and staffing oftentimes required. As a result, treatment is delayed, po-tentially causing “dental conditions to deteriorate and costs to escalate.” According to the dentist, until private benefits companies and the government “realize that this issue won’t go away and funding is increased for care, the untreated dental conditions of special-needs patients will deteriorate.” To read the article, go to http:// nwsdy.li/1QfgTPk.
Please see NEWS, 22
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NEWS from 19
Welcome New FDA Members These dentists recently joined the FDA. Their membership allows them to develop a strong network of fellow professionals who understand the day-to-day triumphs and tribulations of practicing dentistry.
Atlantic Coast District Dental Association Adrian Acosta, North Palm Beach Dalia Al-Azzawi, Palm Beach Garden David Amador, Southwest Ranches Zulma Castaneda-Medina, Weston Joshua Chupp, Port Saint Lucie Candace Colella, Coral Springs Vikash Dahya, Okeechobee Jason Dale, Fort Lauderdale Jaime Elkind, Coral Springs Caitlin Ferguson, Coral Springs Jose Friman, West Palm Beach George Galluzzo, Fort Lauderdale Yanela Gonzalez, Weston Yang Hua, Parkland Sergio Jacas, Fort Lauderdale Colleen Lam, Lake Worth Albert Lewicki II, Port Saint Lucie Carmen Maco, Fort Lauderdale Matthew McAndrew, Vero Beach Geoffrey Morris, Coral Springs Francisco Oliver, Weston Katelyn Pembroke, Palm City Pablo Prado, Boynton Beach Manuel Pulido, Plantation Daniel Radu, Boca Raton Susan Ramdhan, Davie Mayra Rodriguez, Boca Raton Matthew Rolfes, Fort Pierce David Santana, Parkland Camilla Savardi, Hillsboro Beach Robert Shumate, Davie Ahmed Sirage, Deerfield Beach Ravi Soni, Riviera Beach Ahmed Taha, Coral Springs Yeneir Urquiza, Jupiter
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Central Florida District Dental Association
Northeast District Dental Association
Mariana Al Nasser, Orlando Lauren Andreolas, Southwest Ranches Frank Berdos, Gainesville Shaun Bullard, Gainesville Kevin Carbonell, Gainesville Victor Chou, Gainesville Phillip Claassen, Cape Coral Guneshi de Mel, Orlando Sabrina Diaz, Gainesville Lauren Dickens, Gainesville Tutrinh Do, Orlando Ashley Dubois, Orlando Melania Elsner, Gainesville Connie Feng, Orlando Desmond Foster, Gainesville Nathalie Gal, Ormond Beach Jacqueline Garcia, Gainesville Emmanuel Gavua, Titusville Jose Guerra, Melbourne Erik Holz, Seminole Alexandra Jensen, Clermont Carly Joehl, Deland Jyoti Kansal, Deltona Crystal Kim, Orlando Lindsay Kulczynski, Live Oak Edward Lancaster, Melbourne Olga Luaces, Gainesville Marcia Martinez, Orlando Nicole Martino, Gainesville Farid Mastali, Kissimmee Angela McNeight, Gainesville Ireni Mikhail, Orlando Melissa Nixon, Gainesville Alejandro Piedra, Altamonte Springs Carlos Alberto Pires, Orlando Patricia Prieto, Orlando Johann Ramkissoon, Gainesville Courtney Sargent, Satellite Beach Steven Schrader, Gainesville David Selis, Gainesvile Amrita Singh, Orlando Ralee Spooner, Gainesville Anitha Tetali, Orlando Gabriela Vila, Gainesville Lindsay VonMoss, Gainesville Mohammad Zaman, Maitland
Vladimir Avril, Jacksonville Lorraine Clark, Jacksonville Bennie Clark, Jacksonville Thomas Farrell, Jacksonville Emily Garcia, Orange Park Diana Kinyua, Jacksonville Rachel Monteiro, Jacksonville Kristen Moore, Jacksonville Kim Nguyen, Jacksonville Matthew Scarpitti, Port Orange Joseph Smillie, Jacksonville Vy Truong, Fleming Island Carter Weber, Jacksonville
Northwest District Dental Association Stephanie Curley, Lynn Haven Hilary Grimm, Cantonment Nisha Kumar, Destin Nathan Kupperman, Tallahassee Mini Majumdar, Tallahassee Anh Nguyen, Panama City Kaitlin Pfister, Pensacola Sarika Tamaskar, Pensacola Benjamin White, Milton
South Florida District Dental Association Jorge Borges, Miami Vianca Cabrera, Coral Gables Joaquin Camejo, Miami Jun Cho, Davie Maria Cook, North Miami Beach Delia Cruz Elizundia, Miami Mor Dagan, Miami Shachar Dagan, Miami Yalda Davoodi-Semiromi, Davie Andrea Diaz Vasquez, Hallandale Beach Marcela Echeverry, North Miami Beach Giselle Fernandez Dominguez, Hialeah Jaime Franco, Aventura Jose Garcia, Miami Anahi Garcia-Labori, Hialeah Yudith Gonzalez, Hialeah
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Claudia Green, Hollywood Anaely Guevara, Miami Mike Hoang, Sunrise Tawana Jenkins, Miami Gardens Jeremy Kay, Miami Patrick Lolo, Miramar Katherine Lorenzo-Machado, Miami Jean Macajoux, El Portal Amanda Merikas, Miami Yudisbel Molina Ariza, Miami Tamer Moustafa, Miami Beach Moneeze Mujtaba, Pembroke Pines Laura Ortega, Hialeah Blake Parker, Davie Adrian Paruas, Hollywood Anabel Paya, Miami Ilieg Perez, Miami Kelli Prescott, North Miami Beach Evelyn Prieto, Pembroke Pines Azadeh Rezale, Hollywood Aliana Ribot, Miami Milagritos Rios Ku Hop, Doral Julieta Rodriguez, Coral Gables Diego Romero, South Miami Dania Santana, Miami Tamara Santos, Miami Beach Raynel Sarduy, Weston Andres Seoane, Miami Peter Shih, South Miami Alessandra Sigillo, North Bay Village Adi Suta, Cutler Bay Alfredo Tendler, Pembroke Pines Noah Turk, Hollywood Marina Vasilaros, Miami Ettie Weisser, Aventura Marnie Yanes, Opa Locka Joyce Yu, Miami
West Coast District Dental Association Christiana Ajmo, Dunedin Reem Akel, Spring Hill James Allor, Tampa Kellie Bateman, Lake Placid Anthony Benza, Naples Yosuel Blanco Sanchez, Brandon Amir Boules, Lutz www.floridadental.org
Ralph Ciasullo, Bradenton Matthew Dockus, Largo Sara El-Sherbini, Largo Tamer Eshra, Bonita Springs Michael Foley, Tampa Steven Frey, Fort Myers Alexandra Griffin, St. Petersburg Jonathan Hale, Zephyrhills Trevor Hamm, Lehigh Acres Hanny Hamoui, Brooksville Ann Ho, St. Petersburg Robyn Jenkins, Clearwater Eric Jensen, Spring Hill Shalini Kamodia, Naples Elena Kan, Lakeland David Kellogg, Land O’ Lakes Noel Keyzer, Bradenton Casey Lynn, Naples Zunith Martinez, Tampa John McAninch, Sarasota Annissa Michael, Lakeland An Nguyen, Winter Haven James Nguyen, Naples Cong Nguyen, Brandon Asha Patel, Tampa Michael Powell, Seminole Fadi Raffoul, Tampa Stevy Raju, Seffner Evelyn Ramirez-Lee, Naples Amaurys Ramirez-Torres, Hudson Saimon Ramos, Seminole Emily Relkin, St. Petersburg Jeremy Robbins, Valrico Ronak Shukla, St .Petersburg Egle Skruodyte, Land O’ Lakes Sara Spear, Tampa Gabriele Spinuso, St. Petersburg Yoan Suarez Zayas, St. Petersburg Ashley Tate, Palm Harbor Barrett Tindell, Tampa Srividya Vulugundam, Tampa Jason Watts, Cape Coral Timothy Whaley, St.Petersburg Trevor Williams, Tampa Courtney Worlinsky, Clearwater Ali Yazback, Naples
In Memoriam The FDA honors the memory and passing of the following members: Theofelos Aliapoulios West Palm Beach Died: 6/22/2015 Age: 88 Peter B. Sanderson Fort Lauderdale Died: 7/13/2015 Age: 87 Robin B. Dodd Chuluota Died: 7/21/2015 Age: 64 D. Kenneth Morrow Jr. Seminole Died: 8/15/2015 Age: 79 Samuel J. McNeil West Palm Beach Died: 8/26/2015 Age: 77 Seymour Oliet Pompano Beach Died: 8/26/2015 Age: 88
September/October 2015
Today's FDA
23
Board of Dentistry
Board of Dentistry Meets in Safety Harbor By Casey Stoutamire FDA LOBBYIST
The Florida Board of Dentistry (BOD) met in Safety Harbor on Friday, Aug. 21. The Florida Dental Association (FDA) was represented by FDA BOD Liaison Dr. Don Ilkka and FDA Lobbyist Casey Stoutamire. Other FDA members in attendance included Drs. Andy Brown, Zack Kalarickal, Charles Llano and Mark Romer. Also in attendance were several dental students from the Lake Erie College of Medicine (LECOM). Ten out of 11 BOD members were present, which included Dr. Bill Kochenour, chair; Dr. Leonard Britten, vice chair; Drs. Dan Gesek, Robert Perdomo, T.J. Tejera, Joe Thomas and Wade Winker; hygienists, Ms. Catherine Cabazon and Ms. Angie Sissine; and consumer member, Mr. Tim Pyle. Mr. Anthony Martini resigned from the BOD and his position is still vacant. Dr. Kochenour gave a report on the Curriculum Integrated Format (CIF) exam, also known as the “Buffalo Model,� which
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is administered by the Commission on Dental Competency Assessments (CDCA). The dental schools in Florida are interested in using this new testing model. However, they wanted the BOD to discuss whether it falls within the guidelines set forth in Florida statute and rules. After much discussion, the BOD decided to table this issue until the November meeting to allow members who are not familiar with this testing model to do their own research on it. However, a majority of the BOD members did support this testing model and would like to see it offered at Florida dental schools. More information on this type of exam can be found at http://www.cdcaexams.org/dentalexams/. Mr. David Flynn, BOD attorney, explained that the BOD contracts out the exam and its administration, and if the CIF exam were given in a Florida dental school, it would not be in violation of Florida statute or rule because it would be administered by the CDCA, which Florida statute requires. Dr. Winker gave a report on the American Board of Dental Examiners (ADEX) annual meeting. ADEX has ended its relationship with the Southern Regional Testing Agency (SRTA) due to security concerns that arose during the last exam. States now will have to decide to continue with ADEX or with SRTA (if they create a new exam). In addition, Dr. Winker is chair of a committee
tasked with coming up with a new way to test the periodontal portion of the exam on a live patient without just doing scaling and root planing. He has asked the FDA for its help and ideas. Several BOD members then brought up the issue of a national licensure exam and whether Florida should continue its requirement of testing on a live patient. However, no consensus was reached and no motion was proposed. The current FDA policy is to support a live patient exam (including the periodontal portion). If you would like to provide input on new ways to test the periodontal portion of the exam, please contact Casey Stoutamire in the Governmental Affairs Office (GAO) at cstoutamire@floridadental.org or 850.224.1089. Mr. Flynn gave an update on Rule 64B517.002, Written Dental Records: Minimum Content, Retention, which now is effective. Mr. Flynn worked with the Joint Administrative Procedures Committee (JAPC) on their approval of the rule; specifically section (9) pro bono dental events. JAPC recommended striking section (9) of the rule because it is in conflict with statute, which says if treatment is provided, then records need to be kept for four years. The BOD approved a motion to remove subsection (9) from the rule; thus, if treatment is provided at a pro bono event then records will need to be kept for at least four years.
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Board of Dentistry
The BOD discussed two petitions for declaratory statements, which, unlike a variance or waiver of a rule, only affect the petitioner if granted. The first petitioner wanted to know whether a dentist operating through a professional association may form a limited liability company and refer patients of the professional association to the limited liability company for surgical, endodontic or other specialty care without such action constituting a violation of Florida statute. Per Mr. Flynn’s advice, the BOD granted this declaratory statement as it falls within one of the exceptions found in Florida statute 456.053, the Florida Self-referral Act of 1992. The second petition dealt with whether the definition of a supplemental general dentistry program included a pediatric residency program. Dr. Ilkka testified and reminded the BOD that this issue was voted on at the February BOD meeting and at that time, the BOD approved a motion that stated specialties are not included in the definition of a supplemental general dentistry program. However, after a spirited debate, the BOD sent this issue to the Rules Committee for further discussion and the creation of a rule to put this issue to rest. The petitioners withdrew their request pending the result of the Rules Committee. If the BOD had taken a vote on this issue at the meeting, there may have been enough support for a pediatric residency program to be included in the definition of a general supplemental dentistry program. It is the FDA’s position that specialty training is not equivalent to general dentistry training. Dentists who are graduates from nonaccredited dental schools must complete two consecutive years in a general dentistry program, which cannot be a specialty
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(pediatrics, prosthodontics, etc.). In the past, the BOD granted numerous variances and waivers allowing applicants in specialty programs to use those programs to sit for the exam. Eventually, to address those who already had started their programs when the legislation passed, the BOD adopted a grandfathering rule to allow those in the middle of their program (specialty and general) to complete it and be eligible to sit for the exam. Now that the grandfathering provision is over, the FDA wants to ensure no more applicants can use specialty programs to satisfy this statute. Currently, when graduates from non-accredited dental schools start their application process, there is no doubt about what the statute requires; they must complete two consecutive years in a general dentistry program to satisfy the statutory requirements. There were four disciplinary cases and one voluntary relinquishment at this meeting. The disciplinary cases were related to treatment of patients in a nursing home. As a result, Dr. Kochenour created a Nursing Homes Task Force to evaluate dental care in nursing homes and invited the FDA to be a part of this task force.
The next BOD meeting is scheduled for Friday, Nov. 20, 2015 at 7:30 a.m. EST in Lake Mary at the Orlando Marriott Lake Mary, 407.995.1100.
If you have not yet attended a BOD meeting, it is suggested that you take the opportunity to attend and see the work of the BOD. It is much better to be a spectator than a participant in BOD disciplinary cases. Ms. Stoutamire can be reached at 850.350.7202 or cstoutamire@floridadental. org.
September/October 2015
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Treating Children
“
When the day came to volunteer, I was sweating. I was totally underqualified. I didn’t know the first thing about telling an expectant mother of a baby with Down syndrome what the baby’s teeth are going to look like.
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Treating Children
I’m Just a Regular Guy Treating Special Children As she told me she would let me know the
By Dr. John Gammichia
specifics later, I thought to myself, “What I first met the Smith family when I was in high school; we went
have I gotten myself into?” See, she obvious-
to the same church. They were great friends with my parents and
ly didn’t know that my experience treating
had kids the same age as my brother and sister, but 11 and 13
patients with Down syndrome was limited
years younger than me, respectively. The Smiths’ had four boys,
to treating her daughter. Yes, I had a grand
but they wanted to take one more chance for a girl.
total of one patient with Down syndrome. Dr. Charlie Bertot, whose office was about
Several years later, I was a senior in college when Mrs. Smith be-
nine miles from mine, is the expert. He’s
came pregnant. Oh, how they prayed for a girl. Back then, know-
had all the training and experience, and he
ing the sex before the baby was born was not commonplace.
actually knows what he’s talking about.
Nine months later, Mrs. Smith gave birth to Cathy, a beautiful baby with Down syndrome. The Smiths were wonderful people and were blessed with the ability and resources to do
But for some reason, maybe she was busy
everything they could for Cathy.
and knew my phone number, and had to check off “dentist” from her list. During the
I saw Cathy fairly often at family functions when I was home from school. It wasn’t until
Special Day for Special Kids event, families
my first year in dental school that I spent any significant amount of time with a child with
with children with Down syndrome are
special needs. Fast forward through the four long, tortuous years at the University of Florida
able to meet with multiple specialists at one
College of Dentistry (sorry, Dr. Gale) to when I joined my father’s practice. As you all may
location: a cardiologist, geneticist, ophthal-
know, the new young dentist at a practice sees all the children and the adults who act like
mologist, orthopedic surgeon, occupational
children. So, naturally, along with all her brothers, I became Cathy’s dentist; it wasn’t much
therapists and a dentist.
different than seeing the other children. Mrs. Smith and I discussed sealants and everything else dentists discuss with parents. We talked about the options for Cathy’s congenitally miss-
When the day came to volunteer, I was
ing teeth (she eventually would get orthodontics and a couple of implants) and referred her
sweating. I was totally underqualified. I
to an orthodontist when it was time.
didn’t know the first thing about telling an expectant mother of a baby with Down
One day, Cathy’s mom, who was the president of the local Down syndrome association at
syndrome what the baby’s teeth are going to
the time, asked me to volunteer at the inaugural Special Day for Special Kids event. I think
look like. All I did to prepare was a Google
my exact response was: “Uh, well … I don’t know. Well, I guess. Whatever you want. Sure.”
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Please see CHILDREN, 29
September/October 2015
Today's FDA
27
benefit
Membership NUMBER Concierge
15
Thanks for your conscientiousness and follow-up. Info was just what I requested and very helpful. — Dr. Mel Kessler I wanted to thank you for resolving my issue. I greatly appreciate everything and you helping me situate things in a prompt manner. — Dr. Sheena Patel
CHRISTINE MORTHAM
Do you have a question, suggestion, or a compliment? Call or email Christine, your membership concierge, to get the answers you need.
800.877.9922 or 850.350.7136 cmortham@floridadental.org
Treating Children
CHILDREN from 27
search (keep in mind Google in 1999 was not as profound as Google in 2015) and found three articles on the development of the oral cavity on a patient with Down syndrome — that was it. I arrived, put on the T-shirt and went to the designated room. I was relieved to find one of my friends, Dr. Ofilio Morales, was joining me. Dr. Ofilio’s 16-year-old son has Down syndrome, so I knew I was in good hands. I told him, “You can do it all, and I will just watch and get the free lunch at the end.” He was so relaxed and gracious with me and the families that came in. We discussed with the parents what we know about the development of the oral cavity. We answered their questions and concerns, such as, “Where are my kid’s teeth? He is two years old and still not a single tooth,” or, “My kid is getting teeth, but they are pointed and there are so few of them.” The first hour we spoke to multiple families about their kid’s teeth and I interjected when appropriate — like when they asked a general dentistry question. But then we noticed the line for the dentist had more than 10 people waiting. Dr. Morales noticed the room next to us was empty. He told me to help the next family and, “Be the man.” The first people I helped were parents of a six-week-old baby boy with Down syndrome — their third child. They were almost in tears. Imagine going to every one of the above specialists and hearing about all the challenges and therapy recommended for their son, and all the ways that their new baby was going to be different from their first two children. They were overwhelmed. To help calm them down, I had them just sit and breathe. After a few minutes, I asked them about their day and we eventually laughed about how overwhelmed they had been. Then, I just talked about teeth, which they didn’t need to worry about for a couple of years because their son wasn’t going to get any for a year or two.
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Next thing you know, I am doing it by myself. I am telling people what to expect when you are expecting a child with Down syndrome. I was telling people what to expect in their teenaged child with Down syndrome. It was such a wonderful experience, and I knew I wanted to continue to be involved. I volunteered at the Special Day for Special Kids for 16 consecutive years, and I had the pleasure of seeing these children grow up. I also got my friends involved — I brought Dr. Bertot, a pediatric dentist, and Dr. Andy Tringas, an orthodontist. And you remember Cathy? One of her brothers became a dentist. That is what you call full circle. I am a normal, everyday wet-fingered dentist. But I can tell you that I am blessed beyond belief because I know the Smith family and their special daughter, Cathy. All because I said, “Yes.” Dr. Gammichia has a general practice in Apopka and can be reached at jgammichia@aol.com.
September/October 2015
Today's FDA
29
TRY MY AGENT
Insurance for your Dental Career
“
Joe Perretti has always been very efficient and responds to my questions and concerns at a record speed! He is very easy to contact and reliable. I am very happy with his service and that is why I keep coming back to FDAS for all of my insurance needs!
“
- Irenia Mendoza, DDS New Smiles Dental Associates Miami, FL
800.877.7597 ∞ insurance@fdaservices.com ∞ www.fdaservices.com
LET US KNOW! DON’T MISS OUT on important information and updates from the FDA! Let us know if any of your contact information has changed. UPDATE your information with the FDA by calling us at 800.877.9922. Or, email us at fda@floridadental.org.
RETIRING? Not all good things have to come to an end! Privileged members can stay active and save money. Contact us to find out how! Also, remember to notify the Florida Board of Dentistry with any changes. Go to floridasdentistry.gov or call 850.488.0595. Your professional licensure depends on it!
Dental Lifeline
You Can Change the Lives of People Like Sandy Dental Lifeline Network • Florida
Through the Florida Donated Dental Services (DDS) program, Dental Lifeline Network • Florida offers comprehensive dental treatment to people with disabilities or who are age 65 or older, or medically fragile and cannot afford care. Medically fragile patients need dental care to qualify for lifesaving or life-sustaining treatments, such as chemotherapy, joint replacement, cardiac surgery and organ transplants. Frequently their medical treatments are covered by Medicare or Medicaid, but Medicare does not cover dental treatment and Medicaid, at best, covers only a small portion of the dental care they need. Sandy, age 57 and living in Plantation, Fla., was committed to her career and loved her work as a licensed clinical social worker for a mental health crisis facility. After years of successfully managing her diabetes, Sandy went into renal failure last year and receives dialysis treatments at a renal facility three days per week. Sandy cannot work, nor can she drive, due to the impact diabetes has had on her vision. Adding to Sandy’s problems, severe dental disease and a broken bridge connected to her eight remaining upper teeth caused considerable pain. She also feared that her 12 remaining lower teeth might be infected. Relying on Social Security disability payments and other government assistance, Sandy had no way to pay for the dental care she badly needed. Dr. Charles Shofnos, a general dentist and one of nearly 400 volunteer dentists in Dental Lifeline Network’s DDS program, came to Sandy’s rescue. He extracted six teeth, placed a crown and fitted Sandy with an upper partial and a lower bridge. Three laboratories also volunteered their services to help Sandy. First Impressions Dental Lab in Hollywood donated the upper partial. Fine Arts Dental Lab in Miami provided a zirconia bridge and Dental Prosthetics in Sunrise contributed a porcelain crown. The three labs are among 209 that volunteer for Florida DDS.
You Can Support Donated Dental Services With a Gift to the FDA Foundation! Your donation to the Foundation is an investment in our mission to promote dental health for all Floridians. It also helps the Foundation continue important programs like Donated Dental Services and FLA-MOM. It’s easy to make a donation and every bit counts! Visit floridadental.org/foundation to learn how.
Sandy is happy to eat salads again and to actually bite into a hamburger. With her oral health restored, she sees her life improving. Sandy is completing requirements to be placed on a kidney transplant list.
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Dental Lifeline
Dear Dr. Shofnos, “Thank you so much for the last few months — you have restored my smile. I have had a great experience with your staff and recommend you to anyone I know in need of dental care. Your generosity in donating to this program is greatly appreciated by me, and countless others, I am sure. I will never forget the great work you achieved.” – Sandy
Volunteer Now! Join Florida’s DDS volunteers to help vulnerable people who have no access to dental care. Hundreds of people are on waiting lists and more volunteers are needed statewide — especially in north Florida and the Panhandle. You can treat one patient per year or as many as you choose. Your DDS coordinator ensures that patients arrive on time for appointments, arranges for assistance from specialists and laboratories, and serves as the liaison between your staff and the patient to facilitate everything.
Volunteering is easy. Your staff will love the experience! n Patients are prescreened. n You review the patient profile in advance and choose to see or decline any patient. n You determine your own treatment plan. n You see patients in your office on your schedule. n You never pay lab costs. n You and your staff have no extra paperwork. Volunteers say they never expected how much their staff appreciates the DDS experience. Staff members celebrate the success of patients and value the teamwork they provide with their dentists.
“There aren’t a lot of things we do in dentistry that make a truly big difference. Working with DDS is one of the most important things I do. It is the best part of my professional life. Sandy is a great lady. She was appreciative from beginning to end. She wouldn’t smile and now she does. She couldn’t eat and now she can. She’s very happy and I’m very happy.”
To volunteer, contact Florida DDS Coordinator Megan Manor at 850.577.1466 or mmanor@ DentalLifeline.org, or go to http://dentallifeline. org/florida/ for more information.
– Dr. Charles Shofnos
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Office Lease Negotiations
Can Your Landlord Relocate Your Dental Practice? By Alain Sabbah PARTNER AT CIRRUS CONSULTING GROUP
Picture this: You’ve built — or bought — your dream dental practice, amassed a loyal patient roster and are enjoying the fruits of your successful dental practice. You’ve found a space that works for your business and you’re lulled into a sense of security by what you thought was a good and solid dental office lease. Suddenly — without warning — you receive notice from your landlord that the dental practice you have worked so hard to build is being relocated to another location to make room for the accountant next door who is expanding. You realize that the office lease you thought was designed to protect your interests, is actually riddled with clauses that the landlord can exploit to their advantage; in this case, it’s the “relocation clause.” So, what does this mean for you and your practice?
What is the “Relocation Clause”? A relocation clause gives your landlord the right to relocate your dental practice to another location in the center or build-
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ing. Landlords generally exercise this right when they have a tenant interested in expanding into the space or is willing to pay higher rental rates. When this happens, the landlord requests current tenants to vacate their space — with typically 30 days’ notice — and move to a new location. Dental practices in particular are expensive to maintain and difficult to relocate; a hidden relocation clause can pose major problems for a tenant.
Is a Dental Practice Relocation Really So Bad? A surprise relocation can be devastating to a dental practice for multiple reasons. Here’s what you should consider: m Relocation Costs: Many leases do not put the onus on the landlord to cover relocation/moving expenses. This means all costs associated with the move, including demolition of the current space, renovation and build-out costs in the new location, marketing materials and stationery, movers, etc., are your responsibility. A relocation can easily add up to hundreds of thousands of dollars in unexpected costs to a dental tenant. m Increase in Rent: If you are moved to a more “favorable location” (e.g., from the third floor to the first floor), you may face an increase in rent for the upgraded
“
The most effective way of avoiding a surprise relocation is to identify this clause in advance and negotiate it out of your dental office lease before you sign it.
”
Please see RELOCATE, 37
September/October 2015
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35
Office Lease Negotiations
RELOCATE from 35
real estate. If you are moved to a larger location, you may suffer an immediate increase in rent for the additional square footage. m Size: There is no guarantee that the size of the new location will be comparable to the original premises. If smaller, you will have to downsize, reconfigure layout and operatory rooms, and ultimately suffer a loss in production. m Business Downtime: If you are relocated, you could face business “downtime” or “dark time” while your new practice is being built out. Every day that your practice doors are closed before the new location is functional is a loss of revenue. m Downgrade in Facility: You may be forced to trade in prime real estate for an out-of-the-way corner unit with low visibility and zero foot traffic. The landlord controls the relocation, which means that you could face a serious downgrade in the quality of your environment, as well as a lower potential for walk-in business. m Competition: You also may not have control over potential competition in the vicinity of your new unit. Your new space may mean close proximity to competing dental offices, which could negatively impact your ability to draw in or retain patients. m Accessibility: For both new and existing patients, accessibility is a huge factor. If your new office isn’t easily accessible or doesn’t have parking amenities, you risk
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alienating your client base. When you do open your doors again, you may find that not all of your patients were willing to make the move with you. The most effective way of avoiding a surprise relocation is to identify this clause in advance and negotiate it out of your dental office lease before you sign it. If it cannot be removed, often it can be redrafted in a way that is more favorable to the tenant.
Can’t Remove it? Improve it! The best defense is a good offense, and with a planned, strategic approach, the terms of your dental office lease often can be renegotiated. Consider some of these remedies to altering a relocation clause in your favor: m Landlord is Responsible for All Expenses: Negotiate the terms of the clause so that the landlord becomes responsible for all costs associated with the move, including marketing materials and stationery, moving expenses by trained dental movers, demolition, renovation and the build-out of the new space. Put the onus on the landlord to conform the space to your needs, not the other way around. m Rent Abatement: Ensure you will pay the same or comparable rent in the new location. m Comparable Location: Add language that will ensure the new premises will be comparable with the original space in terms of size, configuration, view and foot traffic. m Sufficient Notice: Demand a sufficient notice period in order to adequately
prepare your staff, patient roster, and build-out of the new space to avoid any practice downtime until the new location is ready. m Limit the Number of Relocations: Because landlords can exercise their right to relocate you indefinitely, negotiate the language so you can only be relocated once during your term. m Lease Termination Rights: Finally, try to negotiate your option to terminate the lease should the landlord relocate you to a less than adequate location.
Better Yet, Avoid the Problem Altogether Starting or buying a dental practice is always exciting, but before you break out the bubbly and sign your name on the dotted line, it’s imperative to conduct a thorough review of the details in your dental office lease. A dental office leasing professional can vet out any hard to spot risks, such as the relocation clause in the lease, and devise an appropriate lease negotiation strategy to improve the terms of your lease agreement before it’s too late. A strong lease can set you up for success by offering security and long-term practice location protection so that you can focus on practicing dentistry without having to worry about packing up your business down the line. Alain Sabbah can be reached at 800.459.3413 or asabbah@cirrusconsultinggroup.com. For a complimentary review of your dental office lease, visit www2.cirrusconsultinggroup.com/FDA.
September/October 2015
Today's FDA
37
benefit
Helping Members Succeed
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16
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Compleat Dentistry
Corporations and the Future of Dentistry By Dr. Edward Hopwood
“
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
I believe that the key to preserving the independent practice is to take advantage of the great parts of our profession that cannot scale to a large corporation.
”
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. There are a large number of corporate entities working their way into the private practice of dentistry. Many lecturers are arguing that a corporate takeover is inevitable. Often, the arguments for the inevitability of a corporate takeover seem to be at odds with each other. For example: It’s too expensive to get started in private practice and the profit margins are so attractive in dentistry, large amounts of private capital are flowing into these corporations. The corporations are able to offer improved efficiency to accommodate the PPO patient and the corporations are better able to train their staff for better customer service. The argument follows that we need to give up and go to work for a corporate master. The only alternative is to form a large group and try to compete with the corporations by becoming more efficient. There is no alternative, this is exactly what happened to the pharmacists and it will happen to us. At least, that is what some consultants would like us to believe. It also happened to the hardware stores and is currently happening to physicians. It also happened to restaurants … no, wait, it did not happen to restaurants. Let’s examine what happened to the Italian restaurants when a large chain — let’s call it Macaroni Garden — came to town. For the purposes of this article, pretend that Macaroni Garden is a large chain that serves huge portions of pasta and unlimited salads, has an honor system for wine and will refill your breadsticks whenever you want.
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Compleat Dentistry
Sure, when it first opened, there was a big line and a big buzz. Lots
future. We need to put forth the best product we can at the best
of small, independent Italian restaurants suffered. But then, the
price we can. I believe that the key to preserving the independent
truth began to seep out. How is the food at Macaroni Garden?
practice is to take advantage of the great parts of our profession
There’s lots of it. Is it any good? It’s served fast. How does it taste?
that cannot scale to a large corporation: taking our time with our
Free salad! You see, Macaroni Garden tries to provide an efficiency
patients, getting to know them, and performing our work as well
of scale and not quality.
as we can and to the best of our ability. These are the tenets of a comprehensive dental practice and they are the basis of preserving
So, which restaurants closed after the Macaroni Garden opened?
the dental profession’s future.
First to close were the poor quality, over-priced (as opposed to the most expensive) Italian restaurants that had been taking advantage
Think the restaurant analogy doesn’t work? Then let’s talk about the
of people for years. They never really cared about fine dining; they
shirt you are wearing – I bet you could have gotten it cheaper and
only cared about bilking unsuspecting and naïve customers out of
more efficiently at Wal-Mart. Suppose you had to attach that shirt to
their money. They should have lowered their prices years ago and
your body for the next 15 years … now, where would you buy that
improved their quality of service, but they did neither and their
shirt?
customers were only too happy to leave for a place with unlimited breadsticks.
Dr. Hopwood is a restorative dentist in Clearwater and can be reached at edwardhopwood@gmail.com.
Another group of restaurants tried to compete with Macaroni Garden — they increased their efficiency, tried to give refills on salad and attempted to mimic the corporate model. But it’s impossible to mimic that model entirely. For example, they couldn’t give away salads and breadsticks and wine. So they folded up. But a third group has thrived. That group worked hard to make the pasta and sauce on site in an efficient manner. They bought great ingredients and served them fresh. They served a meal that while it was technically Italian food, like Macaroni Garden, it really was in a different category. This is the restaurant we all have in our town where we love to go. In fact, there are many of them, and we all know them and love to find out about a new one. Some are expensive and we use them for our anniversary dinners and others are less expensive and we use them for our Friday nights out with our family. The point is, in this day and age, we do all we can to avoid the Macaroni Garden. The restaurant industry has weathered the storm and balanced back out. There is room for the chains and the independents. Dentistry can go the same way. The big key is that we need to be like the third group of restaurants if we hope to preserve our profession’s
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benefit
NUMBER
11
YOUR FDA SERVICES STAFF IS “HELPING MEMBERS SUCCEED” EVERYDAY!
PROFESSIONAL STAFF I HELP MEMBERS SUCCEED by assisting them with their insurance needs. I explain insurance in terms that are easily understood and act as a navigator through sometimes complex insurance processes. I hope that our members won’t hesitate to contact me for assistance with their insurance! — Debbie Lane
FDAS Assistant Membership Services Manager
QUESTIONS ABOUT INSURANCE? 800.877.7597 • 850.350.7157 • debbie.lane@fdaservices.com
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Disability Insurance
A Successful Disability Insurance Claim Begins with the Application for Benefits By Mindy Chmielarz
Applying for disability insurance benefits, as well as maintaining those benefits, requires an understanding of both the policy’s terms and the tactics, and review procedures implemented by different insurance companies throughout the duration of the disability claim. During the application process, many insureds are surprised to learn that having a significant medical condition and statements from their own physician(s) certifying disability are not considered sufficient proof of claim. Additionally, from the claim’s onset and throughout the ongoing evaluation process, adjusters often manipulate the information received by the insured and his/her doctor in an attempt to secure a claim denial or set the claim up for denial at some point in the future. Therefore, consulting with a knowledgeable and experienced attorney before applying for disability benefits can save hours of time, help to avoid unnecessary delays and greatly improve the chance that a claim for benefits will be approved
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and paid in a timely manner. The following case is typical of the delays and difficulties experienced by many of our clients who chose to apply for disability benefits before consulting an attorney. Dr. Green had back pain for the last few years, but continued working as a dentist, hoping that the pain would eventually diminish or resolve. Unfortunately, his pain continued to worsen and his daily office routine further aggravated the condition. Despite many months of conservative treatment, including medication, physical therapy and even trigger point injections, he found his ability to perform the duties of a dentist more and more difficult. Realizing his limitations made him a detriment not only to his own health but to that of his patients, he decided to stop working and apply for disability benefits. Dr. Green had the support of his treating physician and felt quite confident that his disability insurance carrier would review the medical records, understand the duties of his occupation and pay benefits in a timely manner. According to Dr. Green’s disability insurance policy, “Disability benefits will be paid if due to Sickness or Injury, the Insured is unable to perform the material and substantial duties of his Own Occupation.” Own occupation is defined as the insured’s occupation at the time of disability. Without first obtaining a clear understanding of his policy’s terms, conditions and requirements, Dr. Green contacted his disability insurance carrier. He was advised by the carrier that he needed to answer numerous questions over the phone prior to being sent a claim form. Like many of our clients, what Dr. Green did not realize was that the information conveyed during that initial phone call, as well as on the application itself, is an integral part of the claim and often used to delay payment or, where possible, deny the claim. Typically, the initial telephone call is used to “box” the insured into certain parameters and admissions; making it difficult for the insured to clarify or correct the adjusters understanding of what was communicated. Following the initial call, the claims representative made numerous follow-up calls to Dr. Green for “clarification” purposes and sent unending requests for medical, financial, personal and occupational information. After six months of nonstop demands for information — some of which was irrelevant and unnecessary — challenges to his claim and numerous phone calls by the carrier, Dr. Green contacted our firm. We were able to get his claim approved and secure his back benefits www.floridadental.org
Disability Insurance
within a couple of weeks. Had Dr. Green employed an experienced disability attorney from the beginning, he likely would have avoided many headaches and secured his benefits more quickly. While there are times when an insurance company will approve a claim without ongoing requests for information and/or lengthy delays, there is a great deal of financial incentive for these companies to delay, deny or even underpay a claim. As such, the majority of disability claims are highly scrutinized and challenged. Conveying what seems like basic information, i.e., the duties of a dentist, if not described with adequate detail can cause problems, as the claims analyst will simplify those duties and rely on his or her own assumptions. It also is vital to provide sufficient evidence that those duties were actually performed and confirm that the insured was a hands-on, practicing dentist at the time of disability. Many dentists have policies that include the payment of partial/residual disability benefits should the dentist be partially but not totally disabled. Partial benefits normally are payable when, due to illness or injury, a dentist can perform some but not all of his/her material duties, or can perform those material duties but for less time than they were performed before the disability. However, it is not unusual for an insurance company to pay a partial disability benefit when, in fact, the dentist is totally disabled and entitled to the full benefit. A dentist’s decision to remain affiliated with their practice and/ or manage the practice does not necessarily render them partially disabled. However, this distinction must be clearly conveyed to the insurer. As indicated, completing the application for disability insurance benefits is a confusing and time-consuming process. It also is the most important part of the claims process. Employing the assistance of an experienced attorney throughout the application, evaluation and claims process often results in saving both time and money. While there are disability consultants who are available to assist claimants during the application phase, they usually are not qualified to handle an underpayment situation or appeal a claim denial. More importantly, they do not tend to approach the claim in a manner that will ensure that it is prepared for litigation and/or filing a bad faith claim should a lawsuit be necessary. Involving an attorney who is familiar with the claims procedures of most disability carriers and has successfully procured benefits for numerous claimants lets the insurance company know that the insured will provide ample evidence of disability and hold the insurer accountable for the benefits payable under the disability policy. In practice, this also avoids a drawn out review process and results in the timely payment of the appropriate benefit amount. If you are considering applying for disability benefits, have already submitted an application for benefits or your claim for disability benefits has been denied, you should consider seeking advice from a disability attorney to ensure that you fully understand your rights and your insurance company’s obligations under the policy. Mindy Chmielarz, Esq., is a partner with Disability Insurance Law Group, a law firm that focuses on individual and group disability insurance claims and assists clients from the application process through litigation. For more information on the legal issues surrounding disability income policies, call 888.644.2644 or visit DI Law Group’s website at www.dilawgroup.com.
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It is not unusual for an insurance company to pay a partial disability benefit when, in fact, the dentist is totally disabled and entitled to the full benefit.
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Friendship
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Life is not always fun and games; you don’t know what kind of person you really are until difficulties arise.
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Friendship
Organized Dentistry ... Can Take You Places You Never Expected By Dr. Terry Buckenheimer
This is a story about friendship and how being involved in organized dentistry can take you places you never expected! Earlier in my career, I became great friends with Dr. Howard Bell. We had so much in common: we were both dentists, both active members at every level in the dental community and both about the same age. We served on the Florida Dental Association’s (FDA) councils, House of Delegates and were both involved as part of the Florida Dental Health Foundation’s (now the FDA Foundation) leadership. Howard was outgoing and people always knew when he was in the room — another trait we have in common. Early on, some of the best times we had together were at the American Dental Association’s (ADA) annual meetings. Howard would invite me and several other fellow members to accompany him to the social functions that occurred during the five nights of the meeting. At that time, he was an alternate delegate and I wasn’t even on the delegation yet. But we enjoyed meeting the people from all over the country to whom Howard introduced us. Little did I realize that his hospitable nature would strike a spark in me that continues to this day as the 17th District trustee. Howard was quite the dancer! At every social function, he would gyrate all over the dance floor and continue these questionably graceful moves until the very last song of the evening. We’d go to every dinner dance we could — the American College of Dentists, the International College of Dentists and the ADA President’s Ball. And in between, we would attempt to hit every reception and dinner to which we could get an invite. It’s no wonder that his hip finally gave out on him. These memories are from the early 1990s and our friendship continued to grow. But in 2010, Howard found himself battling Stage 4 cancer for the second time. The first was testicular cancer several years prior and he now has prostate cancer. This second episode hit him hard, especially the side effects from the treatment regimen. He ended up in the hospital for several months and became debilitated. Both his parents had recently passed and there were no relatives to help. He had to rely upon the friends that he had enjoyed over the years. When Howard could no longer practice, Drs. Rick Stevenson and Ted Hauessner helped by seeing some of Howard’s patients a few days a week to keep the doors open. But as his health declined, he had to give up the practice, his house, his car and his freedom. The three of us —
Please see FRIENDSHIP, 47
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Friendship
FRIENDSHIP from 45
Rick, Ted and I — along with his lifelong friend Ron Forsythe closed, his practice, sold his home and car, and arranged for him to stay at a nice long-term care facility. I know that I would have a difficult time being in such a facility at the early age of 58, but Howard was resilient, adaptive and persistent. Ron Forsythe became Howard’s health care surrogate and attained privileges as his power of attorney. He did a lot of work making arrangements for Howard’s insurances to cover his expenses. Luckily, Howard had acquired disability, health and long-term care insurance early in his career. His coverage was through FDA Services (FDAS) and we are all so grateful that Howard purchased these insurance policies early on and paid for them diligently over the years. We are grateful to Frank Lauria, Scott Ruthstrom, Carrie Millar and all the other talented people at FDAS. Howard would not be with us had it not been for them and the coverage they recommended. And now, I’ve been Howard’s power of attorney for a few years, along with his health care surrogate and administrator of his will. This transpired after Ron Forsythe passed away suddenly at an early age. Since Howard was like a brother to me, I didn’t mind being there for him at all. That’s what friends are for. I have the honor to be his
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representative, make health-related decisions, pay bills, keep insurance in place, keep his medications current and — most importantly — be his friend. Life is not always fun and games; you don’t know what kind of person you really are until difficulties arise. True character is shown by how you react at such difficult times. Howard has a lot of character, and at age 63, is still defying the odds just by living. In fact, he’s doing so well that he has to fight off the women at the assisted living facility every time he goes to the dining room. Life is still not easy for him. Gall bladder surgery is up next and a new hip is on the horizon. But Howard still makes me and others smile when we visit him in Jacksonville and our phone calls always end with a sense of appreciation for each other. So here are a few words of advice from this experience: n Enjoy your life, even during the bad times. There is always someone worse off than you, and your character is built by your reaction to those difficulties in life. n Enjoy your profession of dentistry as it allows you to make a comfortable living. It also provides you with a unique work environment, intimate interactions with patients and a platform for making the community around you a better place.
n Enjoy the fellowship of membership in the ADA, FDA and your local district and affiliate. You have a lot in common with your peers when you consider them friends and not competitors. n Buy appropriate insurance coverage early in your career and invest in “you” and your retirement. Use reputable and trustworthy individuals when you allow them to assist you with your insurance needs. FDAS is there to help you. Contact Scott Ruthstrom, Carrie Millar or your local representative at 800.877.7597 or insurance@fdaservices. com and seek their advice. n And finally, be a friend to someone! Put yourself out and be there for someone. It’s not as much of a burden as it seems to others. And the rewards are indescribable. Dr. Howard Bell and I will be friends for the rest of our lives. He gave me permission to use his name in this story in hopes that it may inspire others to do the same for their friend if the time arises. Photos: 1. Dr. Bell relaxing at home. 2. Dr. Buckenheimer and Dr. Stevenson help Dr. Bell decorate his Christmas tree. Dr. Buckenheimer is an FDA Past President and can be reached at tbuckenheimer@bot. floridadental.org.
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benefit
NUMBER
Helping Members Succeed The more that you read, the more things you will know. The more that you learn, the more places you’ll go. — Dr. Seuss, from “I Can Read With My Eyes Shut!”
BEYOND THE ! W E N
THE OFFICIAL BLOG OF THE FLORIDA DENTAL ASSOCIATION
Industry trends, tips to strengthen your practice, FDA programs, and more. Resources to support your professional growth and your practice’s success. Posts from FDA leadership and staff, your local dental leaders, and YOU! FOR MORE INFORMATION 800.877.9922 • jrunyan@floridadental.org
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Wheelchair Transfer
Wheelchair Transfer: A Health Care Provider’s Guide his chest. Place your arms under the patient’s upper arms and grasp his wrists. n Second clinician: Place both hands under the patient’s lower thighs. Initiate and lead the lift at a prearranged count (1-2-3-lift). n Both clinicians: Using your leg and arm muscles while bending your back as little as possible, gently lift the patient’s torso and legs at the same time. n Securely position the patient in the dental chair and replace the armrest.
The National Institute of Dental and Craniofacial Research
Six Steps to a Safe Wheelchair Transfer Some patients who use wheelchairs can transfer themselves into the dental chair, but others need assistance. The extent of your involvement will depend on the patient’s or caregiver’s ability to help. Most people can be transferred safely from wheelchair to dental chair and back by using the two-person method. The following outline describes a safe transfer with a minimum of apprehension for the patient and clinician. Practice these steps before doing an actual patient transfer.
STEP 1: Determine the Patient’s Needs n Ask the patient or caregiver about the: n preferred transfer method. n patient’s ability to help. n use of special padding or a device for collecting urine. n probability of spasms. n Reduce the patient’s anxiety by announcing each step of the transfer before it begins.
STEP 2: Prepare the Dental Operatory n Remove the dental chair armrest or move it out of the transfer area. n Relocate the hoses, foot controls, operatory light and bracket table from the transfer path. n Position the dental chair at the same height as the wheelchair or slightly lower.
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The Two-Person Transfer Fig. 1
STEP 3: Prepare the Wheelchair n Remove the footrests. n Position the wheelchair close to and parallel to the dental chair. n Lock the wheels in place and turn the front casters forward. n Remove the wheelchair armrest next to the dental chair. n Check for any special padding or equipment.
Fig. 2. First clinician stands behind the patient.
STEP 4: Perform the Two-person Transfer n Support the patient while detaching the safety belt. n Transfer any special padding or equipment from the wheelchair to the dental chair. n First clinician: Stand behind the patient. Help the patient cross his arms across
Fig. 3. Second clinician initiates the lift.
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Wheelchair Transfer
STEP 5: Position the Patient after the Transfer n Center the patient in the dental chair. n Reposition the special padding and safety belt as needed for the patient’s comfort. n If a urine-collecting device is used, straighten the tubing and place the bag below the level of the bladder.
n Reposition the patient in the wheelchair. n Attach the safety belt and check the tubing of the urine-collecting device, if there is one, and reposition the bag. n Replace the armrest and footrests. This information can make a difference in your efforts to provide oral health care for patients who use a wheelchair. A skilled and sensitive dental staff can instill confidence during the transfer and encourage the patient to maintain a regular appointment schedule.
Acknowledgments The National Institute of Dental and Craniofacial Research thanks the oral health professionals and caregivers who contributed their time and expertise to reviewing and pretesting the Practical Oral Care series.
Expert Review Panel Mae Chin, RDH, University of Washington, Seattle, WA Fig. 4
STEP 6: Transfer from the dental chair to the wheelchair n Position the wheelchair close to and parallel to the dental chair. n Lock the wheels in place, turn the casters forward and remove the armrest. n Raise the dental chair until it is slightly higher than the wheelchair and remove the armrest. n Transfer any special padding. n Transfer the patient using the two-person transfer (see step 4).
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Sanford J. Fenton, DDS, University of Texas, Houston, TX Ray Lyons, DDS, New Mexico Department of Health, Albuquerque, NM Christine Miller, RDH, University of the Pacific, San Francisco, CA Steven P. Perlman, DDS, Special Olympics Special Smiles, Lynn, MA David Tesini, DMD, Natick, MA
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Transferring to a lower level minimizes the amount of strength necessary during the lift.
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The National Institute of Dental and Craniofacial Research. (Last updated 2014, Aug. 1). Wheelchair Transfer: A Health Care Provider’s Guide. Retrieved Aug. 11, 2015 from http://1.usa.gov/1WT0S6Z.
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Familial Dysautonomia
Familial Dysautonomia Has Impact on Oral Health By FDA Staff
Familial dysautonomia (FD) is a genetic disorder that affects the development and survival of certain nerve cells. The disorder disturbs cells in the autonomic nervous system, which controls involuntary actions such as digestion, breathing, tear production, and the regulation of blood pressure and body temperature. It also affects the sensory nervous system, which controls activities related to the senses, such as taste and the perception of pain, heat and cold. FD also is called hereditary sensory and autonomic neuropathy type III. FD is associated with poor development, progressive degeneration and a high mortality rate. FD is seen almost exclusively in Ashkenazi (central or eastern European) Jews, where it affects approximately one in 3,700 people. Roughly one in 31 Ashkenazi Jews is a carrier of the disease. It is extremely rare in the general population. Problems related to this disorder first appear during infancy. Early signs and symptoms include poor muscle tone (hypotonia), feeding difficulties, poor growth, lack of tears, frequent lung infections and difficulty maintaining body temperature. Developmental milestones, such as walking and speech, are usually delayed, although some affected individuals show no signs of developmental delay. Additional signs and symptoms in school-aged children include bed wetting, episodes of vomiting, reduced sensitivity to temperature changes and pain, poor balance, scoliosis, poor bone quality and increased risk of bone fractures, and kidney and heart problems. Affected individuals also have poor regulation of blood pressure. They may experience a sharp drop in blood pressure upon standing (orthostatic hypotension), which can cause dizziness, blurred vision or fainting. They also can have episodes of high blood pressure when nervous or excited, or during vomiting incidents. About one-third of children with FD have learning disabilities, such as a short attention span, that require special education classes. By adulthood, affected individuals often have increasing difficulty with balance and walking unaided. Other problems that may appear in adolescence or early adulthood include lung damage due to repeated infections, impaired kidney function and worsening vision due to the shrinking size of optic nerves, which carry information from the eyes to the brain. Orofacial features include a tendency toward facial concavity in the child and convexity in the adult. There is increased salivation, and crowded teeth and malocclusion are characteristic. Dental disease prevention is extremely important for those affected. They may have dif-
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“
Dental disease prevention is extremely important for those affected. They may have difficulty holding/ using a toothbrush or floss, and require a prescription or modification for proper hygiene devices, e.g., a powered toothbrush and water pik.
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ficulty holding/using a toothbrush or floss, and require a prescription or modification for proper hygiene devices, e.g., a powered toothbrush and water pik. Children with FD will need a lot of parental oversight. If their sensation of hot and cold are diminished, they will not be as aware when something goes wrong in their mouths, so regular evaluation is important. Otherwise it does not seem they will need any treatment specific to their condition.
This disease claimed FDA Past President Dr. Bob Uchin’s grandson, Eric, in late August. Our thoughts and prayers are with him and his family for this tragic loss.
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5 FDA Services
Important Steps to Purchasing Disability Insurance
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We insure our homes, cars and boats, but fail to insure our biggest asset … our ability to earn a living. 7.
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By Rick D’Angelo FDA SERVICES DIRECTOR OF SALES – WEST COAST
As a dentist, your ability to earn an income is critical to your success, and this income could be at serious risk if you become disabled. Adding disability coverage to your insurance portfolio could mean the difference between financial security or financial hardship. Here are the five most important steps to consider when purchasing disability insurance.
Step 1: Purchase from the right person. How do you find the right insurance agent, especially when everyone keeps telling you their product is right for you? Use an independent agent (one that is not affiliated with just one carrier) who deals with multiple companies and will be able compare different providers, help differentiate plans and lead you to the best plan that fits your specific needs. Also, make sure that your agent has a local office and is trusted. You want to make sure they will be there to assist you throughout your career.
Step 2: Purchase the right type. With so many products on the market, how can you tell which is the right one? There are a few key factors to look for when picking a policy. 1. Group vs. Individual: Many dentists are offered group disability policies when they are in dental school or with other dentists in a group practice. While these plans offer a better alternative to not having coverage, they are inferior to individual, specialty specific disability insurance plans. Individual plans are completely portable and have a stronger definition of disability.
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FDA Services
2. Renewable and Non-cancellable Guarantee: This stipulation ensures that no one can cancel or non-renew your policy for any reason other than non-payment. This can be a problem with group disability policies — most group policies aren’t guaranteed and can be cancelled. 3. The Definition of Disability: This will determine if and how long your policy will pay you in the event of a disability. You need a policy that has the pure own-occupation definition with specialty language. Many policies have the own-occupation definition, but with modification, and leave out the specialty language.
Step 3: Purchase the correct amount. What is the right amount of disability insurance? This question changes with everyone’s specific financial needs, but in general, it is the maximum the carrier will allow you to purchase and your budget will allow. In most situations, if you cannot afford to purchase the maximum when you first graduate, it is important to purchase a Future Purchase/Increase Option rider.
Step 4: Make sure you buy the right policy and riders. There are many riders that can be added to a disability policy. The most important rider available is the Residual Disability option. More than 90 percent of all disability claims are residual. This means you’ll be able to return to work in your profession after being out on claim. This will help you financially while you are rebuilding your income. The second most important rider, especially for less seasoned professionals, is the Future Purchase/Increase Option. This allows you to increase your benefit each year without having to show proof of good health. As your income increases and your need for insurance increases, you only have to show that you qualify financially.
Step 5: Complete the underwriting process Applying is the most important part of the entire process. We all like to talk about getting the insurance, but never actually do it. Disability insurance only gets more expensive and is typically harder to qualify for as we get older. Once you fill out the application with your agent, it then will go into underwriting with the carrier. The underwriting process normally takes four to six weeks and will require a medical exam, often done at your office by a paramedical professional. If you are approved, your agent then will go over the terms of the policy one last time before you make your final purchase. Rick D’Angelo is the FDA Services (FDAS) Director of Sales – West Coast and has been with FDAS for more than 12 years. He specializes in complete insurance portfolio management for FDA member dentists and their practices. Rick can be reached at 800.877.7597 or rick. dangelo@fdaservices.com.
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RISK EXPERTS Dan Zottoli Director of Sales Atlantic Coast 561.791.7744 Cell: 561.601.5363 dan.zottoli@fdaservices.com
Dennis Head 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 Director of Sales South Florida 305.665.0455 Cell: 305.721.9196 joe.perretti@fdaservices.com
Rick D’Angelo Director of Sales West Coast 813.475.6948 Cell: 813.267.2572 rick.dangelo@fdaservices.com
About FDA Services Inc. FDA Services (FDAS) is the wholly owned, for-profit insurance agency of the Florida Dental Association. FDAS is a full-service insurance agency and takes pride in managing the insurance portfolios of each and every client. Last year alone, FDAS contributed more than $1,000,000 to the FDA to help reduce membership dues.
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Diagnostic
Diagnostic Discussion By Drs. Donald M. Cohen and Mohammed N. Islam
Fig. 1: Clinical photograph demonstrates a severe malocclusion in this patient.
Fig. 2: Clinical photograph demonstrating expansile destructive lesion of left maxilla causing superior displacement of the posterior segment.
Fig. 3: Clinical photograph demonstrates a lesion causing massive buccal expansion of the mandible and filling the entire mucobuccal fold area.
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A 25-year-old African-American male presented to Dr. Richard Carlin, an oral and maxillofacial surgeon who works in the Oslo Dental Department at Treasure Coast Community Health in Fellsmere, Fla. His chief complaint was pain and drainage from his lower jaw. Over the last two years, he’s been seen in several hospital emergency departments for jaw swelling and drainage. The patient was seen the month before at the Orange Park Health Science Center for recurrent or persistent swelling of his mandible and drainage from his chin. They noted significant misalignment of his lower incisor and canine teeth as well as the upper molar teeth (Fig. 1). A CT scan was ordered and it demonstrated an advanced and extensive osteolytic expansile lesion involving the body of the mandible with extension to the level of the bilateral molar teeth. The radiologist’s impression was suggestive of advanced dental caries versus benign or malignant odontogenic process. He also noted an extensive osteolytic lesion involving the left maxillary bone with extension into the left side of the hard palate. He specifically noted that the possibility of a malignant process could not be entirely ruled out. He recommended clinical correlation and an oral surgery follow-up. The patient was seen by a general dentist as an emergency walk-in for some crusting and swelling of his lower jaw about 10 days prior. The swelling had reached the size of a quarter and he punctured it with a safety pin. The general dentist referred the patient to see Dr. Carlin for possible mandibular and maxillary neoplasms. The patient’s medical history included bilateral cancer of his hips, which was treated in 2005 with both chemo and radiation therapy. He denies any paresthesia of the tongue or lips. Importantly, despite his complaints regarding the massive mandibular lesion, he has a more subtle second lesion involving the left posterior maxilla that is causing superior displacement of that maxillary segment (Fig. 2). The mandibular lesion extends from the left second molar to the right second molar, and there is significant tender fluctuant swelling and marked fullness in the mucobuccal fold area bilaterally (Fig. 3). Dr. Carlin ordered a Panorex X-ray, which revealed a multilocular expansile radiolucency extending from the left mandible to the right second molar and another radiolucency causing destruction
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Diagnostic of the left maxilla and extending well into the maxillary sinus (Fig. 4). Dr. Carlin’s initial impression was possible ameloblastoma of the maxilla and mandible and to rule out metastatic lesion from the hip. The treatment plan was to place the patient on antibiotics for his infection (Pen V-K 500 mg 1 q.i.d and metronidazole 500 mg 1 t.i.d), place a drain and do an incisional biopsy. The eventual plan was to refer the patient to a teaching center for resection and bone grafting once a diagnosis was rendered. An incisional biopsy was performed and the specimen was submitted to the University of Florida College of Dentistry Oral and Maxillofacial Pathology Laboratory in Gainesville, Fla. Two specimens were submitted, one measuring 2 x 1.5 x 0.3 cm as multiple soft tissue fragments, and multiple pieces of hard tissue measuring 0.9 x 0.5 x 0.4 cm in aggregate for decalcification. Examination of the soft tissue specimen revealed multiple sections composed of a loose inflamed fibrous tissue. The inflamed fibrous tissue contained a dense mixture of inflammatory cells. Most importantly, there were cells with irregular, large, hyperchromatic nuclei. Many of the cell nuclei had a kidney bean or rentiform appearance (Fig. 5). Importantly, admixed with these atypical cells were numerous eosinophils, lymphocytes, plasma cells and neutrophils. The bone lesion demonstrated granulation tissue and viable bone, both reactive and resorbing. Importantly, the granulation tissue contained the same type of dense, normal inflammatory infiltrate admixed with sheets of atypical cells, just as was seen in the soft tissue specimen.
Fig. 4: Panorex X-ray reveals a large expansile, destructive, multilocular radiolucency of the left mandible and a more subtle destructive lesion in the left maxilla. The maxillary lesion involves the maxillary sinus and causes obvious tooth displacement.
When the patient returned for the diagnosis a week later, the drain that was placed had been lost and there was copious pus in the area. At this point, there was slight mobility to bimanual manipulation of both of the involved segments of the mandible and maxilla. Impression was probable pathologic fracture of the mandibular symphysis and left posterior maxillary dental-alveolar segment.
Question: Based on the clinical, radiographic and microscopic features pictured/described above and the brief medical history, what is the most likely diagnosis? A. Ameloblastoma B. Langerhans Cell Histiocytosis C. Multiple Myeloma D. Osteomyelitis E. Keratocystic Odontogenic Tumor
Fig. 5: Higher power photomicrograph showing inflamed fibrous tissue containing a dense mixture of inflammatory cells. Most importantly, there were cells with irregular, large, hyperchromatic nuclei (yellow arrows). Admixed with these atypical cells were numerous eosinophils (red arrows), lymphocytes, plasma cells and neutrophils. (H & E stain original magnification 20 X.)
Please see DIAGNOSTIC, 58 www.floridadental.org
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Diagnostic
DIAGNOSTIC from 57
Diagnostic Discussion A. Ameloblastoma Incorrect, but a good guess. This also was our first impression when the biopsy was first submitted with the radiograph demonstrating a large multilocular radiolucency. However, once we read his history of bilateral hip cancers from 10 years before, and also the presence of a second maxillary destructive lesion, it made us think more of an entity that was characteristically multifocal and aggressive. Ameloblastomas are the most common clinically significant odontogenic tumor and definitely should be considered in the differential diagnosis whenever a large destructive expansile multilocular radiolucency of the jaw is encountered. Its relative frequency equals the combined frequency of all other odontogenic tumors, excluding odontoma. These lesions tend to be slowgrowing, locally invasive tumors that run a benign course in most cases. They usually occur in adults about this patient’s age and are strikingly more common in African Americans. Typically, these lesions present as a painless swelling or expansion of the jaw with the overwhelming majority (about 85 percent) occurring in the mandible. As in this case, ameloblastoma presents radiographically as a multilocular radiolucency with a “soap bubble” appearance. Cortical plate expansion frequently is present along with resorption of the roots of adjacent teeth. However, ameloblastomas are almost never multifocal as in this patient. B. Langerhans Cell Histiocytosis Correct! The two key factors are the presence of multiple destructive jaw lesions and
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a previous history of bilateral cancers in the hips in a relatively young person. The one disease that can explain all these features is Langerhans cell histiocytosis (LCH). Langerhans cell disease (Histiocytosis X) is a disorder involving dendritic histiocytic cells that predominately are located in the skin and originate from the bone marrow. Recent studies have demonstrated that LCH arises from the myeloid (bone marrow) dendritic cells, not those of the skin or mucosa. This disorder is characterized by single or multiple osteolytic bone lesions. The term eosinophilic granuloma is used to describe single lesions of the bone. LCH is a complex collection of disorders that are characterized as low risk (single system LCH) — low-risk multisystem disorder and high-risk multisystem disorder with risk organ involvement. Single system disorder patients do not have systemic symptoms such as fever and weight loss, and just as in the case of our patient, have unifocal or multifocal involvement of just one organ or system (usually bone). In fact, in 55 percent of those with single organ involvement, bone is the site of involvement. Single order involvement is the most common form of LCH accounting for over half of all cases. Our patient probably fits best in this disease category. While bone lesions are found in 77 percent of patients with all forms of LCH, bone lesions are rare in the acute disseminated form. Importantly, if the whole head and neck area is considered, approximately 70 percent of children with LCH will have manifestations of the disease. This is because of the high frequency of skull and ear lesions. The big divider in terms of high-risk and low-risk multisystem disease is involvement of key organs/systems.
The high-risk organs/systems are bone marrow, liver and/or spleen. Multisystem disease refers to two or more systems/organ involvement. Unless the high-risk systems are involved, these are considered low risk despite multisite involvement. Although initially thought to be a proliferative process of unknown etiology, recent studies have indicated that LCH is a clonal (neoplastic) proliferation. The majority of these patients (57-63 percent) have an oncogenic or cancer associated BRAF 600V mutation. This mutation also is found in ameloblastomas, especially those involving the mandible. The presence of this mutation may explain the predilection for both these tumors in the mandible. Interestingly, this disease occurs over a wide age range with patients being reported even in their 60s and 70s. The majority of patients are under the age of 10, and almost all of the multisystem presentations of LCH occur in this younger age group. The bone lesions in children most often involve the skull (40 percent) and rarely the oral cavity (13 percent). In adults however, 30 percent have jaw lesions and another 21 percent have skull lesions. The most common lesions in the oral cavity are “floating teeth,” gingivitis/periodontitis, unexplained mass or mucosal ulcers. Lesions most commonly involve the alveolar process, including both the teeth and gingiva. The boney destruction usually begins in the molar teeth and progresses anteriorly. Microscopic examination revealed sheets of large mononuclear cells with rentiform, rounded or grooved nuclei and abundant eosinophilic cytoplasm. Admixed with
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Diagnostic
these histiocyte-like cells are numerous eosinophils. Focal areas of necrosis also are noted. The gold standard for the diagnosis is electron microscopy and identification of Birbeck granules. However, most labs rely on a CD1a stain, which is almost specific for Langerhan cells and S-100 protein, which also has a strong, though nonspecific, affinity for these cells. Both stains were strongly positive in this case. The clinical course of Langerhans cell disease is quite varied depending on the age of the patient and stage of the disease. As in the present case, an initial response to the therapy does not indicate a cure. While not confirmed, we suspect the bilateral cancer in this patient’s hips was actually LCH, which has recurred 10 years after initial remission. Patients with multifocal disease often will respond to therapy initially, only to have subsequent recurrence at the same or distant site. We have observed a patient who had childhood LCH and then developed recurrence as eosinophilic granuloma during a pregnancy 29 years later. Therefore, long-term follow-up is recommended. Initial treatment involves risk stratification. At the time of diagnosis, patients are stratified on risk based on the extent of the disease and specifically if high-risk organs/ systems are involved. For single system disease, choice of therapy is based on site and number of lesions. Treatment may consist of a single agent, such as prednisone intralesional and/or systemic, prednisone combined with vinblastine and/or curettage of readily accessible bone lesions. Intra-lesional steroid injections have been recommended but do not appear to be effective in most cases. Our patient’s treatment may be complicated by the development of second-
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ary infection in his jaws. Smaller accessible bone lesions generally are treated with curettage +/- intralesional steroids or low dose radiation. Low-dose radiation also has been especially employed for solitary, less accessible bone lesions. Spontaneous regression does occur in some cases but the lesion can flare later following surgery, pregnancy, etc. If the patient only has bone lesions, the prognosis is much better; however, progression still can occur, especially if multiple bone lesions are present as was the case with this patient. C. Multiple Myeloma Incorrect, but a great guess (minus the biopsy results, of course!) as it is a lesion that often causes multiple destructive bone lesions. The most common malignant plasma cell tumor is multiple myeloma (MM), accounting for 10 percent of all hematological malignancies and having a prevalence of four cases per 100,000. If metastatic disease is excluded, it accounts for 50 percent of malignancies that involve bone. MM is considered a monoclonal proliferation of abnormal plasma cells in the bone marrow. It presents as a disseminated often multifocal malignancy and fits this clinical scenario fairly well. It may affect any bone, causing multiple osteolytic lesions with a characteristic “punched out” radiographic appearance. These lesions are especially common in the skull and spinal column but can occur up to 30 percent of the time in the jaws. Importantly, myeloma is much more common in African Americans. However, plasma cell neoplasms are diseases found in the elderly, and this patient is way too young for MM. MM most frequently is seen in patients between the age of 50 and 80, with a median age of 60-70. It rarely
presents before age 40, though one case in the mandible was reported in a 22-year-old patient. Bone pain is the most common and most characteristic presenting symptom, and the pain is similar to arthritic pain. Many patients present with pathologic fractures caused by tumor destruction of bone just as in this case. Symptoms of MM of the mandible include: presence of a mass or swelling; vague pain; tooth mobility and loss; and, unlike our patient — paresthesia or anesthesia of the alveolar nerve. Most importantly, MM is a fatal disease with a mean survival of two to three years, so it’s unlikely to have been the cause of his bilateral hip lesions treated in 2005. D. Osteomyelitis Incorrect — but an answer with some merit! In this case, the patient has a long standing destructive lesion of bone and a draining fistula in his neck as can occur with osteomyelitis. The lesion presents as a ragged, ill-defined radiolucency present in the mandible just as we would see with chronic osteomyelitis. There is a strong (75 percent) male predominance and with chronic osteomyelitis swelling, pain, sinus formation, purulent discharge or pathologic fracture may occur. Chronic osteomyelitis often is associated with acute exacerbations and decreased pain with chronic smoldering progression, a clinical scenario not unlike that of our patient. Differential diagnosis would include metastasis — another consideration in this patient. However, it would be unlikely to have a maxillary osteomyelitis in the absence of bisphosphonate therapy. Also, osteomyelitis would not explain the decade-old diagnosis of bilateral Please see DIAGNOSTIC, 61
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References:
hip cancers. Obviously, the histologic findings in this case also would preclude a diagnosis of osteomyelitis.
Braier J, Chantada G, Rosso D, Bernaldez P, Amaral D, Latella A, Balancini B, Masautis A, Goldberg J.: Langerhans cell histiocytosis: retrospective evaluation of 123 patients at a single institution. Pediatr Hematol Oncol. 1999 Sep-Oct; 16(5):377-85.
E. Keratocystic Odontogenic Tumor Incorrect. Keratocystic Odontogenic Tumors (KOTs) are seen in the 10-40 age groups and involve the mandible with a marked tendency to involve the body just as in this case. KOTs usually cause some bone expansion and present as well-defined radiolucencies with smooth and corticated margins. Similarly, large lesions of the mandible typically exhibit a multilocular “soap bubble” appearance. Also importantly, KOTs — especially those associated with the bifid rib or nevoid basal cell carcinoma syndrome — can be multifocal and involve both the mandible and maxilla just as in this case. However, KOTs usually are not as expansile as this lesion and tend to grow in a more anterior posterior direction with much less buccal-lingual expansion. KOTs obviously would have a different histology and would not involve extra gnathic locations, such as the hips.
benefit
NUMBER
16
ONLINE CE: THE EASY WAY
Broadbent V, Gadner H.: Current therapy for Langerhans cell histiocytosis.. Hematol Oncol Clin North Am. 1998 Apr; 12(2):327-38. De Graaf JH, Egeler RM.: New insights into the pathogenesis of Langerhans cell histiocytosis Curr Opin Pediatr. 1997 Feb; 9(1):46-50. Fazio N, Spaggiari L, Pelosi G, Presicci F, Preda L.: Langerhans’ cell histiocytosis. Lancet. 2005 Feb 12; 365(9459):598.
Dr. Bhattacharyya
Hartman KS.: Histiocytosis X: a review of 114 cases with oral involvement. Oral Surg Oral Med Oral Pathol. 1980; 49(1):38-54. Howarth DM, Gilchrist GS, Mullan BP, Wiseman GA, Edmonson JH, Schomberg PJ.: Langerhans cell histiocytosis: diagnosis, natural history, management, and outcome. Cancer. 1999 May 15; 85(10):2278-90. Ladisch S.: Langerhans cell histiocytosis. Curr Opin Hematol. 1998 Jan; 5(1):54-8. Mauro E, Fraulini C, Rigolin GM, Galeotti R, Spanedda R, Castoldi G: A case of disseminated Langerhans’ cell histiocytosis treated with thalidomide. Eur J Haematol. 2005 Feb; 74(2):1724.
Dr. Islam
McClain KL. Treatment, clinical manifestations, pathologic features and diagnosis of Langerhans Histiocytosis. www.Up to Date 2015 Willman CL, McClain KL.: An update on clonality, cytokines, and viral etiology in Langerhans cell histiocytosis. Hematol Oncol Clin North Am. 1998 Apr; 12(2):407-1.
Diagnostic Discussion is contributed by UFCD professors, Drs. Indraneel Bhattacharyya, Nadim Islam and Don Cohen, and provides insight and feedback on common, important, new and challenging oral diseases.
The dental professors operate a large, multi-state biopsy service. The column’s case studies originate from the more than 10,000 specimens the service receives every year from all over the United States. Clinicians are invited to submit cases from their own practices. Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter.
Drs. Bhattacharyya, Islam and Cohen can be reached at ibhattacharyya@ dental.ufl.edu, MIslam@dental.ufl. Dr. Cohen edu and dcohen@ dental.ufl.edu, respectively.
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Intellectual Disability
Practical Oral Care for People with an Intellectual Disability The National Institute of Dental and Craniofacial Research
Providing oral care to people with an intellectual disability requires adapting the skills you use every day. In fact, most people with a mild or moderate intellectual disability can be treated successfully in the general practice setting. This article will help you make a difference in the lives of people who need professional oral care. An intellectual disability is a disorder of mental and adaptive functioning, meaning that people who are affected are challenged by the skills they need to use in everyday life. An intellectual disability is not a disease or a mental illness; it is a developmental disability that varies in severity and usually is associated with physical problems. While one person with an intellectual disability may have slight difficulty thinking and communicating, another may face major challenges with basic self-care and physical mobility. Data indicate that people with an intellectual disability have more untreated caries and a higher prevalence of gingivitis and other periodontal diseases than the general population.
Health Challenges in Intellectual Disability and Strategies for Care Many people with an intellectual disabil-
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ity also have other conditions, such as cerebral palsy, seizure or psychiatric disorders, attention deficit/hyperactivity disorder, or problems with vision, communication and eating. Though language and communication problems are common in anyone with an intellectual disability, motor skills typically are more affected when a person has coexisting conditions. Before the appointment, obtain and review the patient’s medical history. Consulting with physicians, family and caregivers is essential to assembling an accurate medical history. Also, determine who can legally provide informed consent for treatment.
Mental Challenges People with an intellectual disability learn slowly and often with difficulty. Ordinary daily activities, such as brushing teeth and getting dressed, and understanding the behavior of others as well as their own, can all present challenges to a person with an intellectual disability. n Set the stage for a successful visit by involving the entire dental team — from the receptionist’s friendly greeting to the caring attitude of the dental assistant in the operatory. All should be aware of your patient’s mental challenges. n Reduce distractions in the operatory, such as unnecessary sights, sounds or other stimuli, to compensate for the short attention spans commonly observed in people with an intellectual disability. n Talk with the parent or caregiver to determine your patient’s intellectual and functional abilities, and then explain each procedure at a level the patient can understand. Allow extra time to explain oral health issues or instructions and demonstrate the instruments you will use. n Address your patient directly and with respect to establish a rapport. Even if the caregiver is in the room, direct all questions and comments to your patient. n Use simple, concrete instructions and repeat them often to compensate for any shortterm memory problems. Speak slowly and give only one direction at a time. n Be consistent in all aspects of oral care, since long-term memory is usually unaffected. Use the same staff and dental operatory each time to help sustain familiarity. The more consistency you provide for your patients, the more likely they will cooperate. n Listen actively, since communicating clearly often is difficult for people with an intellectual disability. Show your patient whether you understand. Be sensitive to the methods he or she uses to communicate, including gestures and verbal or nonverbal requests.
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Behavioral Challenges While most people with an intellectual disability do not pose significant behavioral problems that complicate oral care, anxiety about dental treatment occurs frequently. People unfamiliar with a dental office and its equipment and instruments may exhibit fear. Some react to fear with uncooperative behavior, such as crying, wiggling, kicking, aggressive language or anything that will help them avoid treatment. You can make oral health care a better experience by comforting your patients and acknowledging their anxiety. n Talk to the caregiver or physician about techniques they have found to be effective in managing the patient’s behavior. n Schedule patients with an intellectual disability early in the day if possible. Early appointments can help ensure that everyone is alert and attentive, and that waiting time is reduced. n Keep appointments short and postpone difficult procedures until after your patient is familiar with you and your staff.
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n Allow extra time for your patients to get comfortable with you, your office and the entire oral health care team. Invite patients and their families to visit your office before beginning treatment. n Permit the parents or caregiver to come into the treatment setting to provide familiarity, help with communication and offer a calming influence by holding your patient’s hand during treatment. Some patients’ behavior may improve if they bring comfort items such as a stuffed animal or blanket. Please see INTELLECTUAL, 66
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Record strategies that were successful in providing care in the patient’s chart. Note your patient’s preferences and other unique details that will facilitate treatment, such as music, comfort items and flavor choices. INTELLECTUAL from 65
n Reward cooperative behavior with compliments throughout the appointment. n Consider nitrous oxide/oxygen sedation to reduce anxiety and fear and improve cooperation. Obtain informed consent from the legal guardian before administering any kind of sedation. n Use immobilization techniques only when absolutely necessary to protect the patient and staff during dental treatment — not as a convenience. There are no universal guidelines on immobilization that apply to all treatment settings. Before employing any kind of immobilization, it may help to consult available guidelines on federally funded care, your state department of mental health/disabilities and your state’s Dental Practice Act. Guidelines on behavior management published by the American Academy of Pediatric Dentistry (http:// www.aapd.org/) also may be useful. Obtain consent from your patient’s legal guardian and choose the least restrictive technique that allows you to safely provide care. Immobilization should not cause physical injury or undue discomfort.
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People with an intellectual disability often engage in perseveration, a continuous, meaningless repetition of words, phrases or movements. Your patient may mimic the sound of the suction, for example, or repeat an instruction over and again. Avoid demonstrating dental equipment if it triggers perseveration, and note this in the patient’s record.
Physical Challenges An intellectual disability does not always include a specific physical trait, although many people have distinguishing features, such as orofacial abnormalities, scoliosis, unsteady gait or hypotonia due to coexisting conditions. Countering physical challenges requires attention to detail. n Maintain clear paths for movement throughout the treatment setting. Keep instruments and equipment out of the patient’s way. n Place and maintain your patient in the center of the dental chair to minimize the risk of injury. Placing pillows on both sides of the patient can provide stability. n If you need to transfer your patient from a wheelchair to the dental chair, ask the patient or caregiver about special preferences, such as padding, pillows or other things you can provide to ease the transition. The patient or caregiver often can explain how to make a smooth transfer. n Some patients cannot be moved into the dental chair, but instead must be treated in their wheelchairs. Some wheelchairs recline or are specially molded to fit people’s bodies. Lock the wheels, then slip a sliding board (also called a transfer board) behind the patient’s back to provide support for the head and neck during care. Cerebral Palsy occurs in one-fourth of those who have an intellectual disability and tends to affect motor skills more than cognitive skills. Uncontrolled body movements and reflexes associated with cerebral palsy can make it difficult to provide care. n Place and maintain your patient in the center of the dental chair. Do not force arms and legs into unnatural positions, but allow your patient to settle into a position that is comfortable and will not interfere with dental treatment. n Observe your patient’s movements and look for patterns to help you anticipate direction and intensity. Trying to stop these movements may only intensify the involuntary response. Try instead to anticipate the movements, blending your movements with those of your patient or working around them. n Softly cradle your patient’s head during treatment. Be gentle and slow if you need to turn the patient’s head. n Help minimize the gag reflex by placing your patient’s chin in a neutral or downward position. n Stay alert and work efficiently in short appointments. n Exert gentle but firm pressure on your patient’s arm or leg if it begins to shake.
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Intellectual Disability
n Take frequent breaks or consider prescribing muscle relaxants when long procedures are needed. People with cerebral palsy may need sedation, general anesthesia or hospitalization if extensive dental treatment is required. Cardiovascular anomalies, such as heart murmurs and damaged heart valves frequently occur in people with an intellectual disability, especially those with Down syndrome or multiple disabilities. Consult the patient’s physician to determine if antibiotic prophylaxis (http://www.heart.org/) is necessary for dental treatment. Seizures are common in this population, but usually can be controlled with anticonvulsant medications. The mouth is always at risk during a seizure: Patients may chip teeth or bite the tongue or cheeks. Persons with controlled seizure disorders easily can be treated in the general dental office. n Consult your patient’s physician. Record information in the chart about the frequency of seizures and the medications used to control them. Determine before the appointment whether medications have been taken as directed. Know and avoid any factors that trigger your patient’s seizures. n Be prepared to manage a seizure. If one occurs during oral care, remove any instruments from the mouth and clear the area around the dental chair. Attaching dental floss to rubber dam clamps and mouth props when treatment begins can help you remove them quickly. Do not attempt to insert any objects between the teeth during a seizure. n Stay with your patient, turn him or her to one side and monitor the airway to reduce the risk of aspiration. Visual impairments, most commonly strabismus (crossed or misaligned eyes) and refractive errors, can be managed with careful planning. n Determine the level of assistance your patient requires to move safely through the dental office. n Use your patients’ other senses to connect with them, establish trust and make treatment a good experience. Tactile feedback, such as a warm handshake, can make your patients feel comfortable. n Face your patients when you speak and keep them apprised of each upcoming step, especially when water will be used. Rely on clear, descriptive language to explain procedures and demonstrate how equipment might feel and sound. Provide written instructions in large print (16 point or larger). Hearing loss and deafness also can be accommodated with careful planning. Patients with a hearing problem may appear to be stubborn because of their seeming lack of response to a request. n Patients may want to adjust their hearing aids or turn them off, since the sound of some instruments may cause auditory discomfort.
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n If your patient reads lips, speak in a normal cadence and tone. If your patient uses a form of sign language, ask the interpreter to come to the appointment. Speak with this person in advance to discuss dental terms and your patient’s needs. n Visual feedback is helpful. Maintain eye contact with your patient. Before talking, eliminate background noise (turn off the radio and the suction). Sometimes people with a hearing loss simply need you to speak clearly in a slightly louder voice than normal. Remember to remove your facemask first or wear a clear face shield.
Ackowledgments The National Institute of Dental and Craniofacial Research thanks the oral health professionals and caregivers who contributed their time and expertise to reviewing and pretesting the Practical Oral Care series.
Expert Review Panel Mae Chin, RDH, University of Washington, Seattle, WA Sanford J. Fenton, DDS, University of Texas, Houston, TX Ray Lyons, DDS, New Mexico Department of Health, Albuquerque, NM Christine Miller, RDH, University of the Pacific, San Francisco, CA Steven P. Perlman, DDS, Special Olympics Special Smiles, Lynn, MA David Tesini, DMD, Natick, MA The National Institute of Dental and Craniofacial Research. (Last updated 2014, Nov. 3). Practical Oral Care for People with an Intellectual Disability. Retrieved Aug. 11, 2015 from http://1.usa.gov/1dXR35X.
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Embracing Variety: Helping Our Patients with Special Needs Do Better in the Dental Chair By Paige Anderson, RDH
If I’m being completely honest with myself, when I hear I will be seeing a special needs patient, my reaction generally ranges somewhere between perturbation and anxiety. My mind immediately jumps to the patient’s potential limitations: What won’t they be able to do, and how much extra time will they need? This was the case when I was told this past spring that I would be seeing an adult male with Down syndrome. We’ll call him Jay. I started mentally preparing for what I wouldn’t be able to accomplish with this patient, and from there, it was not a huge leap to compromising before I had even met the man. “Well,” I thought, “I’ll just do what I can.” Jay came for his new patient exam, which was supposed to entail full mouth X-rays, perio chart, photos, comprehensive exam, prophy and fluoride. I was nervous; Jay was not. He rolled into the office full of smiles and high fives, and let everyone know immediately how happy he was to be there — and how eager he was to get some cute www.floridadental.org
assistants’ phone numbers before he left. Building a rapport with Jay was much easier than I could have hoped. His comprehension was slightly limited, but he followed all of my questions and home care instructions with just a little adjustment in vocabulary. When the time came for X-rays, it was obvious that the patient’s limited control over his lips and cheeks, coupled with an oversized tongue and compromised dentition (he had more root tips than intact molars) would make our usual full mouth series an unreasonable expectation. However, working with Jay to position the sensor and Rinn as comfortably as possible, we were able to take diagnostic bitewings and even a few key periapical shots. Jay invented his own modifications for the six photographs we take for every new patient, and although none of the images were what one would call ideal, they were pretty good considering what I had envisioned we might get.
“
Sometimes it’s not just a patient’s physical limitations that restrict our practice with them. Sometimes, the patient’s assumptions about what they cannot do, as well as our temerity when dealing with a special needs patient, can be equally disruptive.
”
Then it came time for the cleaning. Jay launched into a list of what he didn’t like and wouldn’t allow during a cleaning. He had difficulty with the water, he told me, but I could use air if I needed to. Also, he didn’t like the “needles” we use to scrape, and he also didn’t like the suction. I excused myself to the waiting room, where Jay’s mother was waiting. Please see VARIETY, 70
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I asked what sort of cleanings Jay had been getting at their previous office, and told her all the caveats Jay had given me. I explained that I wanted to provide a therapeutic hygiene treatment, but didn’t want to make her son unnecessarily uncomfortable. She laughed. “Don’t let him browbeat you,” she said.
room with a refreshed attitude and new view of Jay. I explained what we would be doing, and cleaned his teeth just like any other patient with very little in the way of adjusting my practice. By the end, Jay was saying how much he loved the Cavitron, how fun he thought it was to spit into the suction, and once I explained that I don’t use any “needles,” I just use scalers, he was fine with that, too.
Jay had been told his whole life what he couldn’t do, and accommodations were always made at his slightest resistance. He had grown up assuming that his condition made him somehow less able to complete the normal routine. I went back into the
Working with Jay taught me a valuable lesson: Sometimes it’s not just a patient’s physical limitations that restrict our practice with them. Sometimes, the patient’s assumptions about what they cannot do, as well as our temerity when dealing with
VARIETY from 69
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a special needs patient, can be equally disruptive. In both cases, these assumptions should be challenged, and I believe they can be overcome in nearly every case. While we always should take into account what is special about the needs of certain patients, we also should try to adopt an affirming attitude and focus on how we can work with each patient to show them — and ourselves — that good dental care is always possible. Ms. Anderson is a dental hygienst and can be reached at rdhwriterpaige@gmail.com.
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September/October 2015
ANNOUNCING: Oral & IV Emergency Sedation Seminar. Sedation Ready is offering a unique training program that provides your dental team with the tools to handle medical emergencies during oral or IV sedation that may arise in your office. The 9 CE credit ADA-approved course provides lecture/ hands on emergency scenarios with SIM-LAB technology to exclusively train you and your dental team. To book a training near you visit: http://www.sedationready.com/booking]http:// www.sedationready.com/booking. ENDODONTIST – TAMPA BAY AREA. Quality associate needed for busy, modern endodontic office. New graduates encouraged to apply. Send CV to julieh@aeoftb.com. General Dentist and Specialist Openings for Multiple Offices in South and Central Florida. General Dentists and Specialists. Grow with us: Large intimate group practice seeks experienced, highly-productive General Dentists and Specialists for busy growing general and multi-specialty practices. Sage Dental Group operates 34 large, well-established practices in Broward, Palm Beach, Dade, and the Treasure Coast with new practices starting to open in the Orlando Market. Our beautiful and modern facilities are in premium locations and state-of-theart equipment and digital X-rays with a supportive staff and professional management team. Cash, private, and insurance. Highest compensation in industry. Full schedules, excellent benefits, malpractice insurance reimbursement, and CE. http:// www.Mysagedental.com. Call Bradford Cabibi, Doctor Recruiter: 561.999.9650 ext. 6146. Fax or email CV to: 561.526.2576 or bcabibi@gentledentalgroup.com. General Dentist. Dynamic Dental Health Associates of FL and Dynamic Dental Partners Group (DDPG), a new private fee-for service group, is growing and expanding rapidly. Top Compensation, daily guarantee, health insurance, modern facilities with latest technology, great patient flow, no administrative headaches and professional mgmt. We also buy dental practices and create exit/transition strategies for solo and group practices. If interested in selling your practice, please email Marvin Terrell (President/COO) at MTerrell@ddpgroups.com. If interested in a General Dentist position, please email your CV to Jeff Hokamp at jhokamp@ddpgroups.com or call 941.312.7838. Current openings in Gainesville, Jacksonville and St. Petersburg. We are offering a $5,000 signing bonus ($2,500 at start and $2,500 after 6 months) for the full time positions. Please don’t hesitate to send your CV if interested in other areas in FL. FLORIDA – Orlando/Daytona Beach/Jacksonville/Tampa/ Sarasota regions: Join our 60 office group practice. Flexible schedule. Top salaries. Training and mentoring for new/recent graduates. Both General Dentists & all Specialists needed. Fully digital offices. Call Dr. Andrew Greenberg 407.772.5120 (confidential), fax CV to 407.786.8763, visit www.greenbergdental. com or email to drgreenberg@greenbergdental.com. You must look into this Opportunity! It’s one of a kind!! By way of introduction, my name is Dr. Anish Patel, and I practice in Panama City, FL. I am creating a great opportunity for someone who wants to treat people. I will handle the marketing, new patient generating and management hassle. We offer great income potential and great working conditions. I think we have it all, please email us at 10Xdoctor@gmail.com for more information. P.S. If you are the first to refer someone who I hire, I will gladly pay you a $1000.00 finder’s fee, please email 10Xdoctor@gmail. com or fax 850.763.0087; your name, your email address, prospective Doctor Name and Prospective Doctor Phone number. General Dentist Opportunity in Tampa, FL. Coast Dental has an opportunity for a General Dentist in our Tampa, Florida practice. We take care of the administrative burden so you can focus on the dentistry. Sound familiar? Yes, we do that (and do it well), but so does every other group practice. So what else? Here are just few things that separate us from the competition: real clinical autonomy (from implants to invisible braces), private practice environment (most practices have one general dentist, meaning ‘your’ patients, ‘your’ diagnosing, and ‘your’ treatment), favorable schedules (8-12 patients/day) giving you time to build a connection with your patients, agreements that are easy to understand and fair, extremely desirable locations, and a path to equity ownership, to name a few. nina.voelker@coastdental.com.
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General Dentist Opportunity in Orlando, FL. Coast Dental has an opportunity for a General Dentist in our Orlando, Florida practice. We take care of the administrative burden so you can focus on the dentistry. Sound familiar? Yes, we do that (and do it well), but so does every other group practice. So what else? Here are just few things that separate us from the competition: real clinical autonomy (from implants to invisible braces), private practice environment (most practices have one general dentist, meaning ‘your’ patients, ‘your’ diagnosing, and ‘your’ treatment), favorable schedules (8-12 patients/day) giving you time to build a connection with your patients, agreements that are easy to understand and fair, extremely desirable locations, and a path to equity ownership, to name a few. nina.voelker@coastdental.com General Dentist Opening – Jensen Beach and Port St. Lucie. Come join our team! Great Expressions Dental Centers has a current opening for a full-time General Dentist to work in both our established Port St. Lucie and Jensen Beach, FL office(s) in a split role (on a consistent schedule). Our dentists can expect unlimited production based earnings with high earning potential, full benefits (such as medical, dental, 401k, continuing education), malpractice coverage assistance. **Please watch more about our Doctor Career Path (http://www.screencast.com/t/M3xWM5CYN) and apply via this ad to join our team! Ross Shoemaker, MBA | Lead Clinical Recruiter | Great Expressions Dental Centers Practice Support Center - South | 1560 Oakbrook Drive, Norcross, GA 30093 USA phone 678.836.2226 | ext. 72226 | fax 770.242.3251 | http://www.greatexpressions.com. “Look for the Smile Above Our Name!” Apply Here: http://www.Click2Apply.net/fc2dwgkhj9. Pediatric Dentist Opening – Miami. Come join our team in Miami! Great Expressions Dental Centers has a current opening for a part-time Pediatric Dentist to join our Miami, FL practice. Our Specialists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. **Please watch more about our Doctor Career Path (http://www. screencast.com/t/M3xWM5CYN) and apply via this ad to join our team! “Look for the Smile Above Our Name!” Apply Here: http:// www.Click2Apply.net/97k7tqgzgn. Pediatric Dentist Full Time Role: Fort Myers. Come join our Page Field (Fort Myers) office! Great Expressions Dental Centers has a current opening for a full time (4 days/week) Pediatric Dentist in our newly renovated and multi-specialty, Page Field office in Fort Myers, FL. Our Specialists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. Dentists can expect unlimited production based earnings vs. six figure base; with a large, internal referring network of General Dentists; full benefits (such as medical, dental, 401k, continuing education); paid time off; malpractice coverage; a stable patient base with full office staff in place; and long-term practice or regional career growth with possible investment opportunity. Relocation or sign-on bonus possible as well! **Please watch more about our Doctor Career Path (http://www.screencast.com/t/ M3xWM5CYN) and apply via this ad to join our team! “Look for the Smile Above Our Name!” Apply Here: http://www.Click2Apply. net/s569ssgtqj. GENERAL DENTIST. Florida Community Health Centers with multiple sites surrounding the Lake Okeechobee has an excellent opportunity for a GENERAL DENTIST to join our team in Fort Pierce & Okeechobee, FL locations. Both practices are 60-80% Pediatrics, the candidate must be experienced and comfortable working with children and adults. Current licensure in the State of Florida required. Competitive salary & excellent benefits. Possible NHSC loan repayment opportunity. Fax CV to Human Resources at 561.844.1013 or email jobs@fchcinc.org EOE/DFWP. General Dentist – Tampa, FL. Great Expressions Dental Centers has a current opening for a full-time General Dentist to join our Tampa, FL practice. Our dentists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. When considering a career with GEDC, Dentists can expect unlimited production based earnings, full benefits, malpractice coverage, a stable patient base, and longterm practice or regional career growth. Apply Here: http://www. Click2Apply.net/cxk35pshwh.
General Dentist – Jacksonville, FL. Great Expressions Dental Centers has a current opening for a full-time (5 days/week) General Dentist to join one of our Jacksonville, FL practices. Our dentists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. We do it all for you. You became a dentist to help people. It’s your profession and your passion. But the demands of owning and managing an office are not only financially taxing but time consuming. Must have a DDS/DMD from an accredited University and active State Dental Board license. Apply Here: http://www. Click2Apply.net/r9j6f2m5hs.
Kool Smiles – Associate Dentists Needed in Louisiana. KOOL SMILES has Associate Dentist FT/ PT/Multi-Site opportunities in LOUISIANA. UP TO $70,000.00 SIGN-ON BONUS + RELOCATION!!! EARN UP TO $650/DAY GUARANTEE OR A % OF COLLECTIONS!!! We are the nation’s leader in general dental care to under-served kids, teens, and adults. Currently, Kool Smiles has openings in New Orleans, Lafayette, Lake Charles, Monroe, and Shreveport. For more information, contact Renee at rbaron@benevis.com!
General Dentist – Tampa, FL. Great Expressions Dental Centers has a current opening for a full-time General Dentist to join one of our Tampa, FL practices. Our dentists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. When considering a career with GEDC, Dentists can expect unlimited production based earnings, full benefits (such as medical, dental, 401k, continuing education) malpractice coverage, a stable patient base, and long-term practice or regional career growth. **Please watch more about our Doctor Career Path (http://www.screencast.com/t/M3xWM5CYN) and apply via this ad to join our team! **Relocation or sign-on bonus possible as well! Job Requirements: Must have a DDS/DMD from an accredited University and active State Dental Board license. Apply Here: http://www.Click2Apply.net/m6q5tfjc73.
Oral Surgery opening w/ multi-specialty group! Christie Dental is a multi-specialty dental group with approximately 55 dentists and specialty doctors in nearly 20 practice locations in the Brevard and Ocala Florida area. Christie Dental offers individuals and families a full range of dental care, including general dentistry, hygiene and specialty care, such as pedodontics, oral surgery, endodontics, orthodontics and periodontics. We currently have a wonderful opportunity for an Oral Surgeon to join our team in the Space Coast area, on a full or part-time basis. This is an opportunity which provides a high number of referrals from inside and outside the Christie Dental group. We offer a comprehensive compensation and benefits package which includes medical, life, disability and professional liability insurances, flexible spending and 401(K) with employer match! pschwartz@amdpi.com.
General Dentist. Beautiful, upscale office in Jupiter/Port St. Lucie area seeking a long term associateship/partnership option with someone who is passionate about providing excellent care and has the ability to relate to each and every patient. Please email smilesofboca@aol.com or call 561.632.6332. Clinical Assistant/Associate Professor. The University of Florida College of Dentistry is seeking applications for two full-time clinical track faculty positions in the Department of Restorative Dental Sciences, Division of Operative Dentistry at the Assistant/ Associate Professor rank. Responsibilities include didactic/ preclinical/clinical instruction, participation in intramural private practice, excellence in academic pursuits/service, and limited participation in the development of research and/or scholarly activities. Applicant should be comfortable in providing clinical coverage in all aspects of general dentistry. Minimum requirements: DDS/DMD, or equivalent foreign dental degree. Post-graduate training, teaching experience, and/or private practice experience is desirable. To apply, go to http://jobs.ufl.edu/ and search for job number 492503. General Dentist. Private practice in Sun City Center/Ruskin needs Florida licensed full time General Dentist to cover Dentist going on maternity leave from September to December 2015 with opportunity for permanent placement. This qualified Dentist should have strength in endodontic and restorative dentistry, excellent communication skills with a comprehensive approach to patient care. We have a beautiful, modern, digital office with a wonderful patient population and a very enthusiastic team. deep106@aol.com Endodontist -Multispecialty Group, Ocala, FL. Christie Dental is a multi-specialty dental group with approximately 55 dentists and specialty doctors in nearly 20 practice locations in the Brevard and Ocala Florida area. Christie Dental offers individuals and families a full range of dental care, including general dentistry, hygiene and specialty care, such as pedodontics, oral surgery, endodontics, orthodontics and periodontics. We currently have a part time opportunity for an Endodontist to join our team in the Ocala, FL one day per week. This is a great opportunity to supplement your schedule with proven patient demand & referrals with future growth potential. Christie Dental is primarily a fee-for-service and PPO provider. Contact Kate Anderson: kateanderson@amdpi.com or 781.213.3312.
Endodontist. Microscope equipped private Boca Raton office, seeking endodontist. Please contact 561.997.0061 or 561.212.0960.
General Dentists and Specialists. A blockbuster opportunity. Full or part time for General Dentists, Endodontists, Orthodontists, Pedodontists, Periodontists, and Oral Surgeons. Generous compensation with unlimited potential. Guaranteed referrals. Join our group specialty care practice with a significant general dental component. Established in 1975 in Aventura, Coral Springs, Delray Beach, Boynton Beach, Stuart, Ft. Pierce and Melbourne. Call: Kelly Oliver 954.461.0172. Fax resume to: 954.678.9539. Email: careers@dentaland.net. BENEVIS – Associate Dentist Opportunities NATIONWIDE! Benevis is seeking Associate Dentists for our client practices throughout the US! Benevis provides non-clinical practice services including dentist recruitment for private practices, as well as some of the nation’s largest dental organizations. Our clients offer generous compensation, sign-on bonus up to $70,000, paid relocation, sponsorships, CE reimbursement, 401(K) and other benefits. Contact us today about openings NATIONWIDE – jobs@ benevis.com! Kool Smiles – Associate Dentist Opps in 16 States! Associate Dentists Full Time, Part Time, and Multi-Site opportunities. UP TO $70,000.00 SIGN-ON BONUS + RELOCATION!!! EARN UP TO $650 DAILY GUARANTEE OR % OF COLLECTIONS!!! At Kool Smiles, our dentists don’t just shape smiles — they shape the lives of families every single day. We are the nation’s leader in general dental care to under-served kids, teens, and adults. Our compassion and drive make us the best at what we do every day. Currently, Kool Smiles is operating in over 125 locations in AR, AZ, CT, DC, GA, IN, KY, LA, MA, MD, MS, NM, OK, SC, TX, VA. This is the time to join not just an amazing company, but a place where you will be a part of making smiles happen every day! You are just one step away from earning a great living and doing something greater! At Kool Smiles we offer: Generous compensation; Earn up to $650 daily guarantee or % of collections; 401(K) with company match; Outstanding benefits, including paid time off, malpractice insurance, health insurance, life insurance, continuing education, licensing reimbursements and Visa and permanent residency sponsorship; Excellent training, education and advancement opportunities; No practice management expenses and headaches— we take care of it! Kool Smiles Dentists find inspiration, challenge, and reward every day at their job. Do you? Contact one of our recruiters today at http://www. koolsmilesjobs.com/connect!
Benevis – Associate Dentists Needed in Louisiana. Benevis provides dentist recruitment for private practices and some of the nation’s largest dental organizations. Our clients offer generous compensation, continuing education reimbursement and benefits, including 401K and paid time off. Many of our clients also offer a sign-on bonus up to $70,000, paid relocation assistance and Visa/ permanent residency sponsorship. For more information contact Renee Baron today at rbaron@benevis.com!
Please see CLASSIFIEDS, 74
www.floridadental.org
September/October 2015
Today's FDA
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Your Classified Ad Reaches 7,000 Readers!
CLASSIFIEDS from 73 Kool Smiles – Dental Specialists Needed! Kool Smiles has Oral Surgeon, Pedodontist, Orthodontist, and Dental/ Medical Anesthesiologist Full Time and Part Time opportunities available in AR, AZ, CT, DC, IN, KY, LA, MA, MD, MS, OK, SC, TX, & VA! At Kool Smiles, our dentists don’t just shape smiles — they shape the lives of families every single day. We are the nation’s leader in general dental care to under-served kids, teens, and adults. Our compassion and drive make us the best at what we do every day. At Kool Smiles we offer: Generous compensation; 401(K) with company match; Outstanding benefits, including paid time off, malpractice, health, & life insurance, continuing education, licensing reimbursements and Visa/permanent residency sponsorship; Excellent training, education and advancement opportunities; No practice management expenses and headaches — we take care of it! Kool Smiles Dentists find inspiration, challenge, and reward every day at their job. Do you? For more information contact Emily Platto at eplatto@benevis.com! Full Time Associate, Venice. Full time Dentist Associate position available in Venice, Florida. Three doctor high tech practice with great patients and staff. Prefer GPR or 5 years’ experience. Comp projection high 200’s plus benefits. Call Tom at 941.488.1075 or email to: tom@venicedentist.com. Associate Dentists. We are seeking a high energy, highly motivated associate dentist to work with an established dentist relocating to Venice, Florida. The practice is currently a one doctor practice and is expanding to add a second doctor. Ideal candidates will have the desire to train and be mentored in advanced areas of dental care such as endo, oral surgery and implant dentistry. Ownership potential will be based on candidate performance. If you want to change people’s lives through the profession of dentistry, while living in a place that people dream of living in, contact us today! To associate with a Doctor that is relocating to the area. drpaul@ doorcountydentistry.com. DENTIST. General Dentist F/T or P/T Busy offices Palm Beach County. Excellent financial opportunity. Complete lab on premises. Per diem guaranteed plus commission. Email zufi@ comcast.net. Fax 561.738.2116. Dental Associate needed. Need an Associate for a busy Florida East Coast Dental Practice in Brevard County. Full-time or Part-time General Dentist to join our Team in Port Saint John (Cocoa). Must be willing to do Anterior and Molar Endo. Must have a DDS/DMD from an accredited University and active State Dental Board license. Also open to Endo only 1 or 2 days a month. ifixmolars@aol.com. General Dentist Opportunities. We are looking for a general dentist for a busy dental practice. Your daily procedures will include restoration, crown and bridge and core build-ups (veneers, onlays, inlays), extractions, removable prosthodontics, and providing comprehensive treatment plans. Requirements: Complete comprehensive full mouth exams and diagnose dental conditions; Assess treatment planning options and discuss with patient; Educate patients on oral health; Carry out agreed clinical treatments; Assist in the recruitment, training, and management of staff; Keep abreast of new developments in dentistry through structured continuing professional developments. Minimum Education and Experience: Must be a DDS or DMD from an accredited school. What Is Offered: Aggressive Compensation Package, HEALTH INSURANCE, Sign On Bonuses for select locations, RELOCATION Assistance, State-of-the-Art Practices, 401K, PTO, Free CE Credits, MALPRACTICE INSURANCE ASSISTANCE. No Contracts or non-competes... ever! Opportunities Available: Port Richey, Inverness, Sebring, Brooksville, Orlando, Jacksonville, The Villages. About Aspen Dental-branded practices: Aspen Dental-branded practices are independently owned and operated by licensed dentists. The practices receive non-clinical business support services from Aspen Dental Management, Inc., a dental support organization. mioconnor@aspendental.com.
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Pediatric Dentist Opening- Miami Gardens, FL. Come lead our Miami Gardens, FL Specialty team at our North Dade office! Great Expressions Dental Centers has a current, select opening for a full-time Pediatric Dentist to join our Multi-Specialty North Dade office located in Miami Gardens, FL! Enjoy a rewarding role with a dedicated staff while having a strong internal referring network of 15+ local practices! **Sign-on or relocation possible ($$$)! Benefits / Perks: Leaders in the practice: Clinical freedom and treatment autonomy for every Doctor; Patient Focus: Established and Growing Patient Foundation; Multi-Specialty practice; Compensation - six figure annual base vs. percent of production! Doctor Career Path – Partnership / Investment Opportunities; Full Benefits Offered – Healthcare & Dental Benefits, 401K, Short Term / Long Term Disability, Time Off; Malpractice Coverage Assistance; Continued Education Reimbursement, Paid ADA & State Society Dues; Mentorship – Study Clubs, Chairside Mentoring, GEDC University Courses; Please view our Doctor Career Path video: http://www.screencast.com/t/M3xWM5CYN. Apply via this ad to learn more about Great Expressions! For More Information Contact: Ross Shoemaker, MBA | Doctor Recruiting Manager | Great Expressions Dental Centers Practice Support Center - South | 1560 Oakbrook Drive, Norcross, GA 30093 USA; phone 678-836-2226 | ext 72226 | fax 770-242-3251 |web www.greatexpressions.com. “Look for the Smile Above Our Name!” Apply Here: http://www.Click2Apply.net/vxs7m5hmqy. Apply Online - See more at: http://floridadental.co/classifieds/ position-available/pediatric-dentist-opening-miami-gardens-fl. html#sthash.KqXKgB9f.dpuf.
For Sale/Lease FOR SALE: Pediatric Dental Art Collection and Web Domain. Distinctive collection of pediatric dental themed art DECORATIONS and registered web DOMAINS: “TheKIDZDDS. com/.net” to instantly create a unique brand for your practice. Treasured wall art and fun display pieces to fill an entire office. Let my retirement offerings jump start your career. Call Dr. Rick Lebowitz at 352.430.1492 or email TheKidzDDS@hotmail.com. Get details, photos, and pricing. Create exciting memorable first impressions! KODAK & CARESTREAM INTRAORAL X-RAY SENSOR REPAIR. We specialize in repairing Kodak and Carestream RVG 5100 and 6100 dental X-Ray sensors. Repair and save thousands over replacement cost. http://www.KodakDentalSensorRepair. com/919.924.8559. GENDEX & DEXIS INTRAORAL X-RAY SENSOR REPAIR. We specialize in repairing Gendex & Dexis dental X-Ray sensors. Repair & save thousands over replacement cost. http://www. RepairSensor.com/919.924.8559. DENTAPPRAISE PRACTICE APPRAISAL. Nationwide practice appraisals by experienced dental practice brokers since 1992. Ballpark and premier editions. Designed for general and specialty practices. For buyers, sellers, partnerships, mediation, estate planning. For details and brochure: POLCARI ASSOCIATES, LTD. 1.800.544.1297; info@polcariassociates.com. Dental office for sale, lease, or lease/purchase. Excellent opportunity at minimal expense. Centrally located in an attractive 10 unit condominium complex with two general dentistry practices, a chiropractic office, and other professional businesses. Fully furnished/equipped for the practice of dentistry. 3 operatories wired/plumbed for water, suction, compressed air & nitrous oxide/oxygen. Suitable for general dentistry, periodontics, endodontics, prosthodontics or oral surgery. A) Purchase includes all equipment/furnishings; B) 3 Year Lease includes use of all equipment/furnishings; C) Lease/purchase: to be consummated anytime during 3 year period for appraised value at that time. Photos, inventory of equipment/furnishings and floor plan available. Contact Dr. Roger Lee 941.349.1352, royroddyboy@ gmail.com.
FOR SALE. PEDO/ORTHO OFFICE SPACE FOR SALE IN LEESBURG, FL. 3,800 SQ FT, 9 CHAIRS FULLY EQUIPPED, JUST ADD PATIENTS. CONTACT SUZY BUNN, REALTOR, COLDWELL BANKER, TYRE & TAYLOR REALTY. 352.360.8720, OFFICE 352.357.4100. SALE OR LEASE: East Fort Lauderdale. Stand Alone Building!! Class “A” Dental Office for sale or lease. Move your practice to the best location in Fort Lauderdale...a couple of blocks off the beach. Includes all equipment. 4ops, dental lab, sterile room, recovery room, doctor’s office. Does NOT include practice. Current occupant relocating to larger space. wbalanoff@me.com. SALE OR LEASE: Brandon, Fl. FOR LEASE Beautiful 2000 sf lakefront office space available for custom build out. Adjacent to Endodontist. Ideal for Oral Surgeon or Periodontist. Contact Julie at 813.654.3636 or julieh@aeoftb.com. LEASE OPTION: Park Professional Center Furnished and empty office available 2168 & 1270 Sq. FT Park Professional Center, GREAT AND CONVENIENT LOCATION NEAR COUNTRYSIDE SHOPPING CENTER & RTE 19, STARBUCKS, PANERA, MACYS, Dillard’s to mention a few. TWO OFFICES AVAILABLE FOR LEASE: OFFICE 1. Fully furnished Dental Office for Lease, Ideal for a New Graduate or for a Satellite office, with all equipment either for lease or for sale, included 2168 sq ft office. Recently renovated new roof, a/c unit. OFFICE#2. Empty Office 1270 SQ/FT. Recently painted, New carpeting and ready to go for your practice. FLOOR PLAN INCLUDES: 4 offices, 2 bathrooms, Business office and a waiting room, was completely hooked up for an Oral Surgeon and a past Podiatrist office. CONTACT INFORMATION: Richard Norian 617.285.4824, or Ben Kreloff ProCorp Realty 727.643.2314. FOR SALE: Tampa – #FL161. Tampa – General 4 Op, 1,200 Sq Ft Office, GR $488,000, great location, high visibility – Motivated Seller!! Tampa is a vibrant city. Residents can experience a large range of great amenities, year round! Please contact: Henry Schein Professional Practice Transitions Consultant: Heather BrownLicensed Sales Associate, Cell: 727.844.8588, Email: Heather. Brown2@henryschein.com. FOR SALE: Largo – #FL108. 3 Ops –1,200 Square Foot Office – Expandable Office Space Available!! Largo, FL is centrally located less than 15 minutes from Clearwater Beach and ½ hour from Tampa. The local beaches provide activities such as fishing, boating, swimming, kayaking, beaching, and much more. Tampa Bay offers amenities such as the Hard Rock Cafe and Casino, the Amphitheater, Ybor City, the Straz Center, and unlimited restaurants and night life venues. Please contact: Henry Schein Professional Practice Transitions Heather Brown-Licensed Sales Associate Cell: 727.844.8588, Email: Heather.Brown2@ henryschein.com. FOR SALE: Orlando – #FL112. 5 Ops – Well-Established Practice – Dr. willing to stay on as associate! Orlando has unlimited recreation, a variety of restaurants, golf courses, professional sporting events, festivals, and spas. We are also less than 2 hours from either coast offering swimming, fishing, boating, and more. Please contact: Henry Schein Professional Practice Transitions Heather Brown-Licensed Sales Associate Cell: 727.844.8588 Email: Heather.Brown2@henryschein.com. #FL112. FOR SALE: Oldsmar/Palm Harbor – #FL110. 7 Ops – 3,800 Sq. Ft. Office Space in Beautiful, Fast-growing Area!! Updated Equipment and All New Computers – Digital Office with Lab!! **Real Estate Included!!!!** This gorgeous well-established practice is located centrally between Tampa and Clearwater in a continually growing, high traffic area. The white sandy beaches of Clearwater offer recreation such as swimming, fishing, scuba diving, snorkeling, and jet skiing. Tampa offers world-class museums, outstanding theater and concert venues, theme parks, and championship golf courses. Please contact: Heather Brown-Licensed Sales Associate, Henry Schein Professional Practice Transitions 727.844.8588/ Heather.Brown2@henryschein.com.
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FOR SALE: 7 Ops – 2,000 Square Foot Office – VERY MOTIVATED SELLER!! #FL111. We are located in Ocala, FL. Our city is an equestrian lover’s dream! The area boasts 70,000 acres of thoroughbred breeding and training farms; whether you love the thrill of competition or just enjoy riding horseback, this is the place for you! Our city also offers unique attractions, outdoor adventure, championship golf, and rich arts & culture. Please contact: Henry Schein Professional Practice Transitions Heather BrownLicensed Sales Associate Cell: 727.844.8588, Email: Heather.Brown2@henryschein.com. FOR SALE: Tampa, FL – #FL163. Tampa, FL – the city offers unique and exciting recreation for all ages and interests and an exciting nightlife. A diverse selection of great restaurants and some of the state’s best attractions. We are also within 30 minutes of the Gulf! Please contact: Henry Schein Professional Practice Transitions, Heather Brown-Licensed Sales Associate, Cell: 727.844.8588, Email: Heather. Brown2@henryschein.com. #FL163. FOR SALE: Clay County, FL – 4 Ops – 1,200 Square Foot Office-Great Location with High Visibility!! #FL164. 4 Ops 1,200 Square Foot Office – Great Location with High Visibility!! 40 Year Established Practice – ~2,000 Active Patients – $600K Gross on 2 ½ days per week and No Marketing! **HIGHLY MOTIVATED SELLER!!!** Tampa is a vibrant city that takes pride in its rich, cultural heritage. Residents can experience delicious culinary cuisine, exceptional shopping, and year-round fantastic weather! Local attractions include Busch Gardens, The Florida Aquarium, Lowry Park Zoo, Clearwater Marine Aquarium, the Straz Center, MOSI and much more. Professional sporting events abound with teams such as the Tampa Bay Buccaneers, Tampa Bay Lightning, and the Tampa Bay Rays. The nearby gulf offers white sandy beaches with unlimited water sports activities! Beautiful place to work, live and play!! Please contact: Henry Schein Professional Practice Transitions, Heather Brown-Licensed Sales Associate, Cell: 727.844.8588, Email: Heather.Brown2@henryschein.com. Bradenton/Anna Maria Island Beaches; General and Cosmetic Practice 1600 Sqft bldg in park like setting with great traffic view. Five digital ops; paperless; Dentrix, DexIs and Panorex. New compressor and vacuum purchased in 2015. Strictly fee for service; 500,000.00 plus in production with 96% collection. 32 hr work week w/ 6 weeks vacation/yr. Building FOR SALE with new roof and 2 new AC units in 2013. Interior/Exterior Painted in 2014. 250,000.00. For detailed practice info VISIT and REGISTER: dentaldirectsales.com. Owner is retiring and moving. nmpdental@gmail.com.
www.floridadental.org
September/October 2015
Today's FDA
75
OFF THE CUSP
JOHN PAUL, DMD, EDITOR
Isn’t That Special? I’m going to go out and get me a tattoo, so I can be an individual, just like everybody else. I want to be special, don’t you? But, I want to define what makes me special — I don’t want someone else pasting a label on me and putting me in a pigeon hole with other folks who may not be special in the same way I am. I definitely don’t want to be told I’m special in a way that excludes me from the group I’m trying to join. Even if the group I want to be part of is just the patients at the dental office nearby — where I think I will like the people who work there. “Special needs” has become the politically correct label we use to pigeon hole the diagnoses of autism, Down syndrome, fetal alcohol syndrome, Alzheimer’s, deafness, blindness and a host of other cognitive and congenital diagnoses. A lot of folks outside dentistry (and some inside) think we need more education to see patients with “special needs.” You’d think they believe we are treating a rare alien species that wasn’t covered in dental school. A lot of dentists shy away from treating people with “special needs.” I can only speculate why — maybe they are concerned about liability, maybe they are worried they aren’t adequately educated. I’m sure there are some folks who just can’t see past the differences to realize that what our passion does — help people smile, eat and speak better — can be used to
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Today's FDA
September/October 2015
help everyone around us — even those who don’t look exactly like we do. I often admonish my brother and sister dentists that they need to “be a doctor.” A real doctor is a fairly rare beast who can come to the table with empathy and caring for an individual while at the same time possessing enough detachment so the compassion does not cloud their honest evaluation and treatment of their patient. In the rush to complete their evaluation, lots of people with the best of intentions get those qualities confused. As you address patients with special needs, remember they are patients first and the special needs come later. Sir William Osler said, “It is better to know which patient has a diagnosis than to know which diagnosis a patient has.” Any of our patients may require a particular tool, a treatment protocol or a little extra time. They are all special, though some may have a specific clinical diagnosis. Try to see the patient before you apply the filter that often comes with a diagnosis. Look at that photo up in the corner. One of those people is a cancer survivor, one has Down syndrome and one is adopted. One has very short straight hair, one has very long straight hair and one has curly hair. On a day-to-day basis, the hair is a much bigger concern than the other labels. When chemo
took my hair, it was a great concern to me; now that I have it back, how hair gets done each morning can be a trauma for all of us. My youngest is concerned that bows won’t stay in my hair and until just this month, they wouldn’t stay in hers either. What I really don’t want is for someone to see my daughter and think, “She is a Down’s child, so this is all she is capable of.” She is a person who happens to have Down syndrome. Given her diagnosis, all you really know is that she has three copies of chromosome 21 (you don’t actually know that every cell has trisomy 21, just that enough do to qualify for the diagnosis). Given the diagnosis, you also may want to rule out some commonalties with the syndrome, such as a high arched palate, crowded teeth and trouble breathing or breathing through the mouth. Since I share all of those traits, she should probably thank me rather than the extra DNA. To the extent that the labels help our doctors provide us with optimum care, it is OK that they are part of our record. To everyone else, the only label that should matter is we are one big, happy family.
Dr. Paul is the editor of Today's FDA. He can be reached at jpaul@bot.floridadental.org.
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