Virginia Dental Journal Vol 101 #2 April - June 2024

WHERE HAS THE DENTAL WORKFORCE GONE?

COLUMNS

3 CALL TO ARMS

Dr. Dustin Reynolds

5 INSURING DENTISTRY

Dr. Sarah Friend

7 WHY BE A POLITICAL ACTION MEMBER?

Dr. Gary D. Oyster

8 BRIDGING THE GAP: CLEARING THE PATHWAYS TO IN-DEMAND CAREERS IN DENTISTRY

Ryan Dunn

FEATURE

10 VIRGINIA DENTAL WORKFORCE COUNCIL

REPORT TO THE VDA HOUSE OF DELEGATES | JANUARY 2024

SCIENTIFIC

17 EFFECTS OF A NON-INVASIVE DEVICE ON XEROSTOMIA; A PILOT STUDY TO IMPROVE QUALITY-OF-LIFE

Drs. Susie P. Goolsby, Ali Sadeq Al Haddad, Michael Barrett, Caroline K. Carrico

26 THROUGH THE LOOKING GLASS

THE FANTASTICAL WORLD OF ORAL PATHOLOGY

Dr. Sarah Glass

48 ENDODONTIC ABSTRACTS

ADVOCACY

30 VDA PAC UPDATE

Laura Givens

31 2024 DENTAL DAYS

AT THE CAPITOL: VDA MEMBERS SHOW UP FOR DENTISTRY IN A BIG WAY

Laura Givens

32 2024 GENERAL ASSEMBLY SESSION REVIEW

Tripp Perrin and Missy Wesolowski

SHOWCASE

34 2024 VIRGINIA DENTAL SHOWCASE

RESOURCES

29 DENTAL DETECTIVE SERIES

Dr. Zaneta Hamlin

43 THE ROI OF ETHICS

Dr. Robert F. Morrison

45 PAYMENTS IN THE PRACTICE WHAT TRENDS ARE AFFECTING YOUR BOTTOM LINE?

VA DENTAL

EDITOR-IN-CHIEF Sarah Friend, DDS, FAGD

BUSINESS MANAGER

Ryan L. Dunn, CEO MANAGING EDITOR Shannon Jacobs

EDITORIAL BOARD

VDA COMPONENT ASSOCIATE EDITORS

BOARD OF DIRECTORS

PRESIDENT

PRESIDENT ELECT

IMMEDIATE PAST PRESIDENT

SECRETARY-TREASURER

CEO

SPEAKER OF THE HOUSE

NDC CHAIR

COMPONENT 1

COMPONENT 2

COMPONENT 3

COMPONENT 4

COMPONENT 5

COMPONENT 6

COMPONENT 7

COMPONENT 8

ADVISORY

ADVISORY

ADVISORY

EDITOR

VCU STUDENT

VCU STUDENT

Drs. Ralph L. Anderson, Scott Berman, Carl M. Block, Gilbert L. Button, B. Ellen Byrne, Craig Dietrich, William V. Dougherty, III, Wallace L. Huff, Rod Klima, Karen S. McAndrew, Travis T. Patterson III, W. Baxter Perkinson, Jr., James L. Slagle, Jr., Neil J. Small, John A. Svirsky, Ronald L. Tankersley, Roger E. Wood

Drs. Zane Berry, Michael Hanley, Frank Iuorno, Stephanie Vlahos, Jared C. Kleine, Chris Spagna, Anneliese Goetz (VCU Class of 2025)

Dr. Dustin Reynolds

Dr. Justin Norbo

Dr. Cynthia Southern

Dr. Zaneta Hamlin

Ryan L. Dunn

Dr. Abby Halpern

Dr. C. Dani Howell

Dr. David Marshall

Dr. George Jacobs

Dr. Samuel Galstan

Dr. Marcel Lambrechts

Dr. David Stafford

Dr. Marlon A. Goad

Dr. Caitlin S. Batchelor

Dr. Melanie Hartman

Dr. Lyndon Cooper

Dr. Ralph L. Howell, Jr.

Dr. Lorenzo Modeste

Dr. Sarah Friend

Eric Montalvo, VCU Class of 2024

Wendy Yu, VCU Class of 2025

CALL TO ARMS

Dr. Dustin Reynolds

Greetings, fellow members! I hope this note finds you all well and that the new year is off to a great start. I cannot express enough my sincere thanks to all who participated in Dental Days at the Capitol, including our House of Delegates meeting. Our members came out in force, and your presence was appreciated and felt by our legislators. I cannot reiterate enough the importance of making and maintaining contact with our local representatives. They consider us the experts in our field and rely on the information we provide to make decisions that impact our practices and, most importantly, the patients we serve. For those of you who attended our legislative reception on Thursday night, I hope you enjoyed the fellowship, camaraderie, and conversation as much as I did! I will not give names, but a few of the attendees said that our reception was by far the most fun and well-attended event during the legislative session. One senator’s spouse said that they left the Executive Mansion to come to our reception because “those dentists know how to do it right.” We had an impressive number of dental students in attendance, as well as some first-time Dental Days attendees! Hat’s off to a job well done!

As we reflect on a session encompassing the busiest and most robust legislative agenda that the VDA has put forth since my time as a member, I am happy to report that our efforts, time, energy, and pocketbooks are paying off! The Dentist and Dental Hygienist Compact Bills and the Remote Supervision Bills both passed through their respective chambers with no opposition. The Safe Haven Bills both passed through their respective chambers, and the ADA is looking to mimic the SafeHaven™ language and enact it nationwide. The most groundbreaking news is that our

“I ask each of you to reach out to a friend or colleague and encourage them to renew their membership or join for the first time!”

authorization and initial funding for a new VCU School of Dentistry building and a 3% increase in dental Medicaid reimbursement rates.

Dental Insurance Transparency Bill also passed both chambers and is now poised to have Governor Glenn Youngkin act on it. This comes after more than 15 months of advocacy from the VDA and extensive work with the Bureau of Insurance. Virginia becomes one of the first states in the nation to require the disclosure of dental loss ratios and community expenditures from insurance companies, which can inform future decisions by patients, employers, and policymakers. This is a huge victory for dentistry, and our patients, and it has overcome many hurdles to get to this point.

Hopefully, by the time you read this article, these four bills supported by the VDA will be signed by Governor Youngkin and on their way toward implementation. The 2024 Virginia legislative session was a huge success for the dental profession. Thank you to everyone who contributed to these efforts – I am so proud of what we accomplished together!

Two important VDA priorities were included in Virginia’s budget conference report that as of this writing is sitting with Governor Glenn Youngkin. The VDA strongly supported the planning

I now leave you with a challenge. Membership is on the decline nationally, not just here in Virginia. The VDA has a 54% market share amongst dentists in the Commonwealth. We cannot have strength in numbers if we do not have the numbers! If this market share continues to decline, how can our legislators look to us as the voice of dentistry in Virginia?! Again, I ask each of you to reach out to a friend or colleague and encourage them to renew their membership or join for the first time! I have found that peer-to-peer contact is often just like word-of-mouth marketing; it can be the most productive and effective communication method. I also encourage participation in our Tooth PAC. We were just shy of our $375,000 goal for 2023. We accomplished this with only 29% of our membership contributing! We have been fortunate to have a successful and productive legislative session, but could you imagine what we could do if we had 50, 75, or 100% of our members contribute? The sky is the limit. I look forward to seeing everyone at the Greenbrier September 13 -15 for the Virginia Dental Showcase!

INSURING DENTISTRY

Dr. Sarah Friend

The word “insurance” often elicits mixed positive and negative connotations. No one likes dealing with insurance and the caveats and exclusions attached to myriads of policies. Like many of you, I dread the cumulative monthly expenses of all the insurance policies I must carry, professionally and personally. The sum is staggering when I add the premiums paid over a lifetime. Sometimes, I wonder whether all the policies are worth the unseen and often unused investments. I think about all the pleasurable things I could spend my money on. Then, I remind myself of an unfortunate period in my family life where health, disability, and life insurance policies made the difference between survival and ultimate financial ruin. According to Oxford Languages, insurance is a “thing providing protection against a possible eventuality.” We all know that life happens, and it often occurs unexpectedly.

Arguably, the total cost of our formal dental education and continuing education, both in dollars and time, is one of the most significant investments of our lifetimes. Dentists are, by nature, perfectionists who like to be in control of their destinies. We have visions of how we want to practice and live life. We also like to ensure that our dreams become reality.

Who is insuring and ensuring our ability to practice dentistry to support our colleagues, families, and patients the way we envision? There’s no commercial policy we can purchase to assure that our profession will continue to be what we want it to be for ourselves and future generations of dentists. No policy will prevent outside sources beyond our control from imposing policies and restrictions that keep us from practicing how we see fit.

I argue that membership in organized dentistry and advocacy are the best insurance policies that protect the dental profession. Some dentists might say they see no benefit to spending money on a tripartite membership. Those not involved in organized dentistry may view membership as an unused and unprofitable investment until dental life happens and organized dentistry becomes an invaluable problemsolving resource.

“I argue that membership in organized dentistry and advocacy are the best insurance policies that protect the dental profession.”

individual contributes to the overall understanding and eventual solutions to the problems we face as a profession. Every voice of each dental professional matters, whether loud or small. No one else knows what we need as we do. By participating in organized dentistry, we create an insurance policy to help us survive and thrive in times of peace and struggle. If we want to continue to ensure that we control our profession and its future, we must stand up for what we believe in now. We must advocate for the best policies that benefit both us and our patients. We must envision the future we want to work in and work hard to create it to pass on to the next generation. Together, we can ensure dentistry’s future!

We all live in different places and experience different day-to-day realities. Some of us are far removed from any collegial interaction and need help to visualize the sum of the inter-workings of organized dentistry. I encourage all dentists to become involved and contribute whatever they can, no matter how much or little. We, as a membership, function as a surveillance team. When we come together at meetings and interact, we learn what is affecting all of us and strategize on how to solve problems, sometimes before they happen. As we say in clinical practice, “Prevention is the best medicine.” We are here to support one another. Every perspective of every

We are pleased to announce

with 3300 sq/�. Collectes $450K /year with a very strong hygiene program. Real estate is available for sale or lease.

Fairfax County Collec�ng $220K per year on a mix of PPO/FFS pa�ents. There are three equipped operatories, a personal office, digital x-ray, digital pano, and Intra Oral Camera. Beau�ful condo available for sale or lease.

Newport News Grossing around $800K per year. Currently has 7 operatories with room to grow in a 2500+ square feet space. The office is paperless and fully digital.

under contract under contract

Norfolk Collec�ng over $800K per year. Currently has 7 operatories with room for expansion. Office is paperless with digital x-ray. Seller is re�ring.

Fully digital. Real estate for sale or lease. Plenty of visibility, ample parking.

Lynchburg Area This prac�ce has 4 equipped operatories with room for expansion. Generates over $500K in revenue per year with incredibly high cashflow. Pa�ent base is FFS/PPO. Real estate is available for sale.

Greater Yorktown Area Beau�ful, FFS/PPO prac�ce with 5 operatories and room for 3 more. Located in a standalone building with 3300 sq/�. Prac�ce collects $450K with a very strong hygiene program. Paperless and digital. Real estate is available for sale or lease.

SW Virginia Well established prac�ce for sale on a busy road with great visibility. Collects over $750K working only 10

Dr. Stevie Ervil has acquired the prac�ce of Dr. Wes Anderson, Virginia Beach, Virginia.

Dr. Reed Chandler has joined the prac�ce of Dr. Davis Gardner, Richmond, Virginia

(Pictured left.)

Dr. Arin Abrahamian has joined the prac�ce of Dr. Thomas Lenz, Washington, DC

months out of the year. Seller refers out oral surgery, ortho, endo, & perio.

Greater Tyson Endo This prac�ce has a CBCT and laser. Mix of PPO and FFS pa�ent base with 2 very spacious operatories. Seller working very part-�me. Prac�ce is priced to sell.

Arlington The prac�ce operates out of a 1,600 sq � beau�ful condo space that is also available for purchase. Collects $275K per year in revenue on a mix of PPO/FFS pa�ents. 4 equipped operatories, digital x-ray, digital pano, and CBCT.

WHY BE A POLITICAL ACTION MEMBER?

Gary D. Oyster, DDS; ADA Trustee, 16th District

As organized dentistry evolves, policymakers, federal and state lawmakers, and corporations are impacting our ability to maintain dentist/ patient relationships.

Dentists are experiencing what I like to call the “grilled cheese” sandwich effect. First, there is downward pressure from insurance companies and state and federal Medicare and Medicaid programs to reduce reimbursements. Then there is the upward pressure from team members requiring pay increases. The result is that dentists and their practices ooze out from the middle.

We must not allow the current economic situation to adversely affect our contributions to state and federal political action committees. These contributions help us start and maintain relationships with our state and federal legislators. The one word I use to describe advocacy is “relationships.” Without relationships, there can be no advocacy.

Imagine that patient who calls you on a Saturday morning, who has not been in for five years, and was told five years ago that treatment was needed. The patient asks to be seen immediately. Imagine how that makes you feel? Now, another patient calls, who has been coming in regularly. They had an accident and want to be seen immediately. How does that situation make you feel? This is how a legislator, whom you have never supported or previously talked to, feels after you call and request support for or a vote against a bill. The legislator will politely listen, hang up, and be more inclined to dismiss without a second thought. A previous relationship is critical.

The current Workforce Expansion Act, the REDI Act, negotiations with CMS about

“We must not allow the current economic situation to adversely affect our contributions to state and federal political action committees.

These contributions help us start and maintain relationships with our state and federal legislators.”

Medicare, insurance reform, Medicaid reimbursement negotiations, and dental loss ratio legislation are just a few issues being addressed.

One of the best ways to meet legislators is to attend a fundraiser and deliver the PAC check. A great idea to involve a young dentist is to let them attend while the “seasoned” dentist takes a personal check. Another option is to invite your local legislator to come by your office, personally give them PAC and personal checks, and then give them a tour of your office. When they see all the equipment and supplies needed to maintain our “miniature hospitals,” they routinely come away with a greater appreciation of the costs of providing good dental care. The “tooth party” pin has also been a successful idea and emphasizes that the PACs are bipartisan. We have friends on

both sides of the aisle. I have given many of these pins to non-dentists who really liked them.

Unfortunately, only about 20% of dentists are members of ADPAC and fewer are members of their state PAC. There are several levels of giving. The lowest tier is the Capital Club Level, which costs $250 annually or about $21 dollars a month. This contribution level should be within the reach of most members, regardless of their workforce model. If we could get just 75% of the dentists to contribute at that level, we would have more influence at the state and federal level. As a reminder, ADPAC money comes back to the states to support congressional candidates upon the recommendation of the state PAC leaders.

Remember that we are stronger together and, regardless of your personal feelings about politics, it is crucial to participate at some level. ADPAC contributions allow members, who are comfortable attending fund raisers and establishing relationships with legislators, to have more influence on dental issues.

BRIDGING THE GAP: CLEARING THE PATHWAYS TO IN-DEMAND CAREERS IN DENTISTRY

Ryan Dunn, CEO

Across the nation and in the Commonwealth of Virginia, the chief barrier to patients getting timely appointments and receiving essential dental care is the availability of our dental workforce.

There’s huge student demand for our allied dental programs. From Wise County to Richmond to Springfield, allied dental programs only have the available capacity to accept a third to a sixth of the students who apply. Northern Virginia’s (NOVA) and Virginia Commonwealth University’s (VCU) dental hygiene programs are more selective than the University of Virginia, one of the country’s most selective public universities. Their graduates also have less student debt and significantly higher postgraduation earnings.

For too long, dentistry has been viewed by many policymakers through the narrow lens of healthcare and not appreciated for the significant statewide economic impact our members have as employers, with 25,900 Virginians working in dental offices. Most dental hygiene students at NOVA qualify for full tuition reimbursement, with a median pre-enrollment G3 healthcare program income of less than $20,000. The median salary for dental hygienists in NOVA has grown to more than $100,000 annually. These are incredible ladders of opportunity that are being demanded by both students and employer dentists.

Our member dentists got into this profession to heal people. No dentist wants to turn away a patient or wait months to see someone in need of care, but workforce shortages give them no choice. I recently spoke with a member in Richmond who could hire VCU’s entire graduating dental hygiene class immediately and they said the availability of an allied dental workforce is the key

factor preventing their practice from expanding and hiring more associate dentists. And that is one dental practice out of hundreds in the region.

Virginia is blessed with one of the highest concentrations of general dentists in the nation, and we are a net importer of early-career dentists. However, those dentists cannot practice at the top of their ability without the allied dental workforce to support their practice. The result is that fewer patients are getting access to essential dental care.

The Virginia Dental Association (VDA) and our members have been at work, emphasizing the urgent need for collaboration among political and educational leaders to address this issue.

Over the past year, the VDA’s Virginia Dental Workforce Council has brought together program directors, member dentists, and state officials to address these issues and make the data around our workforce needs and paths to solutions accessible to policymakers and educators. Their initial January report, presented to the VDA House of Delegates, is included in this issue of the Journal.

The VDA, representing the employers of dental hygienists and assistants, is leading this collective effort. Just as hospitals have been vocal in their need for nurses and other healthcare workers, organized dentistry must amplify its unified voice to guide further investments and innovative solutions that address barriers to more Virginians pursuing rewarding careers in allied dental professions.

We are working with political and educational leaders to ensure they

understand the health consequences as the bottleneck continues and are bringing promising ideas from across the country to advance solutions. The VDA’s call is clear: to prioritize and invest in the education and training of dental hygienists and assistants, ensuring a workforce that can meet the immediate and growing demands of oral health care in our communities.

“Over the past year, the VDA’s Virginia Dental Workforce Council has brought together program directors, member dentists, and state officials to address these issues and make the data around our workforce needs and paths to solutions accessible to policymakers and educators.”

I have been encouraged by our discussions with Virginia Community College System’s (VCCS) Chancellor David Doré. He has personally visited several of our allied dental programs and has been outspoken about the need for a funding model for VCCS that recognizes

Department of Health Professions

the unique position some of our highercost, high-demand healthcare programs are in.

Several Northern Virginia Dental Society leaders joined us for a meeting with NOVA Community College in February to talk about their plans for a significant expansion of their dental hygiene program capacity. We discussed ways that members can help support both their world-class dental assisting and hygiene programs and we have been engaged with our other community college and four-year programs offering support. Funding for a new building for the VCU School of Dentistry, included in the conference report sent to the Governor, will also include the ability to significantly expand their dental hygiene program’s capacity to expand their enrollment.

In recent years, we have seen an increasing percentage of our newly licensed dental hygienists come to Virginia from other states. We were pleased to work cooperatively with the Virginia Dental Hygienist’s Association, Department of Defense, American Dental Association, and the Association of Dental Support Organizations to become one of the first states to pass legislation enabling the Dentist and Dental Hygienist Compact, which will reduce barriers to dental hygienist licensure portability.

Supporting dentists and team members who have already entered the profession must be part of the workforce solution. In the 2024 General Assembly, Virginia became the first state in the country to pass SafeHaven™ legislation to allow dentists, dental hygienists, and students experiencing burnout or mental health challenges to seek confidential help through the SafeHaven™ program without fear of licensure or liability

repercussions. That legislation, carried by Senator Todd Pillion and Delegate Patrick Hope at the request of the VDA, was signed into law by Governor Youngkin and is now being looked to as a national model.

Solutions to the workforce crisis that many of our members are feeling will take time and be a heavy lift, but we have also seen that the more the VDA pushes into this space, the more opportunities for solutions to address these challenges present themselves. We will call on our members in the weeks ahead to help make their voices heard and engaged.

Virginians’ overall health and well-being depend on the people who provide care, and everyone in a dental office plays a role. Addressing this shortage is a vital step toward ensuring accessible and quality dental care for all. Virginia can

take the lead in addressing the workforce needs of dental hygienists and assistants and set an example for the nation to follow.

Courtesy of the Virginia Healthcare Workforce Data Center

Virginia Dental Workforce Council Report to

the VDA House of Delegates |

Addressing the oral healthcare needs in all of our communities will require a dental workforce to meet those needs. There are innumerable potential barriers to access to dental care throughout the country, but the root cause of many of these issues is that there aren’t providers in the area with the capacity to see additional patients.

Since the onset of the pandemic, the ADA has found that half of dentists nationally have personally taken on duties that were previously assigned to other team members, shifting their time to activities that don’t allow them to practice at the top of their license. But as you’ll see in the pages that follow, there isn’t one simple explanation or solution to the workforce challenges we face, and the challenge

is different in different parts of the Commonwealth.

JANUARY 2024

The Virginia Dental Workforce Council brought in program directors, dentists, state officials, and workforce experts to bring solid numbers around the workforce needs in Virginia and to identify short- and long-term solutions.

I thank them all for donating their time and talent to addressing this critical need. This report is an important step in bringing forward solutions, structures and relationships that will elevate our oral healthcare workforce needs and put in place long-term solutions to address our future oral healthcare needs.

Please use this report as a resource. In the months ahead, the data you find in the report will be included and updated as new information becomes available on the Virginia Dental Association’s website at vadental.org

To effectively implement the report’s recommendations and address the identified needs, we will need our members and their teams engaged. If you would like to be part of the next steps in this process, please reach out to me or a VDA team member to connect with local efforts.

Thank you again to the many VDA members and professionals who devoted time to working on this issue and getting us to this point. The future of dentistry in Virginia is bright, and I have been encouraged over this past year how much willingness there is to work together to make sure Virginia is a national leader in addressing our dental workforce needs.

Sincerely,

Dr. Cynthia Southern Chair Virginia Dental Workforce Council

VIRGINIA DENTAL WORKFORCE COUNCIL PARTICIPANTS

Cynthia Southern, DDS (Chair) Virginia Dental Association

Heather Anderson, MPH Virginia State Office of Rural Health

Benjamin Barber, MPP Virginia Health Catalyst

Cathy Berard, BSDH, RDH, FADHA Virginia Dental Hygienists’ Association

Emily Kate Bowen, DDS, MA Mountain Empire Community College

Jenna Chun VCU School of Dentistry, Class of 2024

Denise Claiborne, Ph.D., RDH Old Dominion University

Benjamin Crowley, DDS Brightwork Family Dentistry

Marlon Goad, DDS Wytheville Community College

Marge Green, MS, RDH, FADHA Virginia Dental Hygienists’ Association

John Hall Virginia Department of Veteran Services

Sarah Holland Virginia Health Catalyst

Sara Holston, DDS Appalachian Highlands Community Dental Center

Antwon Jacobs, MBA Virginia Department of Veteran Services

Sara Leon-Guerrero Harrison, CDA, CRFDA, CDIPC Virginia Dental Assistants Association

Melanie Love, DDS Northern VA Dental Society

Marion Manski, MS, RDH VCU School of Dentistry

Misty Mesimer, MSCH, RDH, CDA Germanna Community College

Darla Miller Virginia Association of Career and Technical Education

Tripp Perrin Lindl Corporation

Rufus Phillips

Virginia Association of Free and Charitable Clinics

VaCora Rainey, DDS VCU School of Dentistry

Anthony Reedy Virginia Department of Labor

Yetty Shobo, Ph.D. Virginia Healthcare Workforce Data Center

Amber Shuler, RDH, MDH Wytheville Community College

Carlos Smith, DDS, M.Div VCU School of Dentistry and Virginia Health Catalyst

Crystal Stokes

Virginia Department of Education

Kelly Tanner, PhD, RDH Virginia Peninsula Community College

Marlana Thomas, MS, RDH, CTTS Virginia Western Community College

Heather Tuthill, MPH, BSDH, RDH Virginia Dental Hygienists’ Association

Emily Webb Virginia Chamber of Commerce

Missy Wesolowski Lindl Corporation

Virginia Dental Association Team

Ryan Dunn CEO

Laura Givens

Director of Legislative & Public Policy

Shannon Jacobs

Director of Communications

Paul Logan

Director of Strategic Initiatives/Innovation

TIMELINE

April 14, 2023

Virginia Workforce Council Convenes at VDA Headquarters

June 9, 2023

Virginia Workforce Council Meets (virtual)

August 4, 2023

Virginia Workforce Council Meets (virtual)

September 24, 2023

Virginia Workforce Council Preliminary Findings Presented to Virginia Dental Association Board of Directors

November 17, 2023

Virginia Dental Workforce Council Meets to Review Draft Report given to the VDA House of Delegates

January 18-20, 2024

Virginia Workforce Council Report Presented to the VDA House of Delegates

Continued Meetings and Collaboration with Council Participants to Implement Recommendations

EARLY OUTCOMES

• Closer working relationship with VDHA, via a joint effort to preserve dental hygiene program at Virginia Peninsula Community College.

• Closer relationship with new leadership at the Virginia Community College system, which is a partner association for the VCCS Healthcare Summit on November 29th, set to identify regional healthcare workforce priorities.

• New data available on Virginia’s dental workforce needs

• New opportunities available to promote allied dental careers:

- Mission Tomorrow presentation to 12,000 Richmond-area 8th graders and high schoolers in October

- Presentation to guidance counselors from around Virginia in March in Williamsburg on the opportunities available through dental careers

• Brought CODA to the table to consider changes in ratios that limit flexibility of allied dental programs.

• Education of VDA members around DAII program

• New open channel with Virginia’s Department of Veterans’ Services around career opportunities

• Closer relationship with allied dental program administrators and channels to promote openings through the VDA Career Center for their graduates

• Legislative priorities to address challenges to licensure and remote supervision

SUMMARY FINDINGS

Dentists

• The ratio of dentists to overall population in Virginia is greater than the national average and has grown over time:

- 63.83 dentists per 100,000 population in Virginia vs. 60.77 nationally

• Virginia has more young dentists moving in from other states than out and 84% of our newly licensed dentists in the past five years graduated from dental programs outside of Virginia.

• Virginia’s challenge is in making rural areas outside of the urban crescent attractive for the dentists graduating and moving to the state.

• An aging dental workforce in rural areas makes this challenge an urgent one to address.

• Compared with pre-pandemic, half of dentists now report personally doing more duties previously performed by dental hygienists, administrators or assistants, as staffing challenges persist. Not caring for patients at the top of their license limits the dentists’ ability to see new patients.

• Newly opening dental schools at Lincoln Memorial University and Highpoint University are recruiting dental students from Virginia and have plans for dental clinic partnerships in rural Virginia that have the potential to help address needs and give students familiarity with those areas as they consider where to practice.

• Approximately 100 dental students graduate annually from the VCU School of Dentistry, about half of whom are recruited from Virginia. Their students have service-learning rotations in 14 free and charitable clinics in health profession shortage areas in-state.

• The VCU School of Dentistry itself is the largest dental Medicaid provider in Virginia, but its current facilities, with tens of millions of dollars in deferred maintenance, are not suited to its growing role in providing dental care to patients from across Virginia.

Source: ADA Health Policy Institute

Source: VA Healthcare Workforce Data Center

SUMMARY FINDINGS

Dental Hygienists

• Virginia’s concentration of dental hygienists is slightly less than the national average, but our above-average concentration of dentists creates a greater workforce gap than indicated by the population.

• Forty-one of Virginia’s localities have more dentists than hygienists, while the national ratio is approximately equal.

• The largest gaps in raw numbers can be found in densely populated areas in Northern Virginia and the Richmond area, which also have concentrations of dentists well above the state average.

• Sixty-seven percent of licensed dental hygienists in Virginia received their initial professional degree in-state.

• Germanna Community College has started a new dental hygiene program with an enrollment of five students per class, expected to increase to ten in a few years as they build out a new space. Their first class graduated in December, 2023.

• Virginia Peninsula Community College recently paused admissions to its program and the VDA has been working with VDHA through the workforce council to address barriers to continuing the program. Approximately 40 dentists and dental hygienists participated in a November, 2023 community meeting to help identify a path forward for the program.

SUMMARY FINDINGS

Dental Hygienists (continued)

• Since peaking at 182 in 2011, the overall number of Virginia graduates from dental hygiene programs has declined, down to 135 students in 2023.

• The share of newly licensed hygienists coming from out-of-state programs has increased somewhat – 41% in the past five years compared to 33% overall.

• The dental hygiene programs in closest geographic proximity to the areas with the largest workforce gaps are Northern Virginia Community College and the VCU School of Dentistry.

• Areas like Norfolk, Virginia Beach, James City County and Roanoke, in close proximity to strong hygiene programs, have healthier dentist to hygienist ratios.

• The workforce of dental hygienists has grown faster than the rate of full-time-equivalent hygienists, meaning they are working on average fewer hours per person.

• Dental hygiene programs are experiencing significant challenges with hiring and retention of full-time and adjunct faculty and proper funding as they have been impacted by increased costs.

• They are also experiencing challenges in licensure, with the Board of Dentistry creating a redundant requirement for hygienists who go through training to become an expanded function dental assistant.

VIRGINIA DENTAL HYGIENE PROGRAM GRADUATES BY INSTITUTION

Source: Virginia State Council of Higher Education

SUMMARY RECOMMENDATIONS

Make healthcare workforce data more accessible for policymakers:

- Create a VDA Dental Workforce Dashboard that makes all available workforce data easily accessible.

Elevate dental workforce needs among policymakers and VCCS:

- Participated in VCCS Healthcare Summit with Governor’s Administration November 29, 2023

- Regular discussions with VCCS administration

- Seek individuals with dental background to serve on workforce boards and commissions

Promote careers in dentistry, particularly in healthcare provider shortage areas and make it easier for dentists and dental hygienists to practice in areas of need:

- Career fair toolkit

- Support and promote VCU Dental Explorer Days.

- Expand activities as G3 program ambassador, which offers tuition assistance for 30% of current VCCS dental hygiene and dental assisting students.

- High school guidance counselor outreach

- Clear path for military veterans and spouses to pursue dental careers.

- Earned media opportunities

Support Virginia’s dental programs:

- New Dental School Building at VCU

- Address faculty, facility and funding needs for allied dental programs and barriers to expanding class needs in areas with significant shortages.

- Address causes of attrition in allied dental programs.

- Continue to seek changes from CODA to allow for appropriate flexibility for allied dental faculty.

- Address allied dental program capacity in areas of significant need.

Address barriers to licensure for dentists and hygienists:

- Ensure a clear, predictable process.

- Support entry into the Dentist and Dental Hygienist Compact to allow an additional path to licensure.

Address barriers for free and charitable dental care:

- Additional dental and allied dental student partnerships

- Partnership with clinics to credential dentists for Medicaid

- Formal partnerships for connecting the workforce with opportunities

Address barriers to entering the workforce:

- Partnerships with dental education programs to promote career opportunities through VDA Career Center

- Mentorship and residency opportunities in high need areas

Support federal initiatives through the ADA:

- CODA flexibility

- Reauthorizing the Action for Dental Health Act workforce grants directed towards programs for dentists and other dental professionals

- S 862, the Restoring America’s Health Care Workforce and Readiness Act, which would double funding for the National Health Service Corps’ scholarships and loan repayment programs for health care workers, including dentists and dental hygienists, who serve in federally designated shortage areas

- S 704, the Resident Education Deferred Interest Act, which would address the difficulty, or inability, of those who must undertake several years of dental residency with very low pay to begin repaying student debt immediately

EFFECTS OF A NON-INVASIVE DEVICE ON XEROSTOMIA; A PILOT STUDY TO IMPROVE QUALITY-OF-LIFE

Drs. Susie P. Goolsby, Ali Sadeq Al Haddad, Michael Barrett, Caroline K. Carrico

Abstract

Persistent dry mouth has a significant negative impact on patients’ quality of life (QoL), due to discomfort, dental caries, difficulty eating and digesting food, and overgrowth of candidiasis. Current treatments focus on palliative care, with some more invasive and systemic treatments, but their use is limited. Medical devices have managed various systemic conditions for more than 20 years, due in part to mitigation of compliance issues. The Voutia™ hydration system addresses the quality of life for patients who suffer from dry mouth. After recruiting and confirming xerostomia in fifteen patients, the Voutia™ system was provided and patients were reassessed after six weeks. There were no adverse events and notable increases in QoL measures.

Keywords: Clinical outcomes, Clinical Studies/trials, Consumer healthcare products, Lifestyle(s), Personalized Medicine, Quality-of-life

Introduction

Often believed to be a natural condition of aging, dry mouth can occur at any stage of life.1 Systemic conditions and medications can contribute to symptoms of dry mouth that can be temporary or permanent.2 Most medications do not damage the salivary glands, but the likelihood of decreased unstimulated salivary flow rates increases in the presence of numerous diseases and medications.1 Physically, feelings range from minor discomfort to great difficulty eating, sleeping, and speaking, with the added emotional effects that range from annoyance to severe depression.3 Candida albicans is part of the normal oral flora in most individuals, but patients with xerostomia often exhibit recurrent oral candidiasis.1 The perception of

oral dryness might also increase with mouthbreathing, dehydration, and neurological or psychological disorders such as depression or anxiety.1 Saliva with a high mucin content is viscoelastic, which is an essential quality for retaining saliva on oral mucosal surfaces and maintaining the surfaces’ lubrication and hydration.4 The overall decrease in saliva leaves the dentition vulnerable to dental caries due to the increased time under acid attack from fermentable carbohydrates. All patients, especially those at high risk, should have their diminished salivary gland function taken into account as part of a thorough caries risk assessment.5

Many factors impact salivary secretion, such as sensory modalities, including auditory, visual, and somatosensory, and they are associated with fear through pathways in the amygdala, the hypothalamus, and the brainstem.6 Several prescription medications commonly used to treat systemic conditions list xerostomia as a side effect. One class of drugs that commonly contributes to xerostomia is the anticholinergic muscarinic (M3) receptor blockers, which are used, for instance, to treat irritable bladders.6 Additionally, the central nervous system’s alpha-2-adrenergic receptors activated by antidepressants might result in salivary hypofunction.7 Furthermore, patients

with Sjogren’s syndrome and those who received head and neck radiation therapy for squamous cell carcinoma were discovered to have the most severe cases of chronic, irreversible dry mouth.6

Dry mouth, often considered interchangeable with xerostomia, is a patient-reported term describing the oral sensation of feeling either perpetually or episodically dry.8 Clinical confirmation of a reduced salivary flow is defined as salivary hypofunction or hyposalivation.8 Hyposalivation is tested through various methods and is confirmed with values

Figure 1: Side Profile of Adult Woman Wearing Voutia™ System

>> CONTINUED FROM PAGE 17

below 0.5- 0.7 ml/min for stimulated flow, less than 0.1 ml/min gravimetrically for whole unstimulated salivary flow, or less than 10mm on an ophthalmic Schirmer’s strip test.9–11

Xerostomia in patients with objective hyposalivation is diagnosed when the salivary flow rate is less than the rate of fluid absorption across the oral mucosa, plus the rate of fluid evaporation from the mouth.12 Salivary gland damage is the most common adverse effect of radiation therapy in the head and neck region.1 Patients with salivary gland hypofunction typically complain of dry mouth and difficulty swallowing and speaking; they

typically cannot tolerate spicy, acidic, and crunchy food and frequently report taste changes or difficulty wearing dentures.13

A careful oral examination is fundamental to identify clinical signs pathognomonic for hyposalivation. Several helpful signs have been proposed by Osailan et al.: 1) sticking of an intraoral mirror to the buccal mucosa or tongue; 2) frothy saliva; 3) no saliva pooling on the floor of the mouth; 4) loss of papillae of the tongue dorsum; 5) altered/smooth gingival architecture; 6) glassy appearance to the oral mucosa (especially the palate); 7) lobulated/deeply fissured tongue; 8) cervical caries (more than two teeth);

and 9) mucosal debris on the palate (except under dentures).14 Symptoms of dry mouth may range from mild oral discomfort to significant oral disease that can compromise patients’ health, dietary intake, and quality of life.1

Over-the-counter dry mouth remedies include oral patches, rinses, lozenges, toothpaste, sprays, gels, and chewing gum. Intraoral appliances, such as the saliva stimulation device Saliwell Crown or the electrostimulating device GenNarino, have been effective in reducing dry mouth and increasing saliva production.15 The use of medical devices improves health outcomes due

Figure 2: Changes in Oral Health Impact Profile (P=0.0487)

Oral Health Impact Profile (P=0.0487)

to mitigation of compliance issues and therefore improve the general health and feeling of well-being in patients. 16–19

The aims of this study were to assess the impact of a medical hydration device on 1) patient perception of quality-oflife (QoL), 2) functional changes using salivary testing, and 3) oral changes using the Clinical Oral Dryness Score (CODS).

Methods and Materials

This pilot study was approved by the Institutional Review Board at Virginia Commonwealth University (VCU IRB HM 20021188). The study was registered with ClinicalTrails.gov identifier NCT

Xerostomia Inventory (P=0.0017)

04901507. Data was captured on the day of unit delivery and again at the unit retrieval appointment (approximately six weeks later) using Research Electronic Data Capture (REDCap™), a secure, web-based software platform to support data capture for research studies hosted at Virginia Commonwealth University.20

The Voutia™ hydration device is an FDA-cleared, hands-free medical device that delivers hydration to a user’s mouth through ultra-fine tubing.21 The rechargeable, battery-operated portable device uses a micro-pump to deliver hydration from the device reservoir to the user’s mouth by way of ultra-fine

tubing that attaches to the ear with an earpiece. A user has two choices of reservoir size and separate earpieces for day and night. The device allows the user to set the hydration flow and adjust as needed or desired. An image of an adult female wearing the Voutia™ system is presented in Figure 1. The system is available for purchase to care providers and individuals suffering from dry mouth through the website https://voutia.com/ For this study, data collected assessed the effects of the use of the device at baseline and at six weeks, and include

1) Oral Health-Related Quality of Life (OHRQoL) using the Oral Health Impact Profile (OHIP-14) and the Xerostomia

Figure 3: Changes in Xerostomia Inventory (P=0.0017)

>> CONTINUED FROM PAGE 19

Inventory (XI), 2), salivary testing using gustatory stimulation for stimulated salivary flow(SSF) and Schirmer’s Strips for unstimulated salivary flow (USSF), and 3) oral indicators using the Clinical Oral Dryness Score (CODS).14,22–26 The responses from the OHIP -14 and XI surveys were scored on a five-point scale (OHIP-14: 0-4, XI: 1-5). The examiner scored the features observed in the patient’s mouth and derived a COD score of 0-10. Clinical findings observed were given a one-point value for CODS, with 10 indicating the most severe oral dryness. Unstimulated salivary flow (USSF) was tested prior to stimulated flow to enhance accuracy. USSF was measured using a

Stimulated Salivary Flow (P=0.0253)

Schirmer strip placed on the floor of the mouth with the patient seated upright. Next, the patient was given unflavored wax to chew and was instructed to expectorate into a medicine cup for three minutes to yield the stimulated salivary flow (SSF).

Informed consent was obtained, and patients were given the external oral irrigation system to wear continuously for six weeks. Instruction was given at the unit delivery appointment to ensure the proper use the device. Patients were encouraged to share additional input on the ease or difficulty of use of the units during the study. The notes from the patients and examiners were recorded.

Statistical Methods

Scores were compared before and after use of the device with paired t-tests. SAS EG v.8.2 (SAS Institute, Cary, NC) was used for all analyses. Significance level was set at 0.05.

Results

A total of 16 subjects were enrolled and a total of 13 participants completed the study. Patients of record over the age of 18 were recruited from the Predoctoral and the Oral Medicine clinic. Patients who met the qualifications for the study included six men and ten women. Seven patients were 65 or older and 9 were between 18 and 65. Conditions which

Figure 4: Changes in Stimulated Salivary Flow (P=0.0253)

resulted in their hyposalivation included prior radiotherapy for carcinoma, Sjögren’s Syndrome, antidepressant and anxiolytic-induced xerostomia, connective tissue disorders, asthma and diabetes mellitus II. The majority were Caucasian (n=13) but Black/African American and Asian subjects were also included (n=3).

Among the 13 subjects with both preand post-scores, there were significant improvements in both quality of life measures: OHIP (p-value=0.0487, Figure 2) and Xerostomia Inventory (p-value=0.0017, Figure 3). The average reduction in the OHIP scoring was 10.2

(95% CI: [0.07, 20.24]). The average reduction in the Xerostomia Inventory was 13.2 (95% CI: [6.04, 20.42]).

Stimulated salivary flow was significantly higher after six weeks of usage of the device, with an average increase of 0.7 mL/min (95% CI: [0.11, 1.36]) (p-value=0.0253, Figure 4). Unstimulated salivary flow also increased but was not statistically significant (p-value=0.1150, Figure 5). The average change in unstimulated salivary flow was 5.7 mm (95% CI: [-1.60, 12.94]).

The average change in the Clinical Oral Dryness Score was marginally significant with an average of 0.8 (95%

CI: [-0.04, 1.73]) (p-value=0.0591, Figure 6) indicating marginal improvements in clinical indicators of xerostomia.

Discussion

The reduction in the OHIP-14 score indicates that the patients’ quality-of-life was positively affected using the device. When the survey questions contained emotionbased terms such as ‘self-conscious”, and embarrassed”, the participants often express the effect of oral dryness on quality-of-life without prompting. The scales offer a means to qualify and quantify their thoughts and feelings in a clinically relevant and empathetic manner. Many patients remarked at the time of delivery

Figure 5: Changes in Unstimulated Salivary Flow (P=0.1150)

>> CONTINUED FROM PAGE 21

how they could feel the water from the unit moisturizing and relieving the need to take sips from their water bottles which were always on hand. Noticeably, nearly immediately after the device was placed intraorally, pronunciation of words improved and the swallowing reflex was initiated.

The reduction in the XI score is also significant for improving the perception of oral dryness. The patients answered daily function-based questions during the survey, such as whether they had difficulty eating dry foods or if they woke up at night to drink water. The participant’s responses, on a Likert scale, including terms such as “never”

Clinical Oral Dryness Score (P=0.0591)

or “hardly ever,” are similar to the OHIP-14. The marginally significant COD change indicated improvements in the clinical signs of the degree of dryness. The examiner looked for various signs, for example, if the mirror stuck to the patient’s tongue or mucosa. Higher scores indicate more signs of dryness were present during the clinical exam. The amount of saliva continuously secreted into the oral cavity was measured using the unstimulated salivary flow rate method, whereas the functional capacity of the salivary gland was measured using the stimulated salivary flow rate, and increased flows positively affected both soft and hard tissues.

The increase in stimulated salivary flow is significant for various reasons. A study in 2020 demonstrated that stimulated saliva was used to monitor the standard physiological concentration of markers liable for diurnal rhythms, like cortisol.27 Studies have shown that increased SSF may be related to the gustatory reflex. Additionally, the feeling of cold in the mouth can increase salivary flow, and lead to liquid gustatory stimulation.28 However, activities that stimulate salivary increase are not performed continuously through the day and are significantly absent at night, when salivary flow naturally decreases in response to circadian rhythms. Although this value

Figure 6: Changes in Clinical Oral Dryness Score (P=0.0591)

significantly increased in the patients in this study, the effects would perhaps be transient at best.

Ultimately, the more significant flow rate of the two, USSF, was not significantly impacted. USSF helps maintain feelings of moisture during times of rest or times when the patient is not chewing or performing gustatory actions. In one study of unstimulated whole-mouth saliva flow, female subjects’ USSF was approximately 70% of that in male subjects.6 The majority of this study’s participants were female, which may be a contributing factor to the findings.

Unstimulated salivary flow is generated from impulses to the region of the brain through neurons. Acetylcholine, a neurotransmitter that affects the salivary glands, is released by nerve endings in response to parasympathetic stimulation. This neurotransmitter predominantly induces the production of water and ions from the salivary glands.29 Unstimulated describes a lack of exogenous stimulus, although physiologically speaking, the conscious person is constantly experiencing some degree of endogenous stimulation.30 Daily saliva production varies between 0.5 and 1.5 liters.31 The average unstimulated whole saliva flow rate in the population is about 0.3 ml per minute; if this rate falls by 50%, symptoms of dryness manifest in patients.19 Schirmer strips measure normal USSF in the range of 25mm or more. On average, the participants in this study had nearly undetectable USSF rates at delivery (9mm), and although they did show some improvement, on average that rate rose to only 15mm, indicating low USSF rates. Patients were solicited for comments at the retrieval appointment. One patient mentioned she could eat comfortably with the device, while another mentioned that doing so eventually caused crimps in the line, which interfered with the water flow. The same patient mentioned that the product worked well while using it but felt her xerostomia symptoms returned five minutes after removing the device. Several patients mentioned that they preferred the larger cheek pad tubing instead of the customized to fit smaller tubing that was threaded between the

Table: Clinical Quality of Life Measures Before and After use of Irrigation Device (n=13)

*Note: Values presented are Mean, SD, and p-value is from paired t-test

teeth to rest on the floor of the mouth. Several patients mentioned their desire to purchase the unit at the end of the study, but most said the cost was prohibitive. One patient mentioned that she never wore the device outside her home and considered it a hassle. Another patient offered that the unit would be improved with a higher flow setting and a misting option. A patient taking amitriptyline, a tricyclic antidepressant, said she was able to reduce the use of the medication while using the device, although this was not encouraged by the examiner at delivery. Further, she stated that the unit was helpful for use at home and is better for people with sedentary lifestyles. For some patients treated for mental disabilities, using the device required additional challenges that they were unwilling to handle. Some patients enjoyed using the device through the night when salivary flow is diurnally lessened. Another patient stated she was able to cut back on other treatment options, such as rinses and lozenges. Several patients mentioned they would prefer the unit to be smaller, and less bulky, and added that transporting the attached water bottle was their greatest inconvenience; one patient mentioned that internally incorporating a water reservoir into the device might be an ideal solution.

Conclusion

The use of the Voutia™ system resulted in observable and reported immediate oral hydration, speech improvement, and swallowing reflex initiation at the time of delivery for participants in this study. Limitations included participants who were not as comfortable using other hand-held technological devices, like smartphones, were less inclined to remain for the duration of the study.

Results merit further studies to include a larger cohort of patients, longer device use, and evaluation of additional clinical outcomes. Future studies should also consider substituting water with solutions and mixtures that imitate the electrolytic profile of saliva.

AUTHORS:

Susie P Goolsby, DDS, MSHA, Oregon Health and Science University School of Dentistry

Ali Sadeq Al Haddad, DDS, Kuwait Ministry of Health

Michael Barrett, DDS, Virginia Commonwealth University School of Dentistry

>> CONTINUED FROM PAGE 23

Caroline K Carrico, PhD, Virginia Commonwealth University School of Dentistry, Associate Professor, Department of Dental Public Health and Policy

AUTHOR CONTRIBUTIONS:

Dr. Susie Goolsby: Contributed to conception, design, data acquisition and interpretation, drafted and critically revised the manuscript. Also, gave their final approval and agrees to be accountable for all aspects of the work.

Dr. Ali Al Haddad: Contributed data acquisition and interpretation, drafted and critically revised the manuscript. Also, gave final their approval and agrees to be accountable for all aspects of the work.

Dr. Michael Barrett: Contributed to data acquisition and interpretation, drafted the manuscript. Also, gave their final approval and agrees to be accountable for all aspects of the work.

Dr. Caroline Carrico: Contributed to conception, design, data acquisition and interpretation, performed all statistical analyses, and drafted the manuscript. Also, gave their final approval and agrees to be accountable for all aspects of the work.

ACKNOWLEDGEMENTS:

This work was supported by the Voutia™ Systems and Dr. Jeff Cash of the Virginia Head and Neck Therapeutics, Inc., Richmond, VA USA. Thank you to Dr. Sarah Glass of the VCU Oral Diagnostics Sciences Department and staff. A special thank you to Dr. Sompop Bencharit for clinical trials research guidance. Declaration of Interests: none.

REFERENCES:

1. Plemons JM, Al-Hashimi I, Marek CL. Managing xerostomia and salivary gland hypofunction. J Am Dent Assoc. 2014;145(8):867-873. doi:10.14219/jada.2014.44

2. Ouanounou A. Xerostomia in the Geriatric Patient: Causes, Oral Manifestations, and Treatment. Compend Contin Educ Dent 2016;37(5):306-311;quiz312.

3. Furness S, Worthington H V, Bryan G, Birchenough S, McMillan R. Interventions for the management of dry mouth: topical therapies. Cochrane Database Syst Rev. Published online 2011. doi:10.1002/14651858. CD008934.pub2

4. Yakubov GE, Gibbins H, Proctor GB, Carpenter GH. Oral Mucosa: Physiological and Physicochemical Aspects. In: Mucoadhesive Materials and Drug Delivery Systems. John Wiley & Sons, Ltd; 2014:1-38. doi:10.1002/9781118794203.ch01

5. Jenson L, Budenz AW, Featherstone JDB, RamosGomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35(10):714-723.

6. Proctor GB. The physiology of salivary secretion. Periodontol 2000. 2016;70(1):11-25. doi:10.1111/prd.12116

7. Proctor GB. Medication-Induced Dry Mouth. In: Dry Mouth Springer Berlin Heidelberg; 2015:33-50. doi:10.1007/978-3642-55154-3_3

8. Thomson WM. Dry mouth and older people. Aust Dent J 2015;60:54-63. doi:10.1111/ adj.12284

9. Fontana M, Zunt S, Eckert GJ, Zero D. A screening test for unstimulated salivary flow measurement. Oper Dent 30(1):3-8.

10. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag 2015;11:45-51. doi:10.2147/ TCRM.S76282

11. Young A, Stenhagen KR, Mulic A, Amaechi BT. Dental Erosive Wear Risk Assessment. In: Dental Erosion and Its Clinical Management. Springer International Publishing; 2015:121-132. doi:10.1007/9783-319-13993-7_7

12. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 38(3):236-240. doi:10.1159/000077760

13. Valdez IH, Fox PC. Diagnosis and management of salivary dysfunction. Crit Rev Oral Biol Med. 1993;4(3-4):271-277. doi:1 0.1177/10454411930040030301

14. Osailan SM, Pramanik R, Shirlaw P, Proctor GB, Challacombe SJ. Clinical assessment of oral dryness: development of a scoring system related to salivary flow and mucosal wetness. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(5):597-603. doi:10.1016/j.oooo.2012.05.009

15. Alajbeg I, Falcão DP, Tran SD, et al. Intraoral electrostimulator for xerostomia relief: a longterm, multicenter, open-label, uncontrolled, clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(6):773-781. doi:10.1016/j.oooo.2012.01.012

16. Mohith S, Karanth PN, Kulkarni SM. Recent trends in mechanical micropumps and their applications: A review. Mechatronics. 2019;60:34-55. doi:10.1016/j. mechatronics.2019.04.009

17. Ma T, Sun S, Li B, Chu J. Piezoelectric peristaltic micropump integrated on a microfluidic chip. Sensors Actuators A Phys 2019;292:90-96. doi:10.1016/j. sna.2019.04.005

18. Furness S, Bryan G, McMillan R, Worthington H V. Interventions for the management of dry mouth: non-pharmacological interventions. In: Furness S, ed. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2013. doi:10.1002/14651858. CD009603.pub2

19. Frost PM, Shirlaw PJ, Challacombe SJ, FernandesNaglik L, Walter JD, Ide M. Impact of wearing an intra-oral lubricating device on oral health in dry mouth patients. Oral Dis 2006;12(1):57-62. doi:10.1111/ j.1601-0825.2005.01161.x

20. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010

21. Virginia Head and Neck Therapeutics I. Voutia. https://voutia.com/

22. Hijjaw O, Alawneh M, Ojjoh K, et al. Correlation between Xerostomia index, Clinical Oral Dryness Scale, and ESSPRI with different hyposalivation tests. Open Access Rheumatol Res Rev. 2019;Volume 11:11-18. doi:10.2147/OARRR.S188937

23. da Mata A, da Silva Marques DN, Freitas FMF, et al. Translation, validation, and construct reliability of a Portuguese version of the Xerostomia Inventory. Oral Dis 2012;18(3):293-298. doi:10.1111/ j.1601-0825.2011.01879.x

24. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005;33(4):307-314. doi:10.1111/ j.1600-0528.2005.00225.x

25. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997;25(4):284-290. doi:10.1111/j.1600-0528.1997. tb00941.x

26. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: a multiitem approach to measuring dry mouth. Community Dent Health 1999;16(1):12-17.

27. Jansakova K, Kyselicova K, Celusakova H, Repiska G, Ostatnikova D. The effect of saliva stimulation on the secretion of cortisol during stress and physiological conditions. Bratisl Lek Listy. 2020;121(6):428-430. doi:10.4149/BLL_2020_069

28. Lee A, Guest S, Essick G. Thermally evoked parotid salivation. Physiol Behav. 2006;87(4):757764. doi:10.1016/j. physbeh.2006.01.021

29. Yoshikawa M, Kawaguchi M. In Vivo Monitoring of Acetylcholine Release from Nerve Endings in Salivary Gland. Biology (Basel) 2021;10(5):351. doi:10.3390/ biology10050351

30. Dawes C. Physiological factors affecting salivary flow rate, oral sugar clearance, and the sensation of dry mouth in man. J Dent Res. 1987;66 Spec No:648-653 oi:10.1177/ 00220345870660S107

31. Iorgulescu G. Saliva between normal and pathological. Important factors in determining systemic and oral health. J Med Life. 2(3):303-307.

CORRESPONDING AUTHOR:

Susie P Goolsby, DDS, MSHA, Oregon Health and Science University School of Dentistry, Office of Admissions, Mail Code: SD-SA, 2730 S Moody Avenue, Portland, OR 9720, (503) 494- 5274, goolsbys@ohsu.edu

LOOKING GLASS THROUGH THE

WITH DR. SARAH GLASS

Explore the Fantastical World of Oral Pathology

An adolescent patient presents with a swelling of the hard palate. From what location should the biopsy be taken? What is the diagnosis?

A 21-year-old male patient presents with painful, recurrent, diffuse oral ulcerations that persist for several weeks prior to healing. You ask him about skin lesions, and he shows you a target lesion on the hand. What is the diagnosis?

A 59-year-old female presents with leukoplakia of the tongue. From what location should the biopsy be taken? What is the diagnosis?

>>

THROUGH THE LOOKING GLASS ANSWERS CONTINUED FROM PAGE 27

1. A tissue specimen was obtained via incisional biopsy from the central portion of the lesion with significant depth to evaluate for a submucosal tumor. There is no need for adjacent normalappearing tissue in the sample. Histopathology demonstrated a malignant salivary gland tumor consistent with mucoepidermoid carcinoma. Make sure to include salivary glands tumors in your differential diagnosis of hard palate masses.

2. Diagnosing conditions with oral ulcerations can be challenging, so gather all the information you can. The clinical presentation is suggestive of recurrent erythema multiforme. When performing a biopsy of an ulceration, including adjacent epithelium is important for diagnosis. Direct immunofluorescence is also beneficial.

3. Two tissue specimens were obtained via incisional biopsies from within the lesion. There is no need for adjacent normalappearing tissue in the sample. Areas of erythroplakia and granular/verrucous surface texture typically show more concerning pathology. In this case, the posterior biopsy showed severe dysplasia; the anterior showed superficially invasive squamous cell carcinoma.

DDS:DentalDetectiveSeries

DENTAL DETECTIVE SERIES

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VDA PAC UPDATE

Laura Givens, Director of Legislative and Public Policy

The VDA PAC has had a lofty goal each year and we have inched our way towards reaching that goal. We are hoping that 2024 will be the year that the goal is conquered! Thanks to all the support through the years from VDA members, the VDA PAC has been able to contribute to incumbents and candidates during very important election years and has continued relationship-building with lawmakers.

The goal for 2024 is $375,000. We are hopeful that this goal can be realized as more VDA members appreciate the important role that the VDA PAC plays in keeping our profession independent,

allowing dentists, not insurance companies, to make treatment decisions with their patients. It is troubling, however, to note that only 30% of the VDA membership contributes to the VDA PAC. This means that 30% of our members are doing 100% of the important political action work done by the VDA PAC.

Join the team and contribute today: Your profession and your patients deserve nothing less!

Visit https://www.vadental.org/vda-pac to make your donation. Contact Laura Givens at givens@vadental.org or 804-523-2185 with questions.

SEE WHERE YOUR COMPONENT IS AND WHAT YOU NEED TO DO TO MEET YOUR 2024 GOAL

2024 DENTAL DAYS AT THE CAPITOL:

VDA MEMBERS SHOW UP FOR DENTISTRY IN A BIG WAY

Laura Givens, Director of Legislative and Public Policy

More than 250 dentists and dental students generated plenty of heat on January 18 and 19 as the VDA’s annual Dental Days at the Capitol took place at Richmond’s Omni Hotel. These loyal advocates spent an evening and early morning with their dental comrades, speaking to legislators about the many important bills and issues currently affecting dentistry. It was an opportunity for old friends to catch up and for new relationships to be built, particularly with the many new faces in the legislature.

This year’s keynote speaker at the Dental Days Lobby Day breakfast was Speaker of the House Don Scott (D-City of Portsmouth). Speaker Scott has a special place in his heart for dentists as his wife and VDA member, Dr. Mellanda

Colson Scott, is a practicing dentist in Norfolk, VA. His positive message kicked off the morning in the best way, providing encouragement to attendees.

VDA lobbyists Tripp Perrin and Missy Wesolowski followed Speaker Scott to the podium and laid out the association’s legislative objectives before sending the troops up the hill to the Virginia General Assembly Building.

This event did not just bring together a robust group of dedicated dentists, dental students, and other members of the dental community to the Capitol. It exemplified the impact of hands-on lobbying and strength in numbers.

2024 GENERAL ASSEMBLY SESSION REVIEW

Tripp Perrin and Missy Wesolowski, VDA Contract Lobbyists

The 60-day 2024 General Assembly session began on January 10 and adjourned on March 9. Delegates and Senators introduced 2,311 bills (not including resolutions), yet only 736 House bills and 480 Senate bills survived after crossover.

In mid-February, both the House and Senate introduced their amendments to Governor Youngkin’s $185 billion biannual budget, which was introduced at the end of 2023.

This year’s session was incredibly active – playing offense and defense on several substantive and important issues. Because of significant effort by the VDA leadership, members, and staff, both prior to and during the session, we feel confident saying this has been the most successful session, from a policy point of view, for the VDA in recent memory.

PROACTIVE LEGISLATION & POLICY GOALS

Holding Dental Insurance Carriers

Accountable- Transparency in Dental Insurance Carriers -

HB 1132 (Hayes)/SB 257 (Surovell)

After over a year’s worth of back-andforth negotiations and meetings with the Bureau of Insurance (BOI), this legislation has passed both chambers and was communicated to Governor Youngkin at the time of this article. He is reviewing it, and the lobbying team has already engaged the governor’s team to sign the bill without amendments. This legislation is very important and produces substantive policy change for our membership as it does the following:

• Defines “actual loss ratio” or the percentage of a patient’s premium that goes directly to patient care versus towards overhead/profit to the insurance company.

• Requires all dental carriers to annually report their actual loss ratio and requires the BOI to make it publicly available.

• Creates a workgroup post-session with the BOI staff to vet and develop solutions for persistent problems the VDA membership may be having with insurance carriers.

License Portability & Workforce

– Authorizing Dentist and Dental Hygienist Compact –

HB 225 (Sickles)/SB

22 (Locke)

Both HB225 and SB22 passed both chambers uncontested and were recently signed by Governor Youngkin.

Funding a New VCU School of Dentistry – Budget Item C-14

Virginia Commonwealth University (VCU) can use up to $5,200,000 in non-general funds to evaluate alternative sites, designs, and operational alternatives for replacing the present dental school facilities. This is an issue the VDA has worked very closely on for the last couple of months. The lobbying team has been working alongside the VCU team to secure funds to begin building a new dental school on the school’s downtown campus. The budget being sent to the Governor has the VCU Dental School funding authorization included.

Remote Supervision of Dental Hygienists - HB 605 (Price)

HB605, only introduced in the House, was unanimously approved by both chambers. This bill simply gives more flexibility in the time between seeing a hygienist remotely and having an in-person visit with the supervising dentist. This time frame has been increased from 90 days to 180 days. This legislation was headed to the Governor for signature at the time this article was written, and we expect approval.

SafeHaven™ for Dentists and Dental Hygienists – HB 42 (Hope)/ SB 629 (Pillion)

This legislation extends the civil liability protections of Virginia’s provider wellness program (known as SafeHaven™) to dentists and dental hygienists and strengthens those protections for providers seeking voluntary inpatient treatment for mental health services. Both pieces of legislation passed the House and Senate uncontested and were signed by Governor Youngkin. This legislation becomes effective on July 1, 2024.

DEFENSIVE LEGISLATION

Medical Debt Reporting - HB 1370 (Delaney)

This bill passed the House on a near party-line vote of 54-46 and is likely going to pass the Senate before the session ends. This legislation, as introduced, was extremely problematic as it would not allow reporting of delinquent debt to credit reporting agencies if a patient used a credit card to pay for the procedure. We have lobbied with other interests to have this bill amended heavily and effectively; any relevant procedures for dentists are NOT included in the bill.

Medical Malpractice Cap - SB 493 (Stanley)

This legislation passed the Senate Courts of Justice Committee, but it was defeated in the Finance Committee. This bill would have raised the long-standing med-mal cap for oral surgeons. The VDA worked alongside the Medical Society of Virginia and many others to defeat it, as we have done in the last several years. However, it is important to note this issue is becoming increasingly difficult to defeat, so there will be discussions in the months ahead on a potential solution for the 2025 Session. We will make sure the VDA is a part of those discussions.

Universal Licensure SB 682 (Suetterlein)

This legislation, as originally contemplated, would have significantly loosened licensure requirements for dentists and dental hygienists. It was heavily debated in the subcommittee and after many conversations with the Youngkin Administration, who supported the bill, we were able to carve out the dental community. Ultimately, the bill was killed. It is likely to be back in future years as access to care and portability of providers’ licenses remain policy goals for many members of the key committees.

We are excited for this year’s agenda for the Showcase, being held for the first time at the worldfamous Greenbrier Resort.

I look forward to the Showcase every year for the insightful presenters who help my practice stay ahead of emerging trends in dentistry. I come back every year because this is where I can surround myself with the most engaged, successful dentists and practice owners in Virginia, who care not only about understanding where the profession is going but are serious about shaping its future. I hope you’ll join us.

Our popular exhibit hall will be held within the historic Greenbrier Bunker, with new exhibitors to help take your practice to the next level and a special focus on AI in dentistry.

Based on your feedback, we’re offering more focused continuing education and continuing the popular Certified Dental Office Professional program, while leaving plenty of time to explore the exhibit hall and the resort.

We will also be providing a diverse menu of experiences to connect and enjoy the amenities offered at The Greenbrier, ranging from skeet shooting, off-roading on Polaris rentals, full-service

spa, falconry, and dozens of other unique options that your whole family will enjoy.

For families, The Greenbrier offers a popular daytime kids-club and has childcare options during the evening receptions.

Don’t forget your formalwear for the president’s party and you can enjoy the Greenbrier’s Casino Club afterwards, including 31 table games.

The VDA is happy to once again partner with the Virginia Academy of Pediatric Dentistry for this time of learning, comradery, and fun, and I look forward to seeing you there.

Sincerely,

Dr. Ralph Howell Chair, VDA Council on Sessions

Schedule of Events

Schedule of Events

Pediatric Dentistry Courses

FRIDAY, SEPTEMBER 13, 2024

CREDITS: 2

SATURDAY, SEPTEMBER 14, 2024

CREDITS: 4

11:00am-1:00pm

Management of Traumatic Dental Injuries in Children and Adolescents

Dr. Elizabeth Berry, Dr. Jayaraman Jayakumar, Dr. Karina Miller

A Review of the Guidelines and Case Series

Pediatric dental trauma can be overwhelming for any dentist. This course is designed to provide evidence-based clinical protocols for the management of pediatric dental trauma. An introduction to trauma will be provided followed by how to properly evaluate a patient. A review of current guidelines will be presented, along with presentations of specific trauma cases.

Objectives:

• Describe the methods of examination and evaluation of pediatric dental trauma

• Explain current guidelines on the management of pediatric dental trauma

• Describe specific cases of pediatric dental trauma in primary, mixed, and permanent dentition

8:00am-1:00pm

WORKFLOW OF THE FUTURE: Revisit your practice’s clinical operations from a workflow and profitability perspective

Dr. Joel Berg and Dr. Chrisina Carter

Revisit your practice’s clinical operations from a workflow and profitability. Take a fresh look at the primary clinical procedures and processes you perform in your office from a workflow perspective and learn how to optimize outcomes. This half-day course will look at the “workflow of the future” that combines modern technologies for information gathering, diagnosis, treatment planning, and delivering excellent restorative and orthodontic care. Learn how digital workflow can assist in coordinating care between the pediatric dentist and the orthodontist, whether you are “co-located” or in separate practices. You will identify ways to achieve the best outcomes in all key realms of the Pedo-Ortho practice using best practices, best technologies, and appropriate metrics.

Objectives:

• Understand the elements of workflow and its conceptual framework

• Describe the diagnostic methods for the future of pediatric dental practice

• Describe the best workflows for restorative dental procedures on children

• Describe the best ways to interact between the pediatric dentist, the orthodontist, and other providers important to our patients

FRIDAY, SEPTEMBER 13, 2024

CREDITS: 1

VDA Academy Courses

4:00pm-5:00pm

Nobody Told Me That! Management Issues

Everyone is Afraid to Talk About

Ms. Teresa Duncan

Do you ever wish someone would have just told you about that strange rule? Or that employee management would be so complicated? Unexpected situations can test even the most experienced manager! Often, we manage by our very strong intuition but still make mistakes. Let’s discuss how

SATURDAY, SEPTEMBER 14, 2024

CREDITS: 2

8:00am-10:00am

Top Coding and Documentation Strategies:

Maximize your Insurance Reimbursement

Dr. Greg Grobmyer

Join Practice Booster’s coding expert, Dr. Greg Grobmyer, as he discusses coding strategies that will help you minimize write-offs, maximize reimbursement, and grow your bottom line. Not only will you learn to avoid common errors, but you will also learn coding strategies and documentation methods that make the most of your insurance participation.

CREDITS: 2

11:00am-1:00pm

Workplace Intelligence: A Guide to The Law of the Workplace and How Workplace Policies Can Help to Automate Productive Employee Conduct

Mr. Charles G. Meyer, III and Ms. Joan McKenna

An Employee Handbook is an often underestimated but powerful tool for all employers, including dental practice employers. Your Employee Handbook is the document that sets forth your practice’s expectations of its employees, as well your commitment to legal obligations to your workers. This presentation will use a model handbook as a starting point for a discussion of various employment considerations to set your practice up for success in maximizing its employment relationships.

to protect ourselves by staying ahead of the game. We will use lessons and examples from each other to make us all stronger business leaders!

Objectives:

• Explore surprising employee management issues

• Prepare your team for strange patient situations

• Discuss potential regulatory pitfalls

Objectives:

• Learn the most common coding errors and how to avoid them

• Discuss proper documentation for clean claim submission

• Gain an understanding of coding and reporting strategies to maximize legitimate reimbursement

• How to involve the entire team in the process of growing your bottom line

Objectives:

• Participants will learn about the nature of the “at will” employment relationship, the limits on the at-will relationship, and the role that workplace policies hold in communicating enforceable standards for workplace conduct within the context of at-will employment

• Participants will receive practice guidance on how to handle frequent employee performance issues in a constructive and legal manner

• Participants will learn the top 3 employee policies to leverage success with your workforce

• Participants will be provided with a model handbook they can adapt for their workplace.

PRESENTED BY VDA PRESIDENT

DR. DUSTIN REYNOLDS SAT SEPT 14 7:00-10:00 PM

JOIN US FOR A COCKTAIL HOUR SPONSORED BY THE NEW DENTIST COMMITTEE BEFOREHAND 6:30-7:00 PM

Event Lodging

THE GREENBRIER RESORT

101 Main Street West

White Sulphur Springs, WV 24986

The VDA’s group rate is $379 plus taxes and fees. The group discount expires on August 28, 2024, OR when the block is full. We highly recommend making your reservation at your earliest convenience.

To book your room, please call 1-855-815-4441 and mention the group VDA Showcase. You may also book your reservation online.

Check in is 4:00pm and Check out is 11:00am

Included in Your Rate and Daily Resort Fee:

• Self-Parking (Valet - $30/day)

• Hairdryer

• Robes and Slippers

• USB Charging Stations

• Daily Turndown Service

• Greenbrier Mineral Spa Toiletries

• Digital Newspaper

• Daily Ice Service

• Flat-Screen TV

• Iron and Ironing Board

• Private In-Room Safe

• Keurig Coffee Maker

• Lighted Vanity Mirrors

• Morning Coffee Service

• Afternoon Tea

• Nightly Movies in the Theatre, Historical Tours and Presentations (Bunker Tours excluded)

• On-property Transportation

• Resort- Wide wireless internet connectivity, Cyber Café with Complimentary High-Speed Internet

• Champagne Toast in the Casino Club

• Culinary Demonstrations

• Hiking Trails, use of the resort’s Fitness Center (at Tennis Center or Indoor Pool)

• Use of the resort’s indoor and outdoor pools

• Local and toll-free phone charges and entertainment provided by the Casino Club’s Beverage Entertainers

*These amenities are subject to change based on seasonality or availability.

Event Dining

Gather around one of our coveted tables. Savor every bite of your Greenbrier getaway in the refined elegance of our fine dining venues, the laid-back charm of our casual eateries, and our mosaic of restaurants, lounges, and bars that celebrate the best of tradition and innovation. Welcome to Southern resort dining at its grandest, where every dish is served with soul and style.

For more information on the various restaurants within The Greenbrier Resort please visit https://www.greenbrier.com/dining/

Reservations at most restaurants are encouraged.

THE ROI OF ETHICS

Dr. Robert F. Morrison

There is a wonderful book, “Everything is Marketing” by Fred Joyal, that is a mustread for anyone in business or working with the public. It is on our required reading list for all our managers in our organization. Why? Every interaction we have with our patients has an impact on their experience. There is an adage by Will Rogers, “it takes a lifetime to build a good reputation, but you can lose it in a minute.” All of us in dentistry work to build a good reputation— online, in the office, in the community, and in the profession. It is important for us as professionals but also as a business. I have told my team for over 30 years, “We are a business. Our business is dentistry.” We must have a healthy business to employ others, purchase equipment, and make good decisions.

Where does ethics fit into today’s practice models—solo practice, group practice, partnership, small DSO, or large DSO? As the book I referenced above shows, everything we do is a form of marketing; in our professional and dental business lives, “Everything is Ethics.” The decisions we make in dealing with patients and their needs with diagnosis, treatment planning, financing, insurance, and referrals are tied to ethics. “Ethics guide us to make a positive impact through our decisions and actions” (Ethics in Business and LifeSanta Clara University, Aug 26, 2019).

So, what is the big deal about a return on investment (ROI) perspective? In today’s professional and business world, our reputation has become more important than ever with social media, reviews, email, and texting. Good or bad information is posted almost immediately. Most of us check reviews and online ratings of the businesses that we utilize. ROI is about getting a return for our business in whatever we invest in—

technology, training, office décor, number of employees, etc. Our biggest investment has been in ourselves. The education and training we received, the loans we took out for education, continuing education, practices, buildings, and improvements. If our biggest investment was in ourselves, we need to protect that investment with our reputation. The biggest investment in a reputation is ethics.

Our patients will not remember us or refer to us because they think we are technically good or great dentists. They will appreciate and even expect that we do good work (and we should). What will get them to come back to us and send their family, friends, and co-workers? The answer is their emotional response to how they feel about us as individuals. Do they feel we are good people? Do they feel we have their best interests in mind? Do they feel that we will be their advocate in their healthcare? Do they feel that we will “do the right thing”? Our reputation is what they base this on. What they read, what they see, and what they hear about us. Staff, patients, and friends will look at and evaluate how we act and the decisions we make because of the leadership positions we all are in as dentists.

A robust referral program for new patients (NP’s) should include external acquisitions of NP’s. However, the overwhelming majority of NP’s (85+%) should come from internal referrals from your existing patients. When our patients feel we are doing the right things, they will refer. These referrals have an outsized impact on the health of your business— in other words, your ROI. As dentists, we refer to specialists and our medical colleagues who we believe will treat our patients ethically and skillfully. Ethics are part of the fabric of our profession, and when we weave them into our daily lives,

they create something that will wear well throughout our careers and beyond. Think about the people you most respect in your life. These people are undoubtedly still building their reputation daily. I invite all our readers to think of this daily and then enjoy the rewards of a satisfying and profitable career.

As dentists and health professionals, it is all too easy to get caught up with the challenges of patient treatment and our schedules. However, we must, as leaders and often business owners, “think outside the operatory.” We are comfortable inside the treatment room where we know the procedures and the equipment. Thinking outside the operatory requires us to put ourselves in the shoes of our staff, patients, and our communities. This can be challenging for some of us, but the rewards are worth it. Have fun!

PAYMENTS IN THE PRACTICE

WHAT TRENDS ARE AFFECTING YOUR BOTTOM LINE?

Phil Nieto, President Of Best Card

Dentistry can be an isolated profession, and it is often difficult to know how your practice compares to that of your peers. While no two practices are identical, how would you know if the trends in your office were being seen by other dental practices? Some questions regarding profit volume and profitability can be embarrassing to ask another practitioner. The landscape of the payments your practice accepts has probably changed drastically in the last few years, but those changes often can slip under the radar even when it is significantly affecting your bottom line.

Best Card, the endorsed payment processor of VDA Member Perks and ADA Member Advantage, has been working with thousands of dental offices nationwide for over 15 years. We want to pull back the curtain on the uncomfortable questions you may not want to ask your fellow practitioners:

• How much does the average dental office collect in credit card payments?

• Have dentists raised their prices to keep up with inflation?

• What are other dentists paying to accept credit card payments?

• How much SHOULD you be paying?

Using our data from thousands of dental offices over the past 15 years, here is a little peek into what the average dental practice has experienced!

How much does the average dental office collect in credit cards?

Dental offices have seen a large increase in the total amount of credit card payments collected over the past 10+ years. Covid accelerated that trend considerably, as patients moved towards payment methods that were more convenient and involved less physical contact. Furthermore, many insurance providers started issuing virtual credit cards as payment for their remittances, which also increased the amount of card payments dental practices accept.

In 2023, the average dental office ran $44,925 in credit card payments per month.

• That is a 45.5% increase over the 2019 average of $30,876.

• It is a 195% increase over the 2009 average of $15,221. The average practice is now running almost three times as much in credit cards as in 2009!1

While accepting credit cards ensures that offices can quickly and easily collect payments, with more patients and insurance providers choosing to pay with cards, it is a much more substantial factor in the practice’s total profitability than in the past.

Have practices raised their costs to keep up with inflation?

Every dentist knows that COVID-19 and the resulting supply chain and inflation issues increased the costs of many items used regularly in the practice. As a result, many dentists have had to raise their prices over the last several years in response to those increased business costs. We can see this trend clearly by looking at the average payment size across all practices.

• The average credit card payment accepted by dental offices in 2023 was $306 compared to $273 in 2019 – an increase of 11.87% in just four years.

• From 2009 to 2019, the average payment only increased 0.12% over a 10-year period.

CONTINUED FROM PAGE 45

• 2023 saw a slight decrease in the average payment compared to 2022, from $307 to $306, indicating that increases due to inflation may be slowing.2

The Consumer Price Index shows that inflation in the U.S. from 2019 to 2023 was 19.2%, so even though the increase in average dental transaction size from 2019 onward marked a substantial

Put into real numbers:

• The average office in 2019 ran $30,876 at a rate of 3.06% for a total of $944 monthly fees.

• The average office in 2023 ran $45,000 in card payments and is now paying 3.45%, for a total of $1,585 per month in fees.

• For the average practice, that is an increase of $7,692 per year in costs over four years.5

difference compared to 2009-2019, the 11.87% increase has not kept up with the economy-wide price hike.3, 4

What does the average practice pay to run cards?

While the average dental office’s payment volume has increased, the costs incurred to run those payments have also increased. Oftentimes, these fees can be hard to understand. What is easy to discern, however, is the impact on the bottom line of the practice. To figure this out, you should calculate your effective rate with some simple math:

Total Fees Paid for the month ÷ Total Run in Card Sales during the month = Your Effective Rate

In 2023, the average dental office in the U.S. paid 3.53% compared to 3.06% in 2019. These rates are already too high, but to put it in perspective, back in 2014, the average dental office paid 2.84%.

The average practice is paying more as a percentage per payment while also accepting 45% more card payments than they did back before the pandemic. That makes a big difference.

Summary:

While the average office paid more than 3.53% in 2023, Best Card’s average dental office on the exclusive rates offered to VDA Members paid 2.22% in 2023 for an average savings of $6,496 annually.

Dental practice owners are busy, and sometimes, it is easy to overlook small increases in the costs of services you are using. However, those small increases are often frequent enough to have a significant impact. Any part of your business that increases substantially over time should be analyzed periodically to ensure that it is meeting the needs of your bottom line.

If you see that you are paying more to accept credit cards and are taking more payments, it might be time to look for a better option.

To find out what Best Card might be able to save your practice, send us a recent monthly statement and we can do a complimentary cost analysis to show you exactly what your practice could be saving.

Phone: (877) 739-3952

Email: Compare@bestcardteam.com

Fax: (866) 717-7247

References:

1. Best Card (2009 – 2023). Average Amount Processed Per Month 2009-2023. Best Card. Retrieved from [Processing Volume Report 2008-2024].

2. Best Card (2009 – 2023). Average Payment Amount Per Transaction 2009-2023. Best Card. Retrieved from [Processing Volume Report 2008-2024].

3. U.S. Bureau of Labor Statistics, (December 2019 – December 2023). CPI Inflation Calculator. Retrieved from [U.S. Bureau of Labor Statistics].

4. Federal Reserve Bank of Minneapolis, (1913-Present). Inflation Calculator. Retrieved from [Inflation Calculator, Federal Reserve Bank of Minneapolis].

5. Best Card (December 2019 – December 2023). Average Effective Rate Dec. 2019_ Dec.2023. Best Card. Retrieved from [Processing Volume Report 2008-2024].

VDA MEMBER PERKS ENDORSES THREADFELLOWS TO ENHANCE BRANDS

Karen Wood, Director of Operations; Virginia Dental Services Corporation

Member dentists can enjoy a 10% discount on products with free logo set up, decoration, and shipping.

VDA Member Perks is endorsing Threadfellows for member dentists looking to enhance their practice’s branded gear for wear or use in the office and beyond.

With apparel, bags, water bottles, and other items from brands like Patagonia, Columbia, Nike, Osprey, The North Face, FjallRaven, and more, Threadfellows can help offices apply their practice logo to apparel and items for themselves, their families, their staff and even patients.

Founded in 2017 and based in Madison, Wisconsin, the Threadfellows team has over 60 years of combined experience in the apparel and uniform industries.

“We wanted to take that experience of protecting our clients’ brands and combine it with the power of strong apparel brands,” said Justin Krbec, Threadfellows’s Senior Vice President. “By putting your practice’s brand on a Patagonia or a Travis Matthew polo, you are raising the prestige of your practice’s name, making that brand’s principles and quality a nod to your own. When you hand a team member a jacket as a gift with your logo on it, that item says something about you and how you feel about the person you are giving it to. Giving someone an apparel piece they wish they would buy on their own does more than check the box that you gave them something; it shows true thought and appreciation.”

“We are really excited about extending this endorsement to Threadfellows,” said Dr. Frank Iuorno, Jr., President of the

Virginia Dental Services Corporation. “More and more, we are hearing from dentists and team members who are requesting brands, styles, fits, and trims that they are buying for themselves in their personal lives. We are excited that Threadfellows can give our members the ability to provide these team members, and themselves, with what they want — whether that is an Adidas polo or a North Face jacket.”

The ordering process for Threadfellows is simple. Go to the website, pick the gear, upload your logo, and Threadfellows will send a proof to approve and then the gear shows up.

VDA members can enjoy a 10% discount on products, free logo setup, free decoration, and free ground shipping.

For more information, visit threadfellows.com/ADA or contact Karen Wood at wood@vadental.org

PRESENT STATUS AND FUTURE DIRECTIONS: VERTICAL ROOT FRACTURES IN ROOT FILLED TEETH

Patel S, Bhuva B, Bose R | Int Endod J. 2022;55(Suppl. 3):804–826

Vertical root fracture (VRF) is a common cause for the extraction of endodontically treated teeth, but accurate diagnosis with cone beam computed tomography (CBCT) can oftentimes pose a clinical challenge. This review article addresses the etiology, predisposing factors, histopathology, diagnosis, and management of VRF.

Vertical root fractures have a multifactorial etiology, with endodontically-treated maxillary premolars and mandibular molars being the most commonly affected teeth. The incidence rises with age and is particularly prevalent in individuals older than 40 years.

Anatomical risk factors include teeth with a presence of an isthmus and narrow mesio-distal dimensions. Reductions in the structural integrity of the tooth, preexisting cracks and fractures, as well as parafunction all increase the risk of VRF. Additionally, inappropriate restoration of endodontically-treated teeth can generate unfavorable stress within the root, leading to an increased prevalence of VRF.

Although the pathogenesis remains unclear, there is a suggestion that this type of fracture initiates as a crack in either the coronal or apical region of the tooth. With prolonged exposure to thermal and cyclic loading, the fracture gradually advances longitudinally, compromising the overall integrity of the root structure.

Early-stage diagnosis can be challenging since patients may not exhibit signs or symptoms of apical periodontitis. As the fracture advances, indicators such as tenderness to palpation, percussion, and biting may emerge. Additionally, increased mobility, the presence of an isolated probing depth, swelling, or the presence of a sinus tract may occur. A deep, isolated, narrow probing depth on both sides of a root is pathognomonic for a vertical root fracture, as are multiple sinus tracts that may be located more coronally.

The radiographic presentation of a vertical root fracture can be highly variable. In advanced cases, the ‘classic’ J-shaped lesion or ‘halo’ radiolucency often involving the furcation region may be apparent. Interproximal crestal bone loss

Ribeiro G, Martin V, et al. |J Endod 2023;49:1733–38

New file systems have been introduced with the goal of being more effective in preserving tooth structure while still allowing thorough cleaning and preparation of the apical region of the canal system during root canal procedures. Current methods for root canal therapy (RCT) focus on

preservation of dentinal tooth structure, keeping the original canal shape during instrumentation, and allowing for the complete obturation of the root canal system. Efforts to retain the original canal architecture, as well as the pericervical dentin, have been shown to have a direct influence on the tooth’s fracture

may be evident when the fracture initiates at the CEJ and progresses apically. Rootfilled teeth restored with cast posts may present with lateral root radiolucencies. Current research indicates that while CBCT may not precisely identify vertical root fractures within the root, CBCT shows significantly higher sensitivity and accuracy in detecting periradicular bone loss patterns indicative of a VRF, when compared to periapical imaging. CBCT use is justified in cases when the clinical and conventional radiographic examinations are inconclusive in reaching a clear diagnosis in a case of suspected vertical root fracture.

The prognosis of a tooth diagnosed with VRF is poor and can be confirmed by surgical exploration or examination after extraction with high magnification. Timely extraction of teeth with a vertical root fracture can minimize the impact on subsequent implant treatment planning.

Ryan Hediger DMD, Resident in Endodontics, Virginia Commonwealth University

resistance and long-term prognosis. The purpose of this ex vivo study was to comparatively evaluate the functionality of WaveOne Gold (WOG), TruNatomy (TN), and ProTaper Ultimate (PU) file systems regarding canal shaping, dentin preservation, and smear layer removal ability. >

THE PULPAL RESPONSE TO CROWN PREPARATION AND CEMENTATION

Ptak DM, Solanki A, Andler L, et al. | J Endod 2023;49(5):462-468

Full coverage restorations are commonplace in the general practice of dentistry and are often necessary and beneficial in many clinical scenarios. Teeth that need full coverage restorations are likely to be missing a large portion of the original hard dentinal tissue that insulates the dental pulp from mechanical stresses and harmful microbes in the mouth. Because of the hindered ability of the adult pulp to repair itself after injury, repeated damage to the tooth can result in a “stressed pulp.” This “stressed pulp” may not be able to withstand further dental treatment without irreversible changes occurring to the pulp tissues.

The study titled “The Pulpal Response to Crown Preparation and Cementation’’ conducted a comprehensive review of 2177 cases to investigate the incidence of pulpal disease following large dental restorations. Their aim was to evaluate the risk factors and occurrence of pulpal disease following the placement of either full-coverage (crowns) or large non-crown restorations (fillings, inlays, or onlays). Only patients with intact pulp tissues were included in the study.

It was observed that about 9% of patients developed pulpal disease after receiving either full-coverage crowns or large noncrown restorations. The development of pulpal disease was determined from those patients who required endodontic intervention or extraction following the restorative treatment. The research found a slightly higher incidence of pulpal disease in patients who received large non-crown restorations compared to those who had full-coverage crowns. Factors such as the type of restorative material used (amalgam versus composite) and the number of surfaces involved in the restoration did not significantly impact the development of pulpal disease. This finding suggests that the incidence of pulpal disease is influenced more by the extent of the dental procedure rather than the materials used or the complexity of the restoration.

when compared to a young adult dental pulp. This is an important consideration for dental professionals when planning extensive restorative treatments, especially for older patients or those requiring full-coverage restorations.

Human maxillary incisors were randomly distributed into three groups for instrumentation by using one of the following file systems: WOG, TN, and PU. Microtomographic evaluation and morphometric assessment on fifteen teeth were used to evaluate the canal shaping ability and pericervical dentin preservation. In six teeth, the smear layer was evaluated by a scanning electron microscope. Results from this study showed that TN and PU had the lowest canal variation from instrumentation, and both were significantly lower than WOG (P<.05). In all groups, pericervical dentin removal was reduced, with TN obtaining the highest preservation of dentin. TN and PU were significantly

The study also highlighted that older patients, along with teeth with fullcoverage restorations, had a higher risk of developing pulpal complications (though not statistically significant), presumably because the advanced age of adult dental pulps reduced the status to rebound higher in the preservation of pericervical dentin when compared to WOG. There was no significant difference between the three file systems regarding smear layer removal ability. The dentinal tubules were opened or partially opened in all the samples.

Amongst the three file systems evaluated in this study, TN and PU provided the most dentin preservation with the least volume change and best preservation of the pericervical dentin when compared to WOG. None of the three file systems tested completely removed the smear layer in the apical area.

In conclusion, the research provides valuable insights into the pulpal response to large dental restorations. Though they are necessary, any dental restorations, by nature, come with inherent risks and are capable of inflicting irreversible damage to the pulpal tissues. Dental providers should be cognizant of these risks and inform their patients. The study quantifies the low but significant risk of pulpal disease associated with these procedures, emphasizing the importance of careful consideration of patient-specific factors in dental treatments. This study serves as a useful reminder for dental practitioners in managing and preventing pulpal complications in patients with a comprehensive restorative plan.

W. Banks Lee, DMD; Resident in Endodontics; Virginia Commonwealth University

Yasamin Mojarad, DDS; Resident in Endodontics; Virginia Commonwealth University

THE CORRELATION OF CRACK LINES AND DEFINITIVE RESTORATIONS WITH THE SURVIVAL AND SUCCESS RATES OF CRACKED TEETH: A LONG-TERM RETROSPECTIVE CLINICAL STUDY

De Toubes KMS, Soares CJ, Soares RV, de Souza Côrtes MI, Tonelli SQ, Bruzinga FFB, Silveira FF | J Endod 2022; 48(2):190-99

Diagnosing and treatment planning a cracked tooth (CT) is a challenge for general dentists and endodontists alike. The prognosis of a CT is often multifactorial, dependent on the location and extent of the crack, the initial intervention, as well as the type of restoration used. Often not visible upon basic clinical inspection, crack lines (CLs) can be visualized with aids like dyes, transilluminators, surgical microscopes, and CBCT. If a CT is not identified and treated early, the crack may propagate, leading to a split tooth and severe periodontal defects.

As such, the type of restoration required to improve the prognosis of cracked teeth remains controversial, varying from adhesive restorations to onlays and full-coverage crowns. The aim of this research, then, was to assess the success and survival rates of cracked teeth within a period of 11 years and their possible correlation with the nature of CLs and the types of restorations provided. The null hypothesis of this study was two-fold and stated there was no correlation between 1) the direction of the CLs and the survival of cracked teeth and 2) the type of restoration and the survival of cracked teeth.

The data was collected from clinical records of patients treated between March 2009 and February 2021 (11 years) at a private endodontic clinic, with the inclusion criteria of 1) the presence of pain during mastication regardless of pulpal diagnosis and 2) the visualization of CLs under a surgical microscope. The exclusion criteria were diagnoses of a split tooth or vertical root fracture.

Of the 111 teeth demonstrating CLs, 86 teeth from 71 patients met the inclusion criteria. The factors assessed in the study were the date of treatment, age, sex, type of posterior tooth, arch, percussion/ thermal/bite tests, eating habits, pulpal/ periapical diagnoses, number/location/ extent of CLs, marginal ridge involvement, pulpal floor involvement, root canal involvement, probing depth, occlusal interference, tooth functionality, and coronary condition (before and after definitive restoration). The study also described the clinic’s treatment protocol for cracked teeth, dependent on clinical signs and symptoms, as well as the extent of CLs.

The majority of cracked teeth were present in the mandibular arch (61.6%),

58.2% of which were mandibular molars. The overall success rate was 93%, and the overall survival rates at 1, 5, and 11year follow-ups were 98.6%, 94.9%, and 55.9%, respectively. The survival of the tooth was not affected by the direction of the CLs. No significant association was noted between the type of tooth, probing depth, root canal treatment, and tooth loss. The analysis showed that previously cracked teeth, the provision of onlay restorations, and the placement of posts had significantly higher correlations with tooth loss. The placement of full-coverage crowns resulted in lower tooth loss compared with the placement of onlays.

In conclusion, survival of a CT was negatively impacted by previous endodontic treatment in teeth that subsequently developed CLs. Early placement of full-coverage crowns should be implemented for cracked teeth regardless of the direction or the number of CLs because it was associated with a higher cracked tooth survival rate.

Will Rudnicki, DDS; Resident in Endodontics; Virginia Commonwealth University

FOUR-YEAR PULP SURVIVAL IN A RANDOMIZED TRIAL ON DIRECT PULP CAPPING

Ballal, Nidambur Vasudev, et al. | J Endod 2024;50:4–9

The outcome of performing direct pulp caps on teeth with advanced carious lesions has been a controversial topic because of the varied approaches in the treatment protocol.

This randomized clinical trial investigated the four-year pulp survival rates

following direct pulp capping in adult teeth with carious exposures. The study assessed the efficacy of pulp lavage with either physiological saline or 2.5% sodium hypochlorite (NaOCl) solution in nonpainful posterior teeth. A total of 96 patients underwent complete caries excavation, direct pulp capping

with mineral trioxide aggregate (MTA), followed by an immediate composite resin restoration. Pulpal fluid was analyzed for matrix metalloproteinase-9 (MMP-9) and total protein (TP) levels to predict treatment outcomes. Clinical and radiographic assessments were conducted after one- and three-year >

RISK FACTORS FOR AND CLINICAL PRESENTATIONS INDICATIVE OF VERTICAL ROOT FRACTURE IN ENDODONTICALLY TREATED TEETH: A SYSTEMATIC REVIEW AND META-ANALYSIS

Haupt F, Wiegand A, Kanzow P | J Endod. 2023 Aug;49(8):940-952

A vertical root fracture (VRF) is defined as a longitudinal fracture along the axis of the root, which can appear as an incomplete fracture, involving only one aspect of the root, or a complete fracture, extending from one side to the opposite side. A VRF has been reported to be a multifactorial phenomenon with both predisposing and contributory risk factors. The prevalence of VRFs in endodontically treated teeth (ETT) has been reported to fall in a wide range from 3.7% to 25%, which may be due to the difficulty in diagnosing a VRF, heterogenous inclusion criteria, and different diagnostic procedures to verify the presence of a VRF.

The purpose of this study was to identify specific clinical signs or symptoms and potential risk factors that are most likely associated with the presence of a VRF in ETT. Electronic databases were searched in October 2022 for prospective and retrospective clinical studies in which at least either the clinical presentation or potential risk factors associated with a VRF in ETT and non-fractured ETT (controls) were assessed. Two reviewers independently performed screening and inclusion of sources. From the included sources, the two reviewers then extracted data, including the authors,

year of publication, country, diagnostic procedures to verify VRF, radiographic features, number of teeth presenting certain clinical signs or symptoms, and the number of teeth associated with certain risk factors. Independent meta-analyses of odds ratios were then performed.

In total, fourteen sources reporting on 2877 teeth, including 489 with VRF and 2388 without VRF, were included in the meta-analyses. Regarding the clinical presentation, the presence of sinus tracts, increased periodontal probing depths, swelling or abscess, and tenderness to percussion were significantly associated with the presence of a VRF. Increased tooth mobility was not significantly associated with the presence of a VRF. None of the assessed risk factors, including sex, type of teeth, tooth location, posts, indirect restoration, and apical extension of the root canal filling, were found to be significantly associated with the presence of a VRF.

A VRF is a multifactorial phenomenon that is challenging to diagnose. However, in this systematic review, the four most significant signs and symptoms of a VRF in ETT were elucidated. These included

the presence of sinus tracts, increased probing depths, swelling or abscess, and tenderness to percussion. In the case of a VRF, the sinus tract is usually located more coronally close to the attached gingiva rather than in the apical region. An isolated, increased probing depth is situated close to the fracture side and is one of the most typical signs of a VRF. None of the assessed risk factors pointed out to be significantly associated with a VRF.

Lastly, the present study notes radiographic examination as one of the most essential tools when diagnosing a VRF; however, due to the heterogenous data regarding the used radiographic features this study was unable to include specific radiologic characteristics. In cases of non-specific symptoms and inconclusive two -dimensional radiography, cone beam computed tomography (CBCT) may be indicated to reveal bony defects adjacent to the fractured side suggesting the presence of a VRF.

Shivali Bhatt, DDS, Resident in Endodontics, Virginia Commonwealth University

post-treatment periods. The KaplanMeier method was used to estimate pulp survival up to 1500 days.

Results indicated that the NaOCl lavage significantly enhanced pulp survival rates compared to saline, with 55% (95% CI, 30%-100%) versus 7% (95% CI, 1%40%) survival rates, respectively. High MMP-9/TP levels were associated with early and painful treatment failures but did not predict late failures. The study concluded that while 2.5% NaOCl lavage improved pulp survival and reduced painful failures, the overall low success

rate challenged the viability of direct pulp capping for the cases included. The findings suggest that inflammatory states under deep caries may not be solely related to neutrophil infiltration, as indicated by the limited predictive value of matrix metalloproteinase-9 (MMP-9) beyond early treatment failures.

Abdulaziz Mallik, DDS, Resident in Endodontics, Virginia Commonwealth University

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CLINICAL MANAGEMENT OF EXTERNAL CERVICAL RESORPTION: A SYSTEMATIC REVIEW

Giulia Bardini DDS, PhD et al. | Aust Endod J. 2023 Dec;49(3):769-787

External cervical resorption (ECR) is a form of invasive root resorption at the enamel–cementum junction that, if untreated, can lead to substantial loss of tooth structure. ECR has been attributed to various predisposing factors, including trauma, orthodontic treatment, occlusal dysfunction, coronal bleaching, periodontal treatment, viral infections, developmental and eruption disorders. While etiology and pathogenesis are not entirely understood, inflammation is a prerequisite for the initiation of resorption. It has been hypothesized that ECR is initiated by the absence of or damage to the external protective cementum layer, during which the exposed dentine is invaded by clastic cells and is progressively replaced by non-infective hyperplastic invasive fibrovascular tissue. In the later stages, the resorptive process reaches the pulp, which may cause pulpitis and, ultimately, pulp necrosis if no treatment is initiated. The treatment objectives focus on removing the resorbing tissue, preventing its reoccurrence, retaining tooth structure, and the restoration of the tooth to reestablish function and esthetics. ECR is typically asymptomatic until pulpal or periodontal symptoms develop, with clinical appearance ranging from resorptive defects at the gingival margin to pink coronal discoloration of the tooth. The radiographic features vary from well-delineated to irregularly bordered mottled radiolucency.

Various treatment options are available, ranging from non-surgical or surgical repair, intentional replantation, periodic review, and extraction. However, no formal and globally accepted guidelines have been developed that link the different therapeutic approaches to specific clinical situations involving

ECR. Heithersay introduced the first clinical classification for ECR based on the location, size, proximity to the pulp chamber, and degree of invasion into the root; this classification includes Class 1 (H1) small cervical lesion with shallow penetration into the dentin; Class 2 (H2) well-defined lesion that has penetrated close to the pulp chamber with little or no extension to radicular dentin; Class 3 (H3) lesion extended to the coronal third of the root dentin; and Class 4 (H4) large lesion extending beyond the coronal third of the root.

This review used a systematic approach to investigate whether any method used to remove the resorptive tissue or the choice of material used to repair the defect influenced the treatment outcome of ECR lesions particularly in relation to the Heithersay classification. A comprehensive electronic search was conducted to identify published papers detailing therapeutic management of ECR with follow-ups and outcome measures after a minimum period of twelve months. The search yielded 870 articles, 60 clinical case reports, and six case series which reported on clinical and radiographic outcomes of 95 teeth with ECR in 80 patients where most cases were treated in university settings, with a nearly equal distribution between genders and an average patient age of 33.51 years.

The research found that access to the resorptive lesion is achieved through either an external approach, including nonsurgical external access, surgical flap reflection, orthodontic extrusion, and intentional reimplantation, or via an internal approach with non-surgical access to the resorptive tissue through root canal treatment, in addition to a

combined approach of internal and external (surgical and non-surgical) therapeutic access. The removal of resorptive tissue is achieved using either mechanical excavation or in some cases, involves the use of chemicals, such as sodium hypochlorite, trichloroacetic acid (TCA), chlorhexidine, calcium hydroxide, camphorated chloramphenicol, hydrogen peroxide, and EDTA, alongside mechanical removal. The study also investigated a range of materials used to repair the defect, such as mineral trioxide aggregate (MTA), glass ionomer cement, composite resin, Biodentine®, gutta percha, and amalgam.

The findings indicated that the external approach, particularly using a surgical flap with mechanical excavation, was the most frequently used method for Heithersay class 2 and 3 defects, while for Heithersay class 4 lesions, internal access was the most frequently used method. When a chemical agent was chosen, TCA in a 90% aqueous solution was the preferred agent and Bioactive endodontic cements were mentioned more often to restore ECR defects. The study concluded that 99% of the cases reported a favorable outcome after a minimum follow-up of 12 months, suggesting that all therapeutic approaches were effective in managing ECR with a high success rate and that there is no single best approach to manage ECR lesions, including the choice of the access, the method to remove the pathologic tissue and the material used to repair the damage.

Mudher Bahar, BDS, DMD; Resident in Endodontics; Virginia Commonwealth University

DIABETES MELLITUS INCREASES THE RISK OF APICAL PERIODONTITIS IN ENDODONTICALLY-TREATED TEETH: A META-ANALYSIS FROM 15 STUDIES

Liu X, He G, et al. | J Endod 2023;49:1605–1616

Irreversible pulpitis and apical periodontitis (AP) are among the most common diseases that affect teeth.

Root canal treatment (RCT) remains the optimal and preferred treatment for both conditions. However, persistent AP following RCT can occur for various reasons. The overall failure rate of nonsurgical RCT has been reported to be around 10%. Common clinical reasons for failure include inappropriate mechanical debridement, residual bacteria in the root canal space and periapical tissues, poor obturation quality, and coronal leakage. However, despite appropriate and adequate RCT, persistent AP still occurs in 10-15% of teeth with pre-operative periapical lesions.

Outside of iatrogenic factors, studies have tried to elucidate risks for persistent or secondary periapical infections. Some studies have identified a higher abundance of the bacteria Enterococcus faecalis in persistent lesions. Additionally, host factors may contribute to an elevated risk of persistent AP.

The link between diabetes mellitus (DM) and oral conditions such as caries and periodontal disease has been well-

established. It has been shown that DM renders patients more susceptible to oral infections. Conversely, oral infections can increase the development of DM in patients with poor glycemic control. Recently, more studies have been investigating the relationship between DM and AP in endodontically treated teeth. It is posited that DM may delay tissue healing, thereby affecting the healing of periapical lesions, eventually leading to AP, resulting in RCT failure.

This study was a meta-analysis of patients diagnosed with DM Types 1 and 2 who had received RCT. After searching databases, 262 relevant studies were retrieved, and fifteen met the inclusion criteria and had their data extracted. In total, 1087 patients with 2226 teeth were included in the statistical analysis. The pooled odds of developing AP after RCT were about 1.5 times more likely in diabetics than non-diabetic patients. Additionally, via subgroup analysis, it was found that if a tooth had preoperative AP, diabetes significantly affected the healing of the lesion. Patients with DM were approximately four times more likely to have a non-healing periapical lesion following RCT.

The mechanism of the bidirectional relationship between DM and AP is thought to be like that with periodontitis via two interactions. First, byproducts of DM can cause an increase in the inflammatory cascade at the periapex and, second, affect the activity of osteoblasts, resulting in an imbalance in bone metabolism. Both effects accelerate bone resorption and poor healing.

Thus, compared to patients without diabetes, patients with diabetes have a higher prevalence of apical periodontitis after root canal therapy. At the same time, DM has a detrimental effect on RCT as it is significantly associated with persistent AP in teeth with pre-operative periapical lesions. Therefore, much like periodontal treatment, diabetic patients should be monitored more closely following endodontic treatment for non-healing or the development of secondary AP so that the dentist can intervene and treat in a timely manner.

Triet Vuong, DDS; Resident in Endodontics; Virginia Commonwealth University

DENTISTRY’S BEST ADVOCATE—YOU!

Michaela Mishoe, Account Executive at The Hodges Partnership

Recent headlines have outlined the shortage of dental hygienists across Virginia. There are several factors impacting the shortages, including the retirement of hygienists during the pandemic, as well as limited programs, faculty, and resources to train students.

“Consider collaborating with local schools and community colleges to serve as a resource who can provide insights into the educational requirements, job prospects, and the impact of dentistry on overall health. The school’s career services office is a good starting point.”

1. Partner with educational institutions and industry associations.

Consider collaborating with local schools and community colleges to serve as a resource who can provide insights into the educational requirements, job prospects, and the impact of dentistry on overall health. The school’s career services office is a good starting point.

In addition, many schools and colleges organize career days, workshops, or seminars where aspiring students can learn about the various positions in dentistry, including dental hygiene, dental assisting, office management, and more.

Community college training programs need dentists to serve as adjunct faculty to supervise students during their training. If your schedule allows, consider giving back to your local community through an adjunct faculty position.

Other health industry associations, such as the Virginia Dental Hygienists’ Association, have chapters across the state and consistently advocate for dental hygiene. Becoming a trusted resource for your local industry leaders is a great way to get involved with issues affecting dentistry.

interactive sessions where attendees can ask questions about dentistry as a profession. Use these opportunities to highlight the importance of preventive care and the role of dentists in promoting overall wellness.

3. Empower staff to become mentors.

Establishing mentorship programs within your practice can provide aspiring students with hands-on experience and guidance. Encourage your team to become mentors and allow opportunities for students to shadow your staff members during consultations, procedures, and patient interactions. Personal mentorship can offer valuable insights into the day-to-day realities of working at a dental office and help students make informed career decisions.

4.Leverage social media.

The VDA is proud to work alongside members and partners to help solve workforce shortages through advocacy and awareness.

You can help. We know word of mouth by dentists and dental teams can be one of the most powerful channels for introducing people to the dental industry. Here are some strategies for promoting dentistry as a career in your community and practice:

2. Host or attend local career fairs and events.

Hosting community events or workshops focused on oral health awareness and career exploration can help make education around the dental field accessible for those interested in learning more about working in a dental office. It may result in new patients looking for a dental home, too.

Consider offering free dental screenings, oral hygiene demonstrations, and

Your social media channels are wonderful places to share engaging content about dentistry as a career. Create videos featuring your team members discussing their career journeys and why they chose dentistry. If there is a patient who is open to sharing their story, have them talk about how their life has been positively impacted by dental care. Social media can be a powerful medium to share information and promote potential careers in dentistry.

5. Use your office (or dental chair) to promote dentistry.

Even if you do not have the time or capacity to hold career fairs or foster mentorship opportunities, you can still leverage the time you have with your patients in the office or dental chair. As you check in with your patients, especially younger ones who are considering the next step in their educational journey, ask them about their aspirations. If the field of

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dentistry is not on their radar as a career path, you and your staff can become resources for any questions they may have about the educational journey and what the day-to-day looks like.

There are also several financial aid programs through Virginia’s Community Colleges that can help cover tuition for select in-demand fields like dentistry, such as Virginia’s G3 tuition assistance. Download and print our dental career one-pager as a resource to share in your office.

While strengthening the Commonwealth’s dental hygiene workforce will take time, you and your staff can play a proactive role in promoting dentistry as a fulfilling and rewarding career choice within your community and practice.

SIX STRONG CYBERSECURITY ACTIONS TO PROTECT YOUR DENTAL PRACTICE

Robert McDermott, CEO; iCoreConnect

The February 21, 2024 cyberattack on Change Healthcare continues to ripple across the healthcare industry. Change Healthcare is working to fully understand the scope of the attack and get back up and running at full capacity. Yet, many providers remain in a limbo state, unable to utilize important services required for patient care.

Practices need to adopt a posture of proactive prevention. In doing so, they will limit the damage from a direct attack or the ripple effects from an upstream hit. To reach an optimal level of security— so you can reduce worry and focus on your work—you need to understand cybersecurity.

What Is Cybersecurity?

Cybersecurity encompasses the security and protection of computers, computer networks or systems, and the data contained within. This includes methods of protecting both hardware and software from intrusion or destruction.

Additionally, cybersecurity focuses on ensuring the transmission of data remains secure and free from efforts to misdirect or steal private information. Cybersecurity for your dental practice goes well beyond basic HIPAA compliance. It’s about securing your practice and its future. The financial cost of an attack can be overwhelming for a practice of any size.

In short, protecting your patient data is about the survival of your business.

What can you do to protect your practice?

Given the threats that currently exist and their ability to evolve quickly, understanding how you can take control of your cybersecurity stance is essential. Having an IT team at your disposal is

“In short, protecting your patient data is about the survival of your business.”

critical, and there are additional steps you can implement quickly as well.

1. Use cloud services. We’ll begin here because this is the base from which to work. From your ePrescription tools to your cloud backup, off-premise cloud solutions ensure there is a team of IT experts who are monitoring your software and network for vulnerabilities and updating as needed to maintain your defense.

2. Improved Security. Cyberthreats are clearly real, as is the need to remain HIPAA compliant. If you’re running your practice and your IT, then you’re setting yourself up for potential disaster. There are experienced IT teams or Managed Service Providers (MSPs) who work remotely, often referred to as cloud service providers, to create and maintain a strong barrier between your practice and cyber attackers. With the support of a cloud service provider, you can be sure that your hardware, software, and network infrastructure are protected, that all firewalls and virus software are updated and patched, and that someone is proactively

monitoring your network for vulnerabilities and signs of potential attacks.

3. Disaster Recovery and Automated Backups. Not only are reliable backups required for HIPAA compliance, but they’re an important part of disaster recovery and business continuity plans. When backups are part of a manual process, human error can result in either a missed backup or a failure to notice that the process wasn’t completed successfully. Cloud services can back up your data automatically and alert the necessary support team members if part of the process fails. In short, you’re assured that your data is available if and when you need it.

4. HIPAA Security Risk Assessment. One of the greatest tools you have at your disposal is a HIPAA security risk assessment performed by a team of IT and security professionals.

Risk assessments provide a baseline assessment of existing security strength as well as a prioritized and strategic plan for improving your security. Often, they include:

- Analysis of data storage and transmission mechanisms (email security)

- Risk and threat identification in the current security landscape

- Comprehensive review of existing security applications and precautions

- Detailed calculations regarding

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the potential impact of a security incident

- A fully mapped out remediation plan and targeted next steps to improve your security stance

- Staff training and education on permissible uses and disclosures of PHI

5. Cloud ePrescribing. The shift to electronic prescribing for all medications, including controlled substances, is a necessary step in ensuring patient safety, minimizing prescription errors, and reducing the potential for misuse. Dentists should be diligent in choosing certified ePrescribing software that has three critical components:

1) regulatory compliance to ensure strong safety and security measures, 2) clear and beneficial clinical workflow efficiencies 3) and improved patient adherence.

6. Encrypted HIPAA Email. When it comes to cybersecurity and dental practices, the truth is that fully HIPAA compliant, encrypted email is often overlooked despite the fact that it may be one of your biggest vulnerabilities. Phishing attempts have grown

more sophisticated, with fake emails looking more convincing than ever. One misstep and your network is open and vulnerable to attacks and data theft and even ransomware.

To protect your inboxes and prevent them from ever receiving spam emails or phishing attempts, ensure your secure email is fully HIPAA compliant with end-to-end encryption. You want to be able to send secure transmissions and safely send files of any size to referral partners and providers.

Take the Next Step

There are a lot of measures you can take to ensure the safety and security of your dental practice’s IT infrastructure and the sensitive data contained within. While no measure is foolproof, implementing risk mitigation efforts is required not just by law, but also through your commitment to your patients, your team, and your practice.

Trusted VDA Member Perks endorsed partner iCoreConnect offers comprehensive security support. The iCoreConnect team of experts is prepared to review, revise, and advise to help you ensure HIPAA compliance and security are fortified in all business facets of your practice.

If you’re ready to discuss how iCoreConnect’s platform of secure, compliant, cloud-based solutions can help keep your practice and its data safe and secure, book a demo at iCoreConnect. com/VA19 or call 888.810.7706. Protect your practice and your patients while strengthening your security stance.

VIRGINIA BOARD OF DENTISTRY MEETING NOTES

MARCH 8, 2024

Ursula Klostermyer, DDS, PhD

Board President, Margret Lemaster, RDH, called the meeting to order at 9:00 am.

There were no public comments.

The minutes of the past board meeting on December 8, 2023, were unanimously approved.

Virginia’s Department of Health Profession’s (DHP) Director Arne W. Owens gave a short report about the General Assembly and stated that 105 bills were reviewed, and comments were made for Governor Youngkin. Budget questions have yet to be addressed. The Virginia Board of Dentistry is funded by licensee’s fees and has thus not incurred any financial issues. Mr. Owens mentioned that the DHP is looking for a new Director of Communications and other positions are opening as well. Several active employees are retiring.

Mr. Rutkowski had nothing to report, as there were no pending appeals or issues.

Dr. Bryant provided information about the online conference of CDCA-WREBCIT and stated that it was a good and informative meeting. Dr. Bryant also attended the Southern Deans and Dental Examiners’ Annual Conference and came away with a positive impression. He stated that a lot of good information was shared and that the networking possibilities with different board members and examiners were also appreciated.

Yetty Shobo, Ph.D., presented DHP reports regarding dentists’ and dental hygienists’ workforces for 2023. The data was pulled from a survey in which 6,900 dentists and 5,500 dental hygienists participated. She reported that the median age of dentists sank from 50 to 47. The current gender ratio is 1:1. The

workforce of dentists in the age group of 60+ consists mostly of males, whereas women dominate the age group of 30-34. Thus, the overall 1:1 relationship does not reflect the trend of more women entering the field.

“Yetty Shobo, Ph.D., presented DHP reports regarding dentists’ and dental hygienists’ workforces for 2023. The data was pulled from a survey in which 6,900 dentists and 5,500 dental hygienists participated.”

increased to 49%, while the number of people expecting to retire in the next ten years has declined. Consequently, the number of licensees in Virginia’s workforce and FTEs has increased. The overall age of dentists in Virginia is younger, and the median education debt increased.

Dr. Shobo’s presentation continued to show that the number of dental hygienist licensees has been in a steady workforce decline since 2022. Ninety-eight percent of dental hygienists are female. There was a slight increase of hygienists in the age group <40 years and a slight decrease in the age group <55 years. She reported a four percent increase of hygienists in the age group of 60+ years. Twenty-nine percent have a median educational debt of $15-25K.

Racial diversity is most prevalent in the age groups of 40 years and below. The trends for both dentists’ income and debt are increasing. Sixty percent of dentists reported themselves to be solo practitioners, whereas 22% work in group practices, and a single-digit percentage works in schools or other institutions. Fifty-one percent of dentists were reported to accept only cash and private insurance. Twenty-five percent of dentists accept Medicaid, Medicare, and private insurances. Six percent of dental practices accept cash only.

Since 2021, the number of people intending to retire at the age of 65 has

The number of hygienists remotely supervised by dentists at a second location increased. There is clearly a geographical mismatch between dentists and dental hygienists in Virginia. In the western and southern parts of Virginia, the ratio is less than one dentist per hygienist. Fifty-seven percent of hygienists hold a full-time position whereas twelve percent hold two or more positions. Fifty-four percent of hygienists work 30-39 hours per week, and fifteen percent work 20-29 hours per week. The median annual income for hygienists has increased from $50-55K to $60-70K. Ninety-five percent of dental hygienists reported being satisfied with their current work situation.

DHP director Arne Owens updated the BOD on current regulatory actions. He stated that duplicate bills have been removed from the list and indicated that there is not much that can be done to get the regulations moved through the final

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stages. He suggested meeting with the administration to discuss the status.

The subject matter of elimination of restriction on advertising dental specialties was submitted in September 2019 and is still in the Governor’s office.

Since 2022, subject matter like training in infection control, jurisprudence CE requirements, and digital scan techs have been sitting in the secretary’s office. The subject matter for the training requirements for botulinum toxin injections for cosmetic purposes has been in the secretary’s office for a few months.

Ms. Weaver presented the November 2023 - February 2024 Disciplinary Report, stating that 135 cases were received during this period. During these months, 154 cases (including older cases) were closed without violation. Eleven cases were closed with violations. Closed cases with violation consisted mostly of instances where the diagnosis/treatment was improper, delayed, or unsatisfactory. There were three cases with recordkeeping or CE-related issues. In one case, an invalid license was the issue. There was no suspension during these months.

SUSTAINABLE DENTISTRY:

A TWO-FOLD STRATEGY TO RECESSION-PROOFING YOUR DENTAL PRACTICE

Ashli Klingaman

Long-term success for a dental practice is centered around the ability to be adaptable and innovative and apply tools that can weather the storm. In a rocky economy, it becomes even more necessary for practice owners to be adaptable, not just for survival but also to ensure growth and stability during those times.

Let us look at a practical plan to build a solid foundation for your practice that can weather economic turbulence. These are functional tools and tips you can use both inside and outside your dental office that will help you run things better, keep your money in good shape, and build strong connections with your patients that last.

Internal Tools for Dental Practice Resilience

Using a robust practice management system (PMS), along with a supporting practice automation solution, can assist in the efficiency of a dental practice and its sustainability during economic downturns. Having a state-of-the-art practice management system that integrates electronic health records and a supporting HIPAA-compliant portal with online patient forms can streamline administrative processes that significantly enhance the operational efficiency of a dental practice.

According to a study by the American Dental Association, practices with an integrated PMS reported a 20% increase in operational efficiency, allowing staff to focus more on patient care. The top automated features which practices reported being the most impactful included:

• Automated appointment scheduling

• Online bill pay

• Automated billing requests and record-keeping

These features not only reduce the administrative burden but also contribute to a more seamless patient experience. By optimizing workflow and improving team collaboration, a well-implemented PMS combined with automation solutions contributes to cost-effectiveness and better use of resources, which are both key factors in maintaining the financial growth of a dental practice during a recession. Not sure how to integrate these solutions into your PMS? Check out ProSites.com/VDA to learn about tools and features available that easily integrate with top practice management software from from VDA Member Perks endorsed partner ProSites.

Cost-Effective Supply Chain Management

Disruptions in the supply chain can have a considerable impact on practice revenue during unstable economic times. Delays, shortages, and increased costs for essential dental supplies can lead to operational challenges and financial strain for dental practices. During the early stages of the Covid-19 pandemic, dental practices faced challenges with the availability and accessibility of personal protective equipment (PPE). This did not just negatively impact the ability of practices to do procedures safely but also led to increased costs due to the high demand for PPE globally.

“Managing the dental supply chain is a critical part of a practice’s day-today operations and plays an important role in keeping the money side of things steady.”

Managing the dental supply chain is a critical part of a practice’s day-to-day operations and plays an important role in keeping the money side of things steady. It is all about talking to suppliers, finding smart ways to manage costs, and making sure you are not drowning in too much of what you do not need or running out of what you do need.

By conducting a thorough analysis of supply needs and consumption patterns, dental practices can identify opportunities for cost savings without compromising the quality of patient care. This strategic approach to supply chain management not only minimizes financial risks but also positions the practice for sustainable growth.

Additionally, the integration of electronic health records systems can improve communication and collaboration among dental team members. Real-time access to patient records allows for more informed decision-making and ensures that all members of the dental team are on the same page, ultimately contributing to enhanced patient care.

External Tools for Dental Practice Resilience

In today’s tech-savvy environment, being online is a big deal for bringing in and keeping patients. BrightEdge found that more than half of a business’s online visitors come from people searching online. So, having a solid plan for digital marketing – like being easy to find online

>> CONTINUED FROM PAGE 61

and using ads that reach the right people – can really make your dental practice stand out and connect you with more patients in your area.

Especially when the economy is uncertain, many businesses tend to reduce their spending on advertising. Surprisingly, the right move is somewhat the opposite – increasing marketing efforts into channels that align with your practice goals can help keep a steady stream of patients. For example, dental practices that use ProSites for their paid advertising see a 30% decrease on average in their cost per lead. Creating a professional website, staying active on social media, and using online ads can all play a part in making your practice more visible online.

Telehealth and Virtual Consultations

Bringing telehealth services into dental practices is like having an extra tool to keep patient care going strong, especially when it is tough for folks to drop by in person. With virtual consultations, dentists can check in on non-emergency cases from afar, giving advice on oral health concerns and freeing up chairs for more revenue-producing services. It is not just about making it easier for patients – it also shows that the practice can roll with the changes in healthcare.

Getting into telehealth means investing in technology that is both safe and easy to use. Dental offices can use different tools to have online visits, share helpful info, and connect with patients from a distance. Some of these features can be integrated into your practice’s website reducing the initial cost investment and providing a seamless experience for patients. You can see a few examples by visiting https://bit.ly/4c5Fx6k. It is not just about solving today’s problems – it is also getting ready for innovative new ways of giving dental care down the road.

Community Partnerships and Networking

Getting involved with the local community and teaming up with nearby businesses and health providers is like building a friendly circle that helps your dental

practice get noticed, especially when things are tough economically. When you partner with local organizations, you can refer patients to each other, and it also makes your practice stand out more in the community.

The American Dental Association found similar findings in a recent survey. In that survey, dental offices that actively connected with their community saw a 15% boost in new patients. So, by being part of local events, supporting community projects, and reaching out to people, not only do you help the community, but you also get more potential patients noticing your practice.

Recession-proofing a dental practice requires a dual-focused strategy that combines internal and external tools. By focusing on efficient practice management and supporting practice automation, cost-effective supply chain management, and patient retention strategies, dental practices can strengthen the foundation of their operations. At the same time, using things like online advertising, virtual health services, and teaming up with the community helps make your dental practice strong and flexible.

Keeping up with the changes in dentistry, being ready to adapt, and making strategic moves to withstand tough times ensures your dental practice not only survives but also does well in challenging situations. At ProSites, we have been helping dental practices build the bridge between patient care and practice success for over 20 years. We understand the evolution of the dental industry, and we are committed to helping your practice succeed with cost-effective marketing and practice solutions. To learn more and claim exclusive discounts as part of your VDA membership, visit ProSites.com/VDA

YOUR VDA MEMBERSHIP COULD EASILY BE PAYING FOR ITSELF

Karen Wood, Director of Operations; Virginia Dental Services Corporation

There are only two ways to make money: either make more or spend less. It is undoubtedly a safe bet to ask you to recall the last time you made thousands of dollars and expect the answer to be, “very recently.” On the other hand, when was the last time you were able to save thousands?

Your VDA membership includes a portfolio of benefits from endorsed vendors designed to save you money with upfront discounts and hidden savings in business efficiency. Many VDA members are already enjoying savings that easily cover the investment cost of annual dues. Frequently, members discover some additional substantial savings beyond covering the cost of the annual dues investment. The highlighted companies below are just a starting point for you to consider for your practice.

Save on insurance for your practice, yourself, and your team with RK Tongue. VDA members receive a 5% malpractice insurance premium discount with the Professional Protector Plan with an opportunity for a 7.5% discount for three years by attending a no-charge risk management course. VDA members will soon see potential savings of 10-15% on group health insurance through the WiseChoice program. RK Tongue has even saved VDA staff members over $1,000 on home, auto, and umbrella insurance. Contact RK Tongue to see where they can help you and your team save. rktongue.com | 800-683-6353

When was the last time you compared credit card processing rates? A few percentage points can add up very quickly. Make sure you are getting the best rate possible by contacting BestCard. VDA members have saved

thousands of dollars a year by taking a few minutes to securely upload their current merchant processing statements. The current average BestCard customers are seeing is $6,496 in annual savings! BestCardTeam.com | 877-739-3952

Is your website driving patients to your office? Is it a valuable resource for communicating with current and potential patients? The marketing power of an informative website is undeniable. Reach out to our endorsed vendor partner, Prosites, for a member discount of 25% off initial website design or to start a free trial. It is worth a visit to their website just to watch their on-demand webinar, “8 Steps to Get on the First Page of Google.” prosites.com/vda | 888-932-3644

Do you have a CBCT and want to send those large DICOM files by email? iCore Exchange can send encrypted files and is fully compliant with no size limitations. VDA members receive a 35% discount on the regular monthly pricing. This is just one of many services from iCore offered to members with special discount pricing. land.iCoreConnect.com/VA8 | 888-810-7706

Do you order supplies from multiple vendors? Torch Dental is a supply procurement dashboard that houses all your vendor accounts in one place to search for items across your usual vendors (and some that you may not have used yet) to find the best pricing on products and shipping costs. VDA members receive free account setup, $300 in Torch reward dollars, and will save an average of more than 16% on supplies.

torchdental.com | demo@torchdental.com

While you are sitting chairside producing in your practice, let your VDA membership save you money. The VDA Member Perks program continues to research resources to help our members find those cost savings and efficiencies that can more than pay for the cost of membership. Using just three of our endorsed vendors can save you thousands of dollars. Don’t delay maximizing your VDA membership! Explore the options our endorsed vendors have to offer. As always, if you need personalized help from the VDA on the Member Perks program, please contact me directly. I am always happy to help.

Karen Wood

wood@vadental.org

C: 804-334-2285

VCU ENHANCES CULTURAL COMPETENCY AND PROVIDES BETTER CARE FOR PATIENTS

Giovanni Flores

There are 63.7 million Hispanics living in the United States, making up 19.1% of the total population, according to the U.S. Census1. Although they comprise the largest minority group, Hispanic communities face numerous healthcare inequities, including a language barrier, structural racism, and inability to access oral healthcare. Hispanic dentists represent 6% of the national dentist workforce, 3% of dental students, and 8.3% of faculty in dental schools2. The low number of Hispanic healthcare providers leads to a huge dilemma in providing service for our Spanish-speaking patients. Limited access to primary care and screening programs staffed by bilingual healthcare providers can have adverse effects on Hispanic patients, compromising both their health outcomes and quality of life2. The Hispanic Student Dental Association (HSDA) at the Virginia Commonwealth University School of Dentistry (VCU) is actively striving to improve the experience of Spanish-speaking patients. HSDA is a student-run organization at VCU and serves as the leading voice for Hispanic oral health. As HSDA members, our vision is to empower the healthcare profession to increase oral health equity and improve healthcare quality for the Hispanic/ Latinx community and for other underrepresented populations3

As one of the few Spanish-speaking providers at VCU, I have frequently found myself in the role of a translator during clinic sessions. One particular encounter stands out vividly in my memory. While assisting in an

operative procedure, I observed a patient who appeared unusually quiet and reserved. I stopped and asked the patient if she was feeling okay. The patient opened up to me about her concerns, and I was able to calm her down and answer all her questions. She later expressed her delight in finding someone around who understood her. In situations like these, patients often feel as though they are an inconvenience to providers because they require additional assistance to acquire proper care. This prevents them from asking further questions and explaining their true feelings at appointments. The HSDA at VCU is determined to avoid situations like these by teaching cultural competency to our student body.

The HSDA accomplishes this by setting forth a strong initiative to overcome healthcare barriers that our patient population faces by teaching our student body Spanish dental terminology. Booklets of common phrases and words used in our clinic have been made available to the student body. This has allowed Spanish speakers to learn dental terminology and beginners to start picking up phrases to communicate with our Spanish-speaking population. Along with the booklets, the HSDA has hosted in-person Spanish workshops that are open to the student body, faculty, and staff. Two sessions were held during the Fall 2023 semester: one dedicated to our beginner group and the other to those at a more intermediate/ advanced level. During these sessions, we covered Spanish vocabulary for

radiological findings, periodontal terminology, and endodontic terminology. In the Spring 2024 semester, we will continue to build on the previous terminology learned while including axiUm form terminology as well as vocabulary used in a pediatric setting. Our latest addition to the clinic includes translation of commonly used forms and handouts for patients’ convenience. A poster was recently placed in the radiology clinic, and it included Spanish phrases to help explain the x-ray process and the positioning needs of the patient when taking a full mouth series or panoramic x-ray.

It is our goal at VCU to promote oral health in Hispanic/Latinx communities across the Commonwealth of Virginia through prevention, treatment, education, and advocacy3. We continue to develop and implement curricula and educational resources to train English-

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A MORE SUSTAINABLE FUTURE FOR DENTISTRY

Jillian Bulter

>> CONTINUED FROM PAGE 64

The quote, “Research is seeing what everybody else has seen and thinking what nobody else has thought,” by Albert Szent-Györgyi, has always resonated with me. I wanted to become involved in research because of my background and my strong desire to learn more about what we do not know. As a biomedical engineering major in college, I was able to do some amazing lab work and take incredible classes that were part of our curriculum, including creating a working EKG (it was tested on me!) and taking courses such as tissue engineering and biomaterials. I was thrilled about the fact that VCU offered so many great opportunities to become involved in state-of-the-art research, from specially crafted surveys on public opinion to meticulous wet-lab work. During the end of my D2 year, I was fortunate enough to find a project suited to my interests when I approached Dr. Eser Tüfekçi, an orthodontist at VCU who has a background in both dentistry and biomaterials. She told me that a team of chemical engineers from speaking students, faculty, and staff on dental terminology and best practices in communication with Spanishspeaking patients in the dental setting. We will fight to overcome the unique barriers these populations face in accessing care and will work together to improve the health and well-being of Hispanic people across our country.

Virginia Tech have been developing a biodegradable plastic that has the potential to replace single-use plastics used in clinics every day. I could hardly contain my excitement when I learned that the project could not only lead to a more sustainable option that could be used in almost every clinical setting but that it also appealed to my engineering background and dental future.

The project began quickly, and our team at VCU met with the Virginia Tech (VT) Engineers and the owner of the company that is developing these novel plastics. I was graciously allowed to work under Dr. Todd Kitten, a renowned researcher in oral and craniofacial molecular biology at VCU. Our goal was to test whether the novel plastics could prevent bacterial contamination of the underlying surface or, in other words, test their effectiveness as a barrier to bacteria. Dr. Kitten and I utilized a modified protocol for our pilot study based on the International Organization for Standardization 22196. We were able to acquire some

samples from the VT team with varying crosslinking times (0 hours, 3 hours, or 6 hours). Our first question was, can our plastics, as well as conventional plastics, protect against bacteria. Our second question was, what degree of crosslinking of our plastics (in hours) would provide the best barrier to bacteria? After we executed the study, Dr. Caroline Carrico at VCU performed a statistical analysis of the results. It was found that further development and subsequent testing of the plastics is needed to ensure no bacterial leakage. In addition, more trials are necessary to establish statistical differences between the groups themselves.

While the results were not what the team had aimed for, our project was a step in the right direction towards a more sustainable option for conventional single-use plastics. In the future, we hope to continue the development of these biodegradable plastics to eventually establish a product that can be used in all clinics and settings outside of healthcare.

References:

1. Bureau, US Census. “Hispanic Heritage Month: 2023.” Census.gov, September 28, 2023. https://www.census. gov/newsroom/facts-forfeatures/2023/hispanicheritage-month.html

2. Kaz Rafia, DDS, and DDS Martha Mutis. “Report: Addressing the Oral Health Needs of the US Hispanic

Population.” Dentistry IQ, October 3, 2023. https://www. dentistryiq.com/dentistry/ article/14299726/reportaddressing-the-oral-healthneeds-of-the-us-hispanicpopulation

3. Ruiz, Lydia M. “About HDA.” Home. Accessed March 6, 2024. https://www.hdassoc. org/about-hda

OPEN VDA LEADERSHIP POSITIONS

Are you interested in getting involved with the VDA in a leadership position? Then you’re in luck! We offer many opportunities for you to get involved in a way that aligns with your skills and interests.

PRESIDENT-ELECT 2025, THEN PRESIDENT 2026

Job Description (President-Elect):

The president-elect is a convener within the organization. Their focus is on understanding the organizational workings of the VDA (by reading its bylaws) and developing relationships with state and component leadership and staff, as well as committee (or council) chairs, so that they can effectively carry out the responsibilities of the president during the subsequent year.

Job Description (President):

The president is the members’ voice and the link between the ADA, the state organization, board members, component leadership, and student networks. The president is the spokesperson for statewide initiatives during his or her term and works closely with component leadership, as well as committee chairs, to make sure program details and expectations are communicated and understood by those executing them. The president is also the state’s eyes and ears, collecting programmatic cues from the ADA and other state associations.

ADA DELEGATE (2025 – 2027)

Four positions available

Job Description:

Attend all the regular sessions of the House of Delegates, the District 16 caucuses, and other meetings as the chair of the ADA Delegation shall designate. Serves a three-year term.

ADA ALTERNATE DELEGATE (2025

– 2026)

Six positions available

Job Description:

Attend all the regular sessions of the House of Delegates, the District 16 caucuses, and other meetings as the chair of the ADA Delegation shall designate. Serves a two-year term.

AWARD NOMINATIONS – NOW OPEN

DENTAL TEAM MEMBER AWARD

The nominee must be a dental team member of a VDA member dentist. This award may be presented to multiple recipients only when worthy candidates are recognized. The nominee(s) should demonstrate that he/she holds the profession of dentistry in the highest regard, promotes the interest and betterment of the profession through the team concept of dentistry, and has five or more years of experience in the dental field.

SPECIAL SERVICE AWARD

This award is presented to a non-dentist who has demonstrated outstanding service, support, and dedication to the profession of dentistry. This award is presented when a worthy candidate is recognized.

NEW DENTIST AWARD

This award is presented yearly to a VDA member who has been in practice for ten years or less. This award is only presented when a worthy candidate is recognized. The nominee must have demonstrated leadership qualities through service to dentistry.

VDA FELLOW

A Fellow nominee must be an active, life, or retired member of the Virginia Dental Association for at least seven years. Nominees shall have given their time and energy freely to their local component society, the Virginia Dental Association and the profession of dentistry. Military and or federal service personnel having served at least two years active duty and maintaining active membership in the ADA may be considered for VDA Fellowship after five years of service.

WELCOME NEW MEMBERS

THROUGH MARCH 1, 2024

Dr. David Bitonti – Virginia Beach –University of Pittsburgh School of Dental Medicine 1985

Dr. Chinwendu Nnagbo – Hampton – Loma Linda University School of Dentistry 2022

Dr. Rachel Stein – Virginia Beach –University of Iowa College of Dentistry 2023

Dr. Shivali Bhatt – Richmond – University of the Pacific Arthur A Dugoni School of Dentistry 2020

Dr. Richard Boyd – Glen Allen – University of North Carolina School of Dentistry 1984

Dr. Erica Broussard – Richmond – Tufts University School of Dental Medicine 2023

Dr. Stuart Hentz – Richmond – Virginia Commonwealth University School of Dentistry 2023

Dr. Fucong Tian – Henrico – Augusta University College of Dental Medicine 2020

Dr. Himabindu Vuddaraju – Newport News – University of California at Los Angeles School of Dentistry 2017

Dr. Caroline Corbett – Williamsburg –University of Texas Health Science Center at San Antonio 2020

Dr. Julita Marasigan – Williamsburg – NY Lutheran Medical Center Department of Dental Service 2015

Dr. Alexander Hubrecht – Richmond –University of Pittsburgh School of Dental Medicine 2023

Dr. Kulsum Iqbal – Richmond – Tufts University School of Dental Medicine 2023

Dr. Anisa Kasiri – Henrico – New York University College of Dentistry 2018

Dr. Sara Khraibut – Richmond – Virginia Commonwealth University School of Dentistry 2020

Dr. Ronald Lowe, III – Fredericksburg –State University of New York at Buffalo School of Dental Medicine 2020

Dr. Aleksandr Baron – Forest – New York University College of Dentistry 2009

Dr. Lindsay Laing – Roanoke – Virginia Commonwealth University School of Dentistry 2014

Dr. Alexandra Rihani – Lynchburg – Indiana University School of Dentistry 2008

Dr. Colin Sherwood – Danville – University of North Carolina School of Dentistry 2016

Dr. Marko Ilich – Hopewell – Virginia Commonwealth University School of Dentistry 2023

Dr. Aleksandra Stefanovski – Chester –Virginia Commonwealth University School of Dentistry 2022

Dr. Neolquidea Mercedes Sanchez –Midlothian – Rutgers School of Dental Medicine 2023

Dr. Mohammed Obeid – Richmond –University of Detroit Mercy School of Dentistry 2023

Dr. Kristin Randolph – Richmond – Boston University Goldman School of Dental Medicine 2023

Dr. Pallavi Singh – Glen Allen – Virginia Commonwealth University School of Dentistry 2013

Dr. Deborah Desa – Blacksburg – University of Pennsylvania School of Dental Medicine 2000

Dr. Carter Mullins – Bristol – University of Tennessee College of Dentistry 2023

>> CONTINUED FROM PAGE 69

Dr. Hayley Marshall – Harrisonburg City –Midwestern University College of Dental Medicine – Illinois 2021

Dr. Charles Smith – Winchester – Virginia Commonwealth University School of Dentistry 2016

Dr. Eric Starley – Winchester – University of Nevada Las Vegas School of Dental Medicine 2010

Dr. Ibrahim Elgarwany – Prince WilliamEgypt University of Alexandria 2006

Dr. Casey Gringer – Arlington – University of Pennsylvania School of Dental Medicine 2022

Dr. Leena Khan – Fairfax – Howard University College of Dentistry 2020

Dr. Sang Kim – Fairfax - University of Pennsylvania School of Dental Medicine 2002

Dr. Julia Lokitis – Alexandria – University of Maryland Dental School Baltimore College of Dental Surgery 2010

Dr. Munira Muluke – Fairfax – University of Kentucky College of Dentistry 2021

Dr. Shikha Nanda – Fairfax – Boston University Goldman School of Dental Medicine 2020

Dr. Eleeka Nejat – Great Falls – University of Tennessee College of Dentistry 2022

Dr. Francisco Rodriguez Lopez – Fairfax –University of Puerto Rico School of Dental Medicine 2009

Dr. Olga Spivak – Fairfax – Boston University Goldman School of Dental Medicine 2016

>> CROSSWORD ANSWERS CONTINUED FROM PAGE 29

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MARSUPIALIZATION

CHEILOSCOPY

OPPORTUNITY

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GREENBRIER

EXPATRIATE

DEAN COOPER

MEMBERSHIP

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EXOPHYTIC

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DELEGATES

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VDA PERKS

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ENDURED PROTOZOA

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FUNCTIONAL DISCONNECT DIVERSIFY GRISELDA COMMERCE REACHER WEGOVY

BARBIE GAMAY

Where’s my Referral Book?

The 2024 VDA Referral Book will be mailed separately from the Journal and directly to your office address. Please share this book with your office manager and staff.

Remember to use this resource to be sure you are referring your patients to other VDA member specialists whenever possible.