NeoBurr dental carbides offer unparalleled quality, strength and performance. To learn more about NeoBurr visit NeoBurr.com

Dental burs are a vital tool required for almost every dental treatment and procedure. They are necessary for cutting, grinding, and removing hard and soft tissue and are designed to attach to the rotary dental handpiece for fast and efficient dental work.

Types of Dental Burs and Their Use

The two most common types of dental burs are tungsten carbide burs and diamond burs. Within those general categories, there are sub-types of burs that come in different shapes, blade configurations, and head angles to suit a variety of procedures.

• Tungsten Carbide Burs

Carbide burs are made from tungsten carbide and three times more robust than steel. Due to the hardness of the metal, they are ideally suited to cutting work such as preparing cavities, cutting through metal fillings, and shaping bone during dental implant surgery. They are also often used for crown removal during endodontic procedures.

Unlike diamond burs, they don’t grind the enamel, leaving a smoother surface and reducing the amount of vibration on the handpiece.

• Diamond Burs

Diamond burs are composed of a stainless-steel frame coated in diamond powder available in various grits. The level of the grit determines the type of procedure the burs can be used for.

Diamond burs are typically used for precision shaping and polishing, but as diamond is one of the hardest known materials, they are often used to cut through zirconia or grind porcelain during the preparation and placement of veneers and crowns.

The Benefits of Single Patient Use Burs and Instruments

Single-patient-use burs and instruments such as probes, mirrors, or procedural kits, are designed to be used and immediately discarded instead of sterilized for the next patient. They have recently gained popularity due to the dramatic reduction in patient and staff infections, and the decreased cost of replacement which can help dental practices to save money.

• Better Hygiene

Even if your practice uses exceptional cleaning and sterilization techniques, a small number of bacteria can withstand the extreme temperature and pressure of an autoclave. Single-patient-use burs and instruments improve your infection control by minimizing the patient-to-patient transfer of oral microorganisms.

While most patients with strong immune systems can withstand mildly contaminated burs and instruments, immunocompromised patients or patients with a significant co-morbidity are at a high risk of infection. Single-patient-use burs and instruments eliminate this risk, especially during the current COVID-19 pandemic.

• Patient-friendly

All types of burs become clogged with enamel and dentin throughout a procedure, which can reduce the cutting efficiency. Clogged burs require additional pressure to achieve the same cutting intensity, which can not only irritate the patient but also damage expensive handpieces and result in longer chair times.

Using a new single-patient-use bur for each procedure keeps chair time to a minimum to reduce fatigue, keeps handpiece bearings in good condition, and provides a more comfortable experience for patients.

• Cost-efficient

Cleaning and sterilizing instruments and burs can increase your overhead costs due to utilities, additional staff, and extra rental space needed to store autoclaves and sterilizing equipment.

Single patient use instruments are a cost-efficient solution to patient care that significantly reduces your overheads and enables you to focus on providing outstanding service to your patients. Despite their low-cost, single-patient-use burs offer the same strength and grinding and cutting ability as their reusable counterparts.

Final Thoughts

The right bur is critical to a successful dental treatment with different sizes, shapes, grits serving different purposes. Single-patient-use burs are now preferred over reusable burs as they offer greater infection control and provide a better patient experience.

About the author

Dr. Fadi Swaida first graduated from the University of Western Ontario with an Honors BSc in Biology before graduating from the University of Manitoba’s Faculty of Dentistry. He is an active member of his church and enjoys football and being by the water! His outgoing personality and fun-loving character will ensure you always feel welcome at Dentist North York.

While many dentists and dental assistants love what they do and have a true passion for helping patients to care for their health and wellbeing, job satisfaction across the industry isn’t as high as it could be. 

Research by the American Dental Association (ADA) and the Health Policy Institute (HPI) found that, amongst those working in dentist owned and operated practices (DOO), only 69% were happy with their working hours, and just 55% were satisfied with their salary. At a time of change throughout ours and many other industries, it is understandable that many trained dentists would be interested in learning more about the different career pathways available to them, or about diversification activities that could help them to expand their practices. 

Introducing Aesthetics

One of the most rapidly emerging diversification activities for dentists is aesthetics, primarily due to the almost unprecedented growth of this alternative healthcare industry. In North America, the facial injectables market was worth a total of $2.1 billion in 2015, and is anticipated to rise to $5.8 billion by 2024. Among these minimally invasive procedures, the American Society of Plastic Surgeons reports that Botox and dermal fillers are the two most widely requested procedures from American audiences. 

Botox? Really?

It’s not as crazy as it seems! As dentists are able to prescribe, are accustomed to working with patients on a day-to-day basis, have mastered their own injecting technique, and boast a comprehensive understanding of the maxillofacial and oral areas of the face, much of the necessary training in facial injectables has solid roots in core dental processes. Even dental hygienists and dental therapists with prescribing rights make excellent candidates due to their extensive training in intricacies of the face and mouth. 

Believe it or not, aesthetic medicine is becoming more heavily incorporated into many dental practices all across the country, and it’s actually pretty easy to see why. Not only are patients becoming more and more savvy and looking for professionals in whom they can fully place their trust to carry out their procedures, but aesthetics is one of the most lucrative areas of diversification for dentists. 

Of course, it’s not just about money. It’s about achieving greater levels of success as a dentist. Cosmetic dentistry procedures have long been used to improve patient satisfaction, and the use of facial fillers can have a significant effect on appearance and even the success rate of necessary dental treatments. 

Career Options for Dentists

Not all dentists will be interested in aesthetics, and that’s OK! We’ve used aesthetics as an example to really highlight the massive diversity in the range of careers that can be enjoyed with dental qualifications. Along with aesthetics and orthodontics, there are also plenty of non-clinical options to consider. The ADA actually reports that clinic ownership in the United States is declining, with an increasing number of trained professionals moving into training and teaching roles, research and technician jobs, and the dental products industry. There’s more to being a dentist than being a dentist!

In the US, parents are widely encouraged to bring their little ones in for their first dentist appointment within six months of the first tooth breaking through. With central incisors typically appearing anywhere from 6 - 12 months of age, closely followed by lateral incisors and first molars, children are usually very young the first time they meet their dentists. So how can we ensure our littlest patients feel comfortable?

The Rise of Dentophobia

Unfortunately, making young patients feel at ease in the chair isn’t always easy, and dentophobia — a fear of dentists — is on the rise. According to a report titled ‘Children’s Perceptions of Their Dentists’, published in the European Journal of Dentistry, around 11% of children surveyed said they don’t like dentist appointments, and an additional 12% claimed to be afraid. Overall, it appears that as much as 16% of the school age population have a fear of dentists, so what can we do to help them handle these necessary appointments better?

Below are 4 ways that dentists can help children feel comfortable at their first appointment:

1. Do a Practice Run

A popular method  used by specialist pediatric dentists is to keep a small doll, teddy, or action figure nearby to use as a ‘practice run’ model. Before asking a child to take a seat in the chair, get them settled with mom and dad (or whoever has brought them to the appointment) and place the doll in the chair. Explain to the child that you’re going to do a practice run with the doll so that they can better understand what will happen during their appointment. This can help to settle nerves and create calm.

2. Show, Don’t Tell

The European Journal of Dentistry report found that the appearance of some common dental tools and equipment, including dental burs, can enhance anxiety in young patients. This is because children can see them, but don’t understand what they do. Some children may even make up uses for the tools in their head, and we all know how logical children are. A dentist can become a torturer in seconds! In order to help children feel at ease, it’s a good idea to briefly go through the tools that you’ll use, showing kids how they are used (and letting them hear any sounds), rather than telling them. 

3. Be Professional

Did you know that your own appearance can make a big difference in how children feel during their appointment? Remarkably, 90% of the children surveyed in the European Journal of Dentistry study said they would prefer their dentist to wear a white coat; an item of clothing that children will have come to associate with helping and healing throughout pediatric doctor appointments. So, while it’s important to be friendly and welcoming to young patients, it’s also important to remain professional at all times. 

4. Give Mom & Dad Homework

Perhaps one of the most important aspects of a child’s first dentist appointment is making sure they don’t feel alone, and they know they have support in maintaining a happy, healthy mouth. A great tip to ensure that children know this is to give mom and dad (or their guardian) homework — a small guide on helping their child to brush their teeth that they should read up on back home. Getting adults involved is essential, and adult help and supervision when brushing should be in place until children are around 7.

Don’t Sweat It

The truth is that it’s not just dentists who are responsible for helping children feel comfortable at their appointments; a significant portion of the work lies with the parents, and it’s not always easy for moms and dads to settle these nerves in their little ones. If you find that you have a patient who isn’t quite comfortable, don’t sweat it. The most important thing at first appointments is simply getting children accustomed to visiting the dentist… thorough checks and treatments can come along a little later.

As dentists, we all know just how prevalent halitosis is across the United States, and it’s something we see in our patients each and every day. Reports suggest that as much as 65% of the population have bad breath, but fortunately halitosis is rarely more than a sign that patients have been brushing properly. 

But what if it is bad brushing?

Oral Causes of Halitosis

Most cases of halitosis are simply caused by a failure to maintain good oral hygiene, and can be effectively treated at home through interdental cleaning, tongue cleaning, and the use of mouth rinses both morning and evening. Sometimes, there can be a little more to it, with bad breath being caused by conditions such as gingivitis or periodontal disease, but again these are all oral causes that we’re trained to both identify and treat at the practice. In total, it’s estimated that between 65 and 85% of halitosis cases are the result of problems arising on the tongue or in the parodontium area of the mouth. 

Non-Oral Halitosis

The remaining 15 - 35% of halitosis cases can be a little more tricky to manage. While it is statistically most likely that non-oral causes are minor, it can’t be overlooked that bad breath can indicate very serious localized or systemic conditions. Diabetes, liver failure, and lung diseases such as respiratory infections and cystic fibrosis can all present with bad breath as one of the most prominent symptoms. 

Perhaps even more incredibly, MIT reports that bad breath can also signal lung cancer. It has been found that, in some cases of lung cancer and some forms of lung infection, bad breath can present as the first noticeable symptom. This occurs long before fever, cough, or chest pain are experienced by the patient. 

Knowing What to Look For

While we are not trained to diagnose or treat these types of conditions, as dentists it is essential that we understand that oral symptoms are not always indicative of oral health or oral conditions. Knowing what’s normal — and what’s not normal — in the presentation of halitosis really could save a life. 

Here are two of the most common indicators that halitosis has a non-oral cause:

• Acetone / Nail Polish Remover

If a patient’s breath smells like nail polish remover, it should be recommended that the patient makes an appointment with their physician to have their blood sugar levels checked. In cases of diabetes, diabetic ketoacidosis occurs when there are very high levels of ketones in the blood, resulting in a greater odor. Ketones have a strong smell which is most commonly associated with nail polish remover. That’s because many nail polish removers contain acetone, a form of ketone that’s often used for cleaning purposes. 

• Sweet / Musty / Perfume

If a patient’s breath smells somewhat perfumey, with a definite sweet and musty aroma, it may be that the cause isn’t due to ketones, but to limonene. Studies have found that those suffering from liver disease have more of the chemical compound limonene in the body than healthy individuals. The link is so strong that limonene is on track to be used as an official biomarker for early stage liver disease. With symptoms rarely presenting in early stages, bad breath could be key to more timely diagnostics. 

Share, Don’t Scare

The most important aspect to keep in mind is that different odors smell different to different people, so even if you do identify an unusual smell on your patient’s breath it does not always mean there is cause for alarm. If there is uncertainty as to the cause of bad breath, or halitosis is not responding as expected to common forms of treatment, advise your patients to visit their physician for further examination.

Is Your Dental Practice Ready For Halloween?

Halloween is right around the corner, and for dentists it can definitely be one of the most frightening times of the year! According to IHS Global Insights, Halloween candy sales now exceed $3.8 billion, and a whopping 94% of American children go trick-or-treating based on figures published by the American Dental Association (ADA). Yet the ADA also reports that less than half of kids brush twice a day. Yuck. 

So it’s really not that surprising to learn that emergency dental appointment rise by 80% on Halloween, with more people requesting appointments on the 31st than any other day in October. That’s according to Sikka Software, who analyzed appointment bookings for 13000 practices in the US...

Spooky stuff indeed! 

Preparing for Halloween

Of course, Halloween poses a bit of a dilemma for dentists. On the one hand, we’re trained to advise against sugary snacks. On the other hand, it’s important to keep our patient base — particularly the little ones — satisfied with their visits. Because of this, around 60% of all dentists in the United States will hand out candy to their patients. Dental insurance firm Delta Dental estimates that 5% hand out toothbrushes, and 25% don’t give anything at all, which isn’t particularly festive of them!

Getting into the spirit of the celebration is important for many practices, but what’s surprising is that around 13% of dentists are giving out hard candies and lollipops… not exactly the best choice in terms of oral hygiene. Fortunately, the majority give out chocolate, which clears more quickly from the mouth to minimize the risk of decay. Other good snacks to hand out, according to research by the Forsyth Dental Center, include certain ‘sticky’ foods, such as caramels, which clear quicker than dried fruits and chips and far quicker than the aformentioned hard candy offenders. 

Think it’s just children that you need to keep an eye on over the spooky season? Think again! The National Confectioners Association confirms that three quarters of adults buy Halloween candies for their households (happily eating what they don’t give away), and 72% tuck into their children's swag. 

The Silver Lining

Halloween is rarely a dentist’s favorite time in the holiday calendar, but there is a bright side to this traditionally candy-fuelled occasion. Halloween is an excellent time to educate your patients not only about caring for their teeth, but also about disease prevention and about making healthy choices.

Here are some great tips to make the most of a tricky holiday:

• Show kids — and their parents — that good oral hygiene isn’t about avoiding sweet treats at Halloween, but about choosing better options (like chocolate) and brushing well afterwards. 

• Don’t be afraid to ‘scare’ your younger patients with a few dental-related Halloween horror stories. Nothing too frightening, of course, but this is a holiday based on ghouls and goblins!

• Do hand out some Halloween treats, but remember that there are non-candy alternatives that kids will love, such as themed coloring sheets and even spooky stickers. 

• And finally, use the holiday as an excuse to reinforce good behaviors and ensure that all your patients understand the best ways to care for their teeth at home and reduce the risk of damage. There are learning moments everywhere at this time of year!

Discoloration, caused by either extrinsic or intrinsic stains, is a remarkably common concern. As dentists, we all want our patients to feel happy and satisfied with the appearance of their teeth. At a time when the value of the global teeth whitening market is rising at an almost unprecedented rate — now exceeding $3.2 million according to the American Dental Association — it’s natural that many people are beginning to look into at-home treatments. But should you recommend these systems to your patients?

Is At-Home Teeth Whitening Safe?

The official line from the American Dental Association is that at-home whitening systems, including trays, strips, pastes, and rinses, are generally safe to use, and can be effective at minimising the appearance of discoloration from the use of certain medicines, removing surface stains from food and drink intake, and lightening and brightening teeth that have become darker with age. However, as a dentist it is essential to understand the risks of at-home teeth whitening, and ensure that all patients are aware of these risks before using any at-home kits, regardless whether they are purchased over-the-counter or from your office. 

Teeth Whitening Risks

Perhaps the most common side effect of teeth whitening is a notable increase in tooth sensitivity, which the ADA estimates affects up to 41% of all patients who undergo a whitening procedure. Gum irritation is also frequently noted, especially when using off-the-shelf trays which have not been purpose-made to match the size, shape, and layout of the individual’s mouth. This is due to movement of the tray and rubbing.

However, the risks are understood to go above and beyond these minor side effects, with a study in the British Dental Journal reporting that products containing sodium chlorite could actually increase the chance of extrinsic stains through the creation of greater surface abrasions, giving stains more to adhere to. The study also noted cases of infections, blistering, and burns as a result of using bleaching gels. 

And that’s not all. While more investigation into the area is needed, researchers have posed the idea of cellular damage as a result of peroxide-based products with the potential for peroxide to interact with DNA to have a wider impact upon human health as a whole. Peroxide has been cited as a carcinogenic, an irritant, and a cytotoxic. Dentists should be aware of this when recommending products. 

Suitable Alternatives

While dentists may wish to recommend at-home whitening products to those presenting with healthy teeth which are in good condition, other options are available that may well prove to be safer overall. 

Dentist-administered whitening treatments carried out by a trained professional may be offered as an alternative, while mild extrinsic stains often respond positively to the Gazelle nanocomposite polisher which restores and shines the surface of the teeth with either a satin or high gloss finish. The results may not be as significant as those that can be achieved through dedicated teeth whitening systems, but polishing can be hugely effective at minimising surface stains and creating a brighter appearance. And best of all, it's safe!

Did you know that dental office overheads are amongst the highest across all industries? According to the American Dental Association, who analyzed figures from the Bureau of Labor Statistics, the average overhead for dental practices in the US stands at almost 75% (74.62% to be exact); much higher than the 35% that is typically agreed to be standard for well-performing organizations.

It’s no secret that running a busy and successful dental practice can be costly, but overheads of nearly 75% can — and should — be avoided to ensure a solid and stable financial future for the firm. 

Here are 3 easy-to-implement ways to minimize outgoings and reduce dental overheads:

1. Switch Supplier

A major challenge that dentists are facing is that many patients are finding it difficult to access the necessary care they need due to rising healthcare costs. A Health Policy Institute Report by the ADA confirms that 40% of American adults do not attend dental appointments because they cannot afford to do so. As a dentist, it is tempting to purchase cheaper, lower quality supplies to reduce the cost of dental work for our patients, but in doing so practices could find that they’re actually paying out much more.

Low cost, low quality tools and equipment not only put our patients’ health at risk, but in many cases also increase the number of products we need to buy. Many low quality polishers, for example, can crumble easily, meaning that they’re unable to fully complete the job they were designed to do. Similarly, the industry is seeing a rise in ‘absorbent’ pads which aren’t absorbent, and burs with very short life spans. Higher quality burs like NeoBurr, are up to 70% stronger than other brands. 

2. Automate Processes

Automation is a hot topic right now, and it’s working its way into practically every industry. One industry that appears reluctant to implement new technology, however, is dentistry. While advanced technologies such as robotics are certainly a long way from being introduced into the average practice in the US, there are many other forms of automation that do have a place. Predictable tasks, such as appointment setting, repeat ordering, and staff rotation, for example, can all be managed by dedicated software. 

In automating many front-of-house and management processes, practices could find that they’re able to free up their valuable internal resources for other, more productive, profit-making tasks such as marketing. More pressingly, automation not only removes the need for skilled employees to spend their time completing mundane tasks, but could actually help to improve attendance rates, too. One study found that no-shows (which can be costly) can be reduced by 23% with automated reminders. 

3. Know Your Audience

Marketing plays a significant role in the overall success of dental practices, helping to raise awareness of the unique skills and experience of the team and getting local patients through the doors. Marketing is certainly an area that’s worth creating a budget for, but one of the primary concerns right now is that dental practices are wasting this budget by failing to tailor their marketing campaign to their niche audience, and are instead attempting to appeal to a very widespread and broad demographic. 

As dentists, we all have a commitment to both promoting and encouraging good oral care for everyone, so it’s natural to want to market the dental practice to all demographics. However, in terms of financial responsibility, it is perhaps more effective for practices to customize their campaigns specifically to attract and engage those most likely to visit a dentist. Colgate reports that women are twice as likely to visit a dentist as men, for example, so campaigns tailored to men could end up being money down the drain.

The Pioneer of Single-Patient-Use

NeoDiamond, the pioneer and #1 single-patient-use diamond, is celebrating its 30^th anniversary. Three decades ago, Microcopy co-founder Thom Maass, Jr. achieved his vision to offer a high quality, sterile and efficient dental diamond bur — even coining the phrase “Single-Patient-Use”. NeoDiamond launched, outfitted in the distinctive magenta packaging, in early 1989. The original NeoDiamond line consisted of 16 shapes. Unbeknownst to Thom, NeoDiamond would go on to become a highly regarded brand by dental professionals around the world.

“Much has changed since NeoDiamond launched in 1989,” said Paul Tucker, CEO, “But through the years Microcopy has stayed true to its mission to bring products to the dental market that make dentistry easier and safer.” The NeoDiamond line now consists of 126 shapes in various grits. Most recently, in May 2019, 6 new pediatric short shank diamond burs were released. Microcopy has expanded globally and maintains a focus to offer innovative, single-patient-use products that enable dentists to fulfill a social responsibility to provide better, healthier patient care. It’s no longer 1989 but Microcopy is planning to keep NeoDiamond around for the next 30 years. As Heather Siler, marketing manager puts it, “NeoDiamond was developed with safety and performance in mind, which is still the driving force for the brand today. Great products like NeoDiamond will never go out of style.”

To celebrate NeoDiamond’s golden anniversary, Microcopy wants to hear from NeoDiamond customers, old and new. Microcopy has launched a photo submission campaign, encouraging customers to submit their “NeoDiamond Story” along with a photo, sharing why they started using or what they love about these single-patient-use diamonds. Entries will be submitted into a drawing to win a trip to Atlanta for a tour of Microcopy and select from a list of other exciting places to visit while in the city. To share your NeoDiamond Story visit: https://microcopydental.com/nd-30form. 

For more information about NeoDiamond visit www.NeoDiamond.com or call 800-235-1863.

The Growing Field of Pediatric Dentistry

Microcopy Dental is expanding the NeoDiamond portfolio with the release of six new pediatric diamond burs. The launch will take place in May at the CDA Presents in Anaheim.

This line expansion comes at a time of rapid growth in pediatric dentistry, one of the fastest growing dental specialties. These new additions to the NeoDiamond line guarantee a precise, minimally invasive cut at an economical price. A precise, minimally invasive cut is imperative, especially for pediatric patients. With that in mind, Microcopy’s Pediatric NeoDiamonds are designed for use on smaller teeth and working with tighter margins.

“On the heels of NeoDiamond’s 30^th anniversary, we are excited to expand our single-patient-use diamond portfolio. This is the first major line expansion for NeoDiamond since the launch of Endo Access and Guide-Pin diamonds in 2011,” said Heather Siler, Microcopy’s core product marketing manager. 

All pediatric diamonds are available at the same price point as the Crown and Bridge NeoDiamonds and will come in the renowned pink box of 25 pre-sterilized burs.

Visit www.NeoDiamond.com or call 800-235-1863 to request a product sample or for more information.

Rheumatoid arthritis (RA) is a systemic autoimmune disease which causes inflamed and stiff joints, severe pain, fatigue, and other moderate to severe symptoms. It’s estimated that 1.5 million in the United States suffer from this debilitating disease responsible for deformed joints and bone erosion.

Doctors once thought that periodontal disease was a result of RA due to severe pain in the patient’s hands inhibiting them from practicing proper oral hygiene. They also surmised that the medications used to treat RA might affect the body’s ability to fight harmful bacteria in the mouth. However, the correlation between the two seems more complicated than hand discomfort or effects of medications as research has also shown a genetic link between the two.

In general, periodontal disease seems to be a key indicator of the presence of many chronic diseases such as heart disease, diabetes, kidney disease, and some cancers. Inflammation and the body’s response are the key factors in these diseases. As studies continue and there’s a better understanding as to what causes RA, improved treatment options and perhaps preventative steps can be taken to fight this crippling disease.

The bottom line is that clinicians must be aware of RA and its relationship to periodontal disease. Patients with RA must be given proper hygiene instruction and any special aids (Power Brushes, Oral irrigators, mouth rinses, etc.) to help them practice proper oral hygiene. They should also be placed on a three-month recare schedule to keep the inflammation under control. Working together will assist in protecting patients from the oral effects of RA.

Unpleasant but necessary, numbing an area before dental treatment is highly recommended to make certain that the treatment goes quickly, successfully, and most importantly, painlessly. Anesthetics are used daily in dental offices and are rated by their safety, duration, and effectiveness and each has benefits and risks. Clinicians use the proper anesthesia based on the patient's medical history and the duration and invasiveness of the procedure.

Before the actual injection, a topical anesthetic gel is applied to the area. This gel is responsible for numbing up to 2mm of tissue and keeps the insertion of the needle from being uncomfortable. Most dental topicals consist of Benzocaine 20% and are very effective when applied to the tissue and left alone for around 2 minutes. After the topical takes effect, the area is injected with a local anesthetic which numbs the tissue and the teeth. Although most patients refer to all dental anesthetic as Novocaine, newer and more effective anesthetics have evolved posing fewer complications such as allergic reactions.

Lidocaine is the most popular choice of anesthetic because of its effectiveness, safety, and medium duration of action. Numbness from Lidocaine usually lasts for 2-4 hours.  

Articaine – Articaine is probably the most effective local anesthetic available today and is surpassing Lidocaine in popularity because of its effectiveness. Like lidocaine, it has a medium duration of action. However, because it’s much more concentrated than Lidocaine, less can be used safely.

Bupivacaine is a local anesthetic mostly used in oral surgery because it has a very long duration. Oral surgeries such as wisdom teeth extractions and implant placements can take an extended period, so Bupivacaine is the anesthetic of choice to keep the patient comfortable.

Local anesthetics enlarge the blood vessels which increases bleeding, and excessive bleeding decreases the field of sight. For this reason, a vasoconstrictor (epinephrine) is added to constrict the blood vessels which decreases bleeding and makes the anesthetic last longer.

Although patient’s dislike getting a dental injection, the effects don’t last too long and being numb during the procedure is certainly worth a few uncomfortable minutes while the anesthesia is placed.

Daily Use & Maintenance of the Unit

Oral irrigators have become increasingly popular because of their success in disturbing plaque biofilm. Patients must receive proper instruction regarding their use and maintenance to prevent injury and infection. Below are guidelines for daily use and maintenance.

Daily Use:

• Recommend the Proper Tip- there are many tips available for use with an oral irrigator. The recommended tip is based on the patient’s condition and failing to use the suggested tip can cause injury.
• Periodontal Tip Usage- Patients with periodontal disease should be instructed on how to use a periodontal tip which is designed to allow access up to 90% of the pocket depth. It’s inserted subgingivally and has a soft rubber tip with a small opening that controls the amount and pressure of the water and antimicrobial entering the pocket. Before turning the unit on, place the tip gently into the pocket at a 45-degree angle, and then turn it on low pressure.
• Add the Recommended Microbial- an antimicrobial increases the effectiveness of irrigation and can be used full strength or diluted with water. Recommendations depend on the patient’s condition and tolerance.
• Proper Use- the patient should be shown how to position the appropriate tip at a ninety-degree angle to the long axis of the tooth and three millimeters from the gingiva. The tip should be swept along the gumline and paused for five seconds interproximally. This process should be followed on the facial/buccal and lingual surfaces. The tip should never be pointed down into the gingiva unless using a periodontal tip.
• Water Pressure – most devices have adjustable water pressure. Patients must begin using a lower pressure (about 3-4) to get accustomed to irrigation. After one week, they should be able to increase the pressure (7-10). However, those with sensitive gums or using a periodontal tip will need to use less pressure.
• Choose the Right Unit- there are many different units available on the market and guidance is necessary to ensure that the patient purchases one that matches their needs.
• Irrigate Daily- Consistency is the key in improving oral health. Microbes form very quickly, and they must be fought daily for maximum benefit.
• Mind the Mess- A water jet causes a huge mess if not used correctly. Placing the tip in the mouth and against the tongue before turning it on is necessary to avoid a disaster. Also, keeping the head down during the entire session will help diminish the mess. Some models have a water control button on the handle which helps tremendously.
• Don’t Forget to Brush and Floss- An oral irrigator is an adjunctive therapy. Brushing at least three times and flossing at least once per day is crucial for maintaining a healthy mouth.

Maintenance of the device on a monthly basis is necessary to establish the irrigator is safe for daily use. Bacteria, fungi, and viruses can easily contaminate the unit if it’s not cleaned on a regular basis. Also, using tap water can cause mineral and other unwanted deposits to build up over time. Certain parts can be placed in the dishwasher to achieve disinfection. Below are the steps to clean a countertop device. Portable or cordless models should be cleaned monthly by following the manufacturer's instructions.

 Maintenance:

• Clean the exterior with a non-abrasive product and a soft cloth.
• Clean the reservoir by removing it if it’s detachable. If it has a removable valve, take it out and rub gently under warm water. The reservoir can be placed in the top rack of the dishwasher and air dried. Don’t place the valve in the dishwasher.
• Clean the internal pieces by placing 16oz of warm water with two tablespoons of white vinegar into the reservoir and turning it on high pressure until all the solution is flushed through.
• Clean the handle by soaking it in one-part white vinegar and two parts water for 7-10 minutes.
• Clean the flosser tip(s) by removing it from the flosser and soaking in one-part peroxide and two parts water for about 5 minutes.
• The flosser tip should be replaced every 3-6 months depending on the hardness of the tap water.
• Never leave water in the reservoir overnight.
• Always run some hot water through the unit after each use.

An oral irrigator is a great investment for every patient provided they’re instructed on usage and maintenance from a dental professional. Patients with orthodontic appliances, implants, crown and bridge, diabetes, gingivitis, periodontal disease, and those whose oral and overall health is less than ideal can certainly benefit from daily use.

Types of Oral Irrigators and Tips

Oral irrigators have become increasingly popular because of their effectiveness in disturbing plaque biofilm. In this blog, the types of irrigators and tips are discussed.

Types of Irrigators-

• Electric or Cordless- the power source is a traditional electrical plug or a rechargeable battery.
• Full size, Compact, or Travel- various sizes are available depending on the user’s lifestyle.
• Removable or Fixed Reservoir- refers to whether the reservoir can be removed from the unit. Removable is best to allow for proper cleaning.
• Pressure Control- most units allow the user to adjust the amount of water pressure.
• Pulsed Flow- This is the most common unit on the market. The water is compressed and decompressed causing bacteria and debris to become disrupted and removed supra and subgingivally.
• Steady Stream- The water comes out in a steady stream without the pulsation.
• Magnetized- The water is charged thereby reducing the formation of calculus. However, studies suggest that this type of unit doesn’t decrease gingivitis and bleeding.
• Oxygenized- The water is incorporated with air which produces bubbles to disturb plaque and anaerobic bacteria. This, in turn, reduces gingival inflammation and bleeding.

 Tip Styles and Usage-

• Standard Tip- This tip is the most common and is used supragingivally daily to remove food particles and disrupt plaque biofilm. It allows the water to reach 50% of the pocket depth.
• Periodontal Tip- This specialized tip is designed to allow access up to 90% of the depth of the pocket. It’s inserted subgingivally and has a soft rubber tip with a small opening that controls the amount and pressure of the water and antimicrobial entering the pocket. The patient must be instructed regarding use and must have sufficient dexterity.
• Orthodontic Tip- Used around orthodontic appliances to effectively remove food particles and disturb plaque biofilm, this tip is also recommended for patients with sensitive gums.
• Combination Sonic Toothbrush and Irrigation Tip- this hybrid tip is excellent for plaque removal and irrigation at the same time. It’s recommended for all patients but especially ones with limited dexterity.
• Tongue Cleaning Tip- this tip assists with halitosis by reducing the number of bacteria on the tongue. Recommended for all patients but especially those with elongated papillae.
• Restorative Tip- this tip is recommended for patients with implants or crown and bridge that may not respond to traditional methods of oral hygiene. Implants, crowns, and bridges may be difficult to access because of their shape and positioning.
• Nasal Tip- Used for flushing the nasal passages.

In the next blog, we’ll delve into proper use and care of oral irrigators.

Antimicrobial Use

Oral irrigators have become increasingly popular because of their success in disturbing plaque biofilm. Furthermore, the addition of an antimicrobial to the water makes using an oral irrigator more effective. By disturbing the plaque biofilm and delivering an antimicrobial above and below the gumline, reduction in bleeding, inflammation, and periodontal pocket maintenance can be achieved. Today, we will focus on the use of antimicrobials in the water.

Types of Antimicrobials Used in an Oral Irrigator-

• Phenolic Compounds- these over the counter rinses contain essential oils and varying other ingredients such as alcohol, hydrogen peroxide, and fluoride which have been proven to reduce the bacteria responsible for bleeding and inflammation especially when the rinse is used full strength.
• Stannous Fluoride- stannous fluoride is excellent in decreasing bleeding and inflammation. It’s also great for decay and tooth sensitivity when used in toothpaste.
• Hydrogen Peroxide- hydrogen peroxide is very efficient at targeting harmful anaerobic microorganisms that thrive in pockets because it introduces oxygen into the area.
• Chlorohexidine- a one to one ratio of water and Chlorohexidine has been shown to diminish inflammation and bleeding significantly. Chlorohexidine is only available by prescription and is the most powerful antimicrobial rinse on the market. However, simply rinsing with this product doesn’t reach more than one or two millimeters below the gumline. Its effectiveness is increased when added to the irrigator because it goes deeper subgingivally.

Stay tuned for part 3 of this blog series as we’ll look at the types of irrigators and tips.

The New Definition of Strength

At this year’s Chicago Midwinter meeting, Microcopy, a leader in the design and development of innovative products for the dental industry, announces the release of its new NeoBurr 330² blended neck® carbide. This new blended neck carbide follows suit with the 557², the section of the bur between the cutting head and the shank is blended so there is no reduction in neck width. This design, coupled with the removal of the weld joint increases the strength of the bur. The new 330² boasts unrivaled strength. This innovative design removes any weak points in the bur’s neck that might otherwise cause breakage.

“It is important for us to provide high-quality products that solve a problem. Carbide breakage is a well-known issue that exists in dentistry. By offering a stronger carbide line, we have made it our mission to make carbide breakage a thing of the past,” said Heather Siler, Microcopy’s core product marketing manager. 

Most of the top-selling NeoBurr shapes are available in blended neck and Microcopy plans to release additional blended neck shapes as they are designed and developed.

After a recent product evaluation of the NeoBurr 330², Dr. Lawrence Cooper says, “Very fast, smooth cutting occlusal and distal preparations.”  The new 330² has all the same great features as the original NeoBurr 330, but now it has a blended neck for increased durability.

Visit NeoBurr.com or call 800-235-1863 for more information.

Oral irrigators have been available for home use since the early sixties, and recently, they’re gaining in popularity. New research reports their effectiveness in disturbing plaque biofilm and as a result, reducing the host’s response to the microbes in the plaque.

When oral irrigators were first developed, studies revealed that their use reduced gingivitis, but they didn’t remove troublesome plaque. Therefore, it was thought that daily oral irrigation wasn’t effective. Water flossing was mainly recommended for patients with orthodontia, crowding, and patients dealing with food impaction. Another concern was that daily use could cause bacteria in the mouth to enter the bloodstream and cause an infection, but research shows that using a water irrigator poses no more threat to infection than any other oral cleaning device.

New findings reveal that oral irrigators alter plaque formation rather than remove it altogether. Disturbing plaque formation dilutes toxins and disrupts bacterial colonies thereby lessening the patient’s immune response. In other words, even though the plaque isn’t removed, the bacteria within the plaque is disorganized, and in turn, inflammation, bleeding, pocket depths, and the patient’s immune response is repressed. Also with the correct tip and instruction, periodontal pathogens deep within the pocket are compromised.

Brushing, flossing, and rinsing with an antimicrobial product doesn’t go underneath the gumline more than one or two millimeters. By incorporating the use of a water flosser, patients remove not only food debris, but also disturb plaque formation from around the entire tooth beyond two millimeters.

Today, oral irrigators are beneficial for all patients, but especially those with orthodontic appliances, implants, crown and bridge, diabetes, periodontal disease, gingivitis, and those whose oral health is less than ideal.

In part two of this blog, we’ll discuss the types of irrigators and the different tips used for specific purposes.

If you’ve been in Dentistry for many years, you’ve probably held a film or sensor in a patient’s mouth during radiographic exposure. Children, patients with a small mouth or tori, severe gaggers, or uncooperative patients can make it seem like there’s no other way to get the perfect shot without compromising your health.

Because radiation is cumulative, it builds over time and can cause significant damage to the body. Exposure has lessened dramatically since the introduction of digital technology, and harmful effects are rare today, but that doesn’t mean that it’s ok to stay in the operatory during exposure. Following are some things to consider while taking x-rays:

• Use appropriately sized film. Unfortunately, there aren’t many options for film or sensor sizes. However, a pediatric size is a must because it can be used for an adult with a small mouth, sensitive gag reflex, or tori.
• Have the patient hold the film. If there’s no other way to get a decent shot, the patient can be instructed to hold the film. It’s a bit risky because the film or film holder must be held firmly, but it’s better than exposing yourself. It also may or may not work with a child. But again, it’s worth a try.
• OSHA mandates that employers provide a safe workplace which includes limiting radiation exposure. Therefore, dosimeters and barrier shields (lead aprons and lead lined walls) should be in place anywhere x-rays are taken. A dosimeter is a scientific instrument (usually a badge that the clinician wears) used to measure exposure to radiation. The badge is monitored by the company from which it’s purchased.
• Employees must be educated and take a course in radiation protection, and anyone who takes x-rays must be certified by the state.
• The maximum annual dose of radiation for healthcare employees is 50 millisieverts (mSv). The maximum allowable lifetime dose is ten mSv multiplied by your age.
• Pregnant clinicians can expose x-rays, but they must wear their dosimeter and a lead apron every time and never remain in the room during exposures. While this may seem like overkill, it’s prudent to have team members who are pregnant stay far from any radiation. Many pregnant practitioners refuse being exposed to any radiation, and their decision should be respected.
• Continued exposure to dental X-rays is linked with an increased risk of cancer. Again, most clinicians today aren’t overexposed because of advances in technology that require far less radiation and precise and focused beams, but it certainly can happen. Specific types of cancer such as thyroid and tumors involving the hands or fingers are linked to the dental profession.

Dental offices are busy places and staying on schedule is a must. It’s easy to justify getting a diagnostic x-ray by holding the film in the patient's mouth, but it shouldn’t occur. Perhaps it’s time to find a course that teaches alternative ways to get a readable x-ray without exposing yourself. Always remember that radiation is cumulative and dangerous when not respected.

Toothbrushes are breeding grounds for all sorts of bacteria, fungi, and viruses, and one toothbrush can host up to ten million microbes. Don’t panic though; research shows that the types of microbes found on your brush aren’t responsible for making you ill if germ-killing toothpaste is used and you store the brush upright so that it can dry. Following are some tips to help get the most use out of your brush without compromising your health:

1. Know when to throw it out- When dismissing a patient and giving them a new toothbrush, many say, “Thank You. I need a new toothbrush. I’m still using the one you gave me six months ago”. Six months is far too long to keep a brush. Dental professionals have been taught to advise patients to replace their brush after three months of use or However, new research suggests differently as you’ll see below.
2. Know how to care for your brush while traveling- When traveling, most people store their brush in a closed container. While this may seem smart, enclosing the brush allows the germs to breed much faster. It’s best to store it upright to dry because enclosing it creates moisture allowing germs to multiply quickly. It’s best to let the brush air dry away from the toilet. Also, use disposable brushes while traveling, and toss them after your trip.
3. Toothbrush sanitizers? There are many electric sanitizers on the market, but studies show that they aren’t effective. You can sanitize your toothbrush without causing harm by soaking it in mouthwash that contains alcohol as the alcohol kills germs. You can also soak it in a mixture of 1 part water and 1 part hydrogen peroxide or dip it in boiling water for ten seconds. You shouldn’t put your toothbrush in the dishwasher or microwave to sanitize it because doing so will cause damage making it unsafe to use.
4. Toothbrushes with built-in indicators- Some brushes have indicators telling you when to throw it away, but you still may have to replace it before the indicator says it’s time. New studies show that toothbrush replacement should be determined by the shape of the bristles and not the calendar.
5. Store your brush in a safe place- You should always store your toothbrush uncovered and in an upright position. It can be near other brushes, but they shouldn’t touch. Also, your toothbrush shouldn’t be stored near the toilet. When flushed, the air becomes contaminated with aerosols from the toilet, and this toxic aerosol can travel up to six feet.

The bottom line is to examine the bristles at each use, and if there’s significant wear, it’s time to get a new one. However, if your brush has noticeable wear after one month, you’re brushing too vigorously and need instruction on how to brush from your dental professional. Store it at least six feet from the toilet and don’t keep it covered. By following these tips, you can rest assured that you get the most out of your brush safely and effectively.

As clinicians and customer service representatives, obviously we’re required to interact with patients, but there’s a fine line between being professional and knowing when you’ve shared a little too much about your personal life. While we certainly don’t want to appear cold and indifferent, getting too involved personally with a patient can have an adverse reaction. Also, some patients would rather not engage during an appointment unless it’s related to their oral health.

Building rapport with patients is extremely important, and we’re expected to be comforting, informative, and professional. However, chatting the entire appointment about irrelevant and personal matters can cause some patients to become annoyed and stressed. Therefore, acquiring the skill of reading people is very important and will prevent awkwardness and embarrassment. It’s not too difficult to pick up on a patient’s demeanor and adjust your communication skills if you pay close attention to their cues and body language.

When a patient comes into the operatory, it’s their time, and they need your undivided attention. They may have issues they want to discuss, or they may not want to talk at all. Patients can change their demeanor from one visit to the next, and everyone has a bad day. If you sense the patient is annoyed, remain silent and let them initiate any interaction. However, if there’s a dental issue at hand, informing the patient is important. You don’t have to overdo it, but make sure they’re aware of any issue(s) you find.

Another important point is to make sure your conversation is appropriate. Some topics such as religion and politics are off-limits. Also, keep the conversation focused on the patient. While you want them to get to know you, they may not want to hear all about your life. Some people will want to know everything about you but use discretion. Vacations, children, career, grandchildren, and pets are usually a safe subject. With a little practice and patience, you’ll become a pro at knowing when to share and when to watch your mouth.

If you’re facing a tooth extraction, you may be wondering if your general dentist or an oral surgeon will be performing the service? While both general dentists and oral surgeons extract teeth, there are several issues to consider before making your appointment.

The first step is to visit your general dentist to determine if an extraction is necessary. A clinical exam and x-rays will be necessary for your dentist to make an accurate diagnosis and decide whether they will perform the procedure. The criteria for extraction by a general dentist is based on:

• Bone around the tooth- If there’s bone loss around the tooth, it’ll be easier to remove. Therefore, a general dentist will frequently extract.
• The presence and extent of infection- If there’s significant infection surrounding the tooth, you may be referred to a specialist.
• The severity of pain- If anesthesia is given and the pain is still intolerable, a referral may be in order so that you may receive a sedative via IV.
• Impacted teeth- More often than not, if your tooth is impacted, you’ll be referred to an oral surgeon because of the intensity of the procedure. IV sedation is commonly used with this type of surgery.
• Broken or severely decayed teeth- If your tooth is broken or severely decayed, it’ll be more difficult to remove because of the probability of breakage. When this occurs, the tooth must be removed in pieces making an oral surgeon the better choice.
• An implant is going to be placed- If your tooth is being extracted and an implant is being placed simultaneously, an oral surgeon is recommended since they place the implant. Even if an implant isn’t placed immediately, the oral surgeon may still want to perform the extraction if the socket needs further treatment to support an implant later.
• Extensive medical history- If you have medical conditions such as heart disease, diabetes, blood disorders, or a complicated medical history, most dentists will automatically refer to an oral surgeon. It’s much safer for you because of the controlled environment and monitoring protocol while under anesthesia.

Most dentists know their limitations when it comes to extracting teeth and won’t hesitate to refer you to a specialist who is proficient in more complicated procedures. For this reason, if you’re referred to an oral surgeon, follow the recommendation.

The Food and Drug Administration (FDA) issued a directive on November 15, 2018, stating that electronic cigarettes and certain flavorings will only be sold to adults in stores where there are age restrictions for entering and buying. Online sales will also continue, but more diligent protocol will be in place for age verification.

The use of e-cigarettes and other vaping devices has been on a steady increase, and a large part of that increase is kids in middle and high school. There’s also a large adult population using these devices to help them quit smoking traditional cigarettes. Most adults prefer mint flavorings in their device while around 50% of kids prefer flavors like chocolate, bubblegum, fruit, vanilla, and cinnamon, to name a few. With adults preferring tobacco, menthol, and mint flavors, the FDA statement excludes these flavors because they assist adults in transitioning from traditional cigarettes. As a result, these flavors will still be available in stores where there’s no age exclusion.

In advance of the directive, there was an increase in warnings sent and fines incurred by stores and online retailers concerning the sale of these products to minors and the consequences of violations will get more severe over time. Even with all these safeguards in place, it’s still important for parents to be aware of teens using e-cigarettes and vapes to prevent the number from becoming higher.

The new year is upon us, and so is the tradition of making New Year’s resolutions. While most people vow to workout, lose weight, or gain control of bad habits, does anyone commit to professional resolutions? Setting goals for your dental practice should be on the top of the list.

The new year is the perfect time to reexamine what works and what doesn’t in your office. Following are some tips on how to brave the new year with a clean slate.

1. Be honest with yourself- Now’s the time to get to the bottom of what is and what isn’t beneficial. A thriving practice embraces change and has a willingness to learn. Furthermore, it’s not unusual to outgrow some of the policies that are in place. What worked last year may not work in the new year and making new policies and procedures shouldn’t be overlooked.
2. Make a list- It’s crucial to list all policies and procedures in and out of the operatory. Covering all the bases from fillings and crowns to insurance and team member management will establish that each department is evaluated and streamlined.
3. Be open to change if it’s necessary- It can be scary to examine popular ideas, but if it’s something you feel compassionate about, go forward. You’ll rarely regret trying something, and if it doesn’t mesh with your goals and morals, revise and begin again. Remember, this is your practice, and you can add or subtract whatever you wish. It’s certainly not a mistake to attempt something and reconsider if it fails.
4. Involve the team- Hopefully, you’ve surrounded yourself with an awesome group of professionals who have your best interest at heart. However, if there are team members who need a change of scenery, it may be best to sit down with them and part ways on a pleasant note. For those who are the foundation of your practice, appreciate them and allow them to learn the unfamiliar and embrace innovation. Keep them involved in deciding what’s best for the practice.
5. Be brave- Change can be scary because the unknown is terrifying but taking baby steps can ease any concerns. You don’t have to implement changes all at once, but not taking the first step will keep you stuck in a rut. Also, don’t be afraid to ask for help. There are educational courses everywhere and having a structured plan in place will help with implementation. Having a professional at your fingertips to guide the way is a very wise investment.

In closing, revisit your resolutions with your team on a monthly basis and be honest, open, and brave. Following through with these tips will assure that you ring in new year with prosperity and happiness.

Although dentures and partial dentures are made with quality materials, they do break from time to time which can be very inconvenient. What causes a denture or partial to break?

• Stress from chewing and occluding weakens the material
• Hot, cold, and acidic foods alter the components causing breakdown
• Bone resorption resulting in pressure points and undue stress leading to breakage
• Deterioration from normal wear and tear
• Accidents like dropping the denture or the family dog chewing it beyond repair

If your denture or partial breaks, the first thing you should do is contact your dentist because eating, talking, and being around others can be a negative experience without your teeth. Depending on the severity of the break, your dentist may be able to fix your denture or partial in the office. However, if the break is serious, it may have to be sent to a lab for repair which can take days. There are denture repair kits over-the-counter, but they aren’t recommended since their use can cause irreparable damage.

If you have a partial denture, there is some good news regarding deterioration and fracture. Traditionally, partial dentures were made with polymethylmethacrylate acrylic and metal which is very rigid and has no flexibility. More and more dentists are now using a biocompatible nylon thermoplastic substance that is flexible and more forgiving than polymethylmethacrylate acrylic. Fabrication with a flexible material reduces breakage, so it may be beneficial to discuss this type of partial with your dentist.

There are steps you can take to prevent a disaster with your denture or partial. You should care for your prosthesis as you would your natural teeth. Daily care and maintenance is a must. Remove the denture or partial at least twice per day and brush them with a denture brush and non-abrasive toothpaste. They should be soaked once per week in a cleaner manufactured for dentures and partials. Taking them out at night and soaking them in water also helps keep the integrity of the prosthesis. It’s important to keep them wet when they’re out of your mouth. By following these guidelines, your denture or partial can give you many years of comfort and a beautiful smile.

If your family dentist has referred your teenager to the orthodontist, you may have experienced some resistance from them. Children are often referred to ortho around age 5 for preliminary treatment, and they usually go along without any fuss. However, teens can be a real challenge when it comes to orthodontic treatment. What can you do to encourage your teen to comply?

1. Instead of flying off the handle, sit down and talk it out calmly. Teens are sensitive, and if you can get to the bottom of why they’re hesitant, you may be able to call a truce.
2. Let the Orthodontist explain why braces are recommended for them. Kids compare themselves to their peers constantly, so educating them with their records (x-rays, models, pictures, etc.) can allow them to objectively see why braces would benefit them in the long run.
3. Be honest with them about discomfort. While monthly adjustments can be uncomfortable, the pain is short-lived, and over-the-counter pain meds help tremendously.
4. Be sympathetic concerning how they look with braces. Today, approximately 75% of kids wear orthodontic appliances. They are extremely common and are considered the norm. There are also some options that help conceal braces such as a clear series of trays and ceramic brackets. Wearing braces can also be fun because they get to choose different colors of bands that fit over the front of the brackets.
5. Be realistic about treatment time. Most orthodontic treatment is completed in 18 months. While this does seem like a lifetime, keeping up with appointments, following the orthodontist’s instructions, wearing any additional appliances (rubber bands, headgear, etc.), maintaining good home care, and celebrating progress along the way can help them stay encouraged throughout treatment.

Being a teenager can be difficult at times, and mostly, they want to be heard and accepted. Following these steps can have your teen saying “yes” to ortho, and they may even clean their room!

With the holidays quickly approaching, here’s some trivia to lighten the mood and spread some cheer.

1. It’s thought that candy canes were invented around 1670 by a German choirmaster who used them to keep children quiet during church services. They were originally white, and when or why the red striping was added is unknown.
2. Fruit Cake was designed to last all year. Sugar and alcohol in the cake act as preservatives, and it was made at the close of the harvest season. It was then eaten at the beginning of the following harvest as a symbol of good luck.
3. Holiday feasts can contain over 7,000 calories per person.
4. Purchasing all the gifts from “The Twelve Days of Christmas” could hurt your pocketbook. Today, it’s estimated that the price tag would be around $40,000-50,000.
5. Most think that Black Friday is the busiest shopping day when, in fact, it’s the two days before Christmas. Also, one out of three men shops on Christmas Eve for all their gifts.
6. Emergency room visits during the holidays are usually due to injuries from decorating, and the most common injury is falling.
7. More people prefer ham instead of turkey at Christmas.
8. Since December is Summer in Australia, most Australians make their Christmas feast “on the barbie” or as it’s referred to in the USA, the grill.
9. Michigan, Washington, Wisconsin, Pennsylvania, and North Carolina are the top producers of Christmas trees, and the trees grow for around 15 years before they can be harvested.
10. With the introduction of electricity in the early 1900s, the wealthy were the only people who could afford electric lights on their tree, and the lights were rented rather than bought.

We hope this trivia will provide some entertainment at your holiday gatherings. Enjoy time with family and don’t forget to brush and floss after the festivities.

Dentistry is an extremely stressful profession both physically and psychologically. Patients have varying personalities which are usually fine until a line is crossed. Inappropriate behavior is experienced and defined differently depending on the person, but most would agree that poor manners aren’t to be tolerated.

There should always be mutual respect between patients and clinicians. Deciding what is and isn’t appropriate must be decided beforehand by the Doctor(s), Office Manager, and all team members. Each person has their idea of what is acceptable, and everyone should weigh in with their opinion. Appointing one person in charge of dealing with patients who have behaved improperly is necessary, and it’s usually the doctor or the office manager.

Some common inappropriate behaviors include:

• Racial or sexual comments or slurs- Any comment meant to degrade another human being regarding their race or gender must be dealt with immediately.
• Inappropriate flirtatious banter- Flirting is usually more complementary than sexual comments and slurs. The receiver can mistake it as friendly, but it can quickly escalate into a dangerous situation.
• Demeaning a team member – Regardless of intent, demeaning another person is very hurtful and can negatively affect self-esteem. Unfortunately, it does occur, and it must be addressed.
• Physical interaction- If a patient ever puts their hands on anyone in the office in a hostile or sexual manner, they must be dismissed from the practice immediately. A formal notice to the patient is mandatory, and the practice is legally obligated to be available to them on an emergency basis for 30-45 days to give them time to find a new dentist.

If a patient does commit an inexcusable act, it’s best to escort them to a private area with a witness. Ask them if they’re aware of the behavior or comment that offended a team member. Let them talk and explain why they acted in such a manner. Make them aware that a team member was affected negatively by the situation and that it won’t be tolerated in your practice. However, keep in mind that some people are very direct and they may not be aware of the offense.

Although awkward, dealing with these situations is part of the profession. By being open and direct, you should be able to address the problem and prevent future indiscretions.

Can a registered dental hygienist scale and polish an animal’s teeth? It depends on the state. The American Veterinary Dental College (AVDC) defines veterinary dentistry as “the art and practice of oral health care in animals other than man.” A licensed veterinarian must diagnose, treat, and manage the oral health care of an animal. The AVDC permits certain healthcare professionals to assist and/or perform oral procedures on animals while under direct (in the room) supervision of a licensed veterinarian if state law permits. These professionals include certified, registered, or licensed veterinary technicians, veterinary assistants with advanced training, and licensed dentists and dental hygienists.

While there are similarities between treating animals and humans, there are some significant differences. Extensive education and training are necessary because the prophylaxis is considered a surgical procedure requiring anesthesia. Also, the oral anatomy of an animal is very different from a human. Learning how to administer anesthesia and closely monitor (heart rate, temperature, blood pressure, & pulse oxygenation) the pet while under anesthesia is imperative because lack of knowledge could mean the difference between life and death.

Unlike human prophylaxis, before any surgical procedure, an extensive exam including bloodwork is done to ensure that the animal is healthy enough to undergo surgery. Once the pet has been cleared, they will be sedated and intubated so that the procedure can be done quickly, thoroughly, and safely. Also, after the cleaning portion of the procedure, any teeth that are decayed, abscessed, fractured, mobile, or periodontally involved are removed.

Making the transition to veterinary dentistry is significant and so is the pay difference. Most clinics pay half the salary of human dental practices. Rules and regulations vary by state, and you must follow their direction if you are a registered dental hygienist seeking a position to practice veterinary dentistry.

If your vet has suggested that Fifi needs dental prophylaxis, it’s because she has a significant amount of tartar on her teeth causing problems of which you’re probably not aware. Like humans, plaque forms on pet’s teeth and can lead to gingivitis, periodontal disease, abscesses, and tooth loss. Furthermore, the harmful bacteria in the plaque can enter the bloodstream and go to vital organs including the heart, kidneys, and liver causing detrimental health problems. As tartar continues to form, the gums recede exposing the root surfaces which can be painful for your pet.

Because a veterinary cleaning is considered a surgical procedure, your pet must be medically cleared before the appointment. A thorough exam including bloodwork is very important because of the anesthesia administered throughout the procedure. Without a complete workup, the vet has no idea how they will respond to the anesthesia and not knowing can cost your pets life.

If the pre-surgical workup is clear, the process begins with antibiotic premedication and sedatives through an IV catheter. Then, an endotracheal tube is placed in their airway to prevent anything from entering the lungs. At all times during the surgery, temperature, blood pressure, pulse oxygenation, and heart rhythm are monitored closely. Examination before the cleaning includes taking x-rays and measuring periodontal pocketing. After the exam, scaling with an ultrasonic instrument, hand scaling, and polishing removes the tartar and stain from the teeth and fluoride is applied. After the cleaning, any teeth with fractures, mobility, or infection are extracted.

After the cleaning and any extractions, your pet is weaned off of the anesthesia and sent to an area where they’re still closely monitored for a couple of hours. You can usually take them home with pain medication and an antibiotic after they’ve been cleared from recovery. Recovery is usually smooth, and they will need to eat soft foods for a little while until they’re comfortable with a more solid diet.

Follow the advice of your veterinarian regarding the frequency of cleanings. The biggest risk is always the anesthesia, and your vet should never proceed with administering anesthesia if your pet isn’t healthy enough to withstand surgery. Keeping your fur baby’s mouth healthy with proper home care helps tremendously. Brushing their teeth at least once per day and giving them treats recommended by your vet for tartar control can cut down on the frequency of cleanings keeping everyone safe and happy.

Dental professionals spend a significant amount of time with patients and typically see them at least twice per year for routine prophylaxis. Frequent visits provide the opportunity to be on the lookout for oral cancer inside and outside of the mouth since most people spend more time with their dental team than their primary care doctor, and many never visit a dermatologist. Examinations should consist of looking and feeling for abnormalities such as flat discolored surfaces, moles, freckles, lumps or bumps inside the mouth, and any exposed skin in the head and neck region.

The American Academy of Dermatology and The Skin Cancer Foundation have guidelines for recognizing a suspicious spot. The ABC’s of skin cancer are A- Asymmetry, B- Border, and C- Color. Asymmetry is determined by imagining or drawing a line through the middle of the surface. If the two halves don’t match or aren’t symmetrical, it may be cancerous. Border refers to the edges of the area. Cancerous lesions tend to have uneven borders. Color specifies the color of the area. If an area has a variety of colors or the color has changed since their last visit, it may be of concern.

Make it a priority to look for suspicious areas, and take note of shape, borders, size, elevation, and color. Speak to the patient about these areas of concern and ask about them each visit. Pay attention to any changes such as increased growth, bleeding, itching, color change, border change, or asymmetry. Pictures are also helpful. Refer the patient to a dermatologist or oral surgeon depending on where the surface is located if anything looks suspicious. Taking a little extra time to examine the patient from the neck up is extremely important and can definitely save a life.

On a daily basis, dental professionals hear about strange home remedies for tooth and gum health and whitening ranging from coconut oil to charcoal, and now turmeric. Turmeric is a bright yellow root often used in cooking, but it has also been used for medicinal purposes.

Although generations have used turmeric as an antimicrobial and anti-inflammatory agent, no clinical findings are available stating its effectiveness or safety. The anti-inflammatory and anti-microbial properties of turmeric are thought to promote the reduction of inflammation and harmful bacteria in the mouth. The abrasiveness of turmeric is assumed to be the whitening property.

There are several ways to incorporate the use of turmeric for oral health and whitening. It’s available through pastes, teas, mouthwash, and chewing gums. The most common use is pastes sold in stores and on the internet, but many people prefer to make their paste from turmeric powder, baking soda, and coconut oil. People report that the paste tastes horrible and stains everything.

What do dental professionals think of using turmeric for oral health and whitening? Most are not recommending these products for several reasons including:

• Abrasiveness- Turmeric is very abrasive. Using a high-level abrasive twice per day for any length of time is detrimental to the enamel.
• Staining- Turmeric stains everything it touches. It also stains the teeth after brushing or chewing it for up to an hour after use making it inconvenient to be around other people until the staining fades.
• No fluoride- Most, if not all, turmeric products don’t contain any fluoride. Fluoride is essential in the prevention of cavities and using products without it greatly increases the incidence of decay.
• Contraindications- individuals with gallbladder disease, gastroesophageal disease, and blood disorders shouldn’t use an abundance of turmeric because it can cause problems such as increased bile production, increased acid production, and clotting difficulties.
• Lack of clinical studies- there are no verified clinical studies based on the effectiveness or safety with the use of turmeric for oral health and whitening.
• Whitening success- for teeth to whiten, there has to be an oxidant effect by hydrogen or carbamide peroxide, and neither is Turmeric relies on abrasiveness to achieve whitening, and that can be destructive to enamel.

Although turmeric is popular, no clinical findings state its effectiveness or safety. We do know that because turmeric is highly abrasive, it’s certainly not safe to use long-term. The best way to keep your mouth healthy and your teeth white is to visit your dentist at least every six months for a cleaning and exam and follow their recommendations for home care products and whitening. 

Thanksgiving is quickly approaching, and today we’re looking at how the Pilgrims and Native Americans cared for their teeth. As you can imagine, there were no dentists, and oral health wasn’t a top priority.

First, we’ll take a glimpse at the Pilgrims. They spent a lot of time on ships which directly affected their diet, and in turn, affected their oral health. They ate preserved food like dried fruit, hard biscuits, and salted dried meats. These types of foods are harmful to the teeth and promote bacterial growth responsible for tooth decay, gingival issues, and periodontal disease. The Pilgrims were technically more advanced than the Native Americans, but most didn’t have a toothbrush. The available toothbrushes had a bone handle and hog hair bristles and were used by the upper class. Toothbrushes became popular a century after the Pilgrims landed in America.

The Pilgrims drink choices may have been even more detrimental than the food. Water was avoided because it wasn’t clean and led to sickness and even death. Therefore, wine and beer were consumed. Neither was ideal for a healthy mouth, but the wine was more harmful because of the high sugar content and high acidity level causing break down of the enamel and decay.

The Native Americans, on the other hand, had decent teeth and gums, and like the Pilgrims, it was directly related to their diet. They were hunters and gatherers and lived off the land. Their food sources consisted of corn, wild game, squash, beans, fish, fruit, and nuts. Everything they consumed was high in fiber and wasn’t refined, so there was a lot of chewing resulting in plaque removal.  

The Native Americans didn’t have access to toothbrushes, but that didn’t stop them from taking care of their teeth and gums. They chewed on twigs and fresh herbs to clean their mouth. The twigs were shaped to resemble a toothbrush on one end and a toothpick on the other end.

As you enjoy Thanksgiving with your family, be grateful for all you have including access to oral health care, and don’t forget to brush and floss after the big feast.

“What does the schedule look like today?” is the first question asked in the dental office each morning, and if you have no idea what the day holds, it may be time to take a closer look at how you’re being scheduled. All team members should be trained in the art of scheduling, but it’s usually the responsibility of the front desk. With a little practice and patience, your office can run like a well-oiled machine maximizing production while minimizing inconvenience to the patients and the team. Which schedule below looks familiar?

Schedule types:

1. Pandemonium- There’s absolutely no organization to the schedule, no one’s in charge, and no regard is given to the doctor’s or patient’s time. Guidelines for scheduling probably don’t exist and the amount of time necessary to perform treatment is disregarded. The entire team runs behind and never recovers. Most times, there is no lunch break, and everyone works past closing only to come in the next day and repeat the entire process. This schedule is absolute chaos, and it’s very stressful. Patients may not receive the standard of care because everyone’s always in a hurry.
2. Somewhat Organized- There’s a bit more management, but patients are placed in openings without any thought as to how they should be scheduled. The base schedule (patients who have an appointment for a planned procedure) is properly set, but emergencies are added Emergencies happen every day, and they must be handled correctly to prevent a schedule breakdown. There either isn’t a scheduling guideline, or it isn’t followed. This type of schedule can be very stressful as well, and the team can’t operate at the optimal level.
3. Organized- An appointment coordinator or office manager is in control of the schedule allowing everyone to perform their duties more efficiently. In this case, fewer patients are scheduled, and there’s more time available for all team members to spend with the patients. Emergencies are planned for, and interruptions of the schedule are minimized. All employees have an understanding of how to book patients by maximizing production while providing excellent care.

The key to an organized schedule is having a designated coordinator and guidelines based on how you want the day to be constructed. While doctor’s can be designated leaders, most offices find that having an appointment coordinator or office manager is the perfect way to keep things going smoothly. Besides,  the doctors time is better spent focused on clinical tasks.

Another important element of successful scheduling is a morning huddle. A morning huddle sets the tone for the day and allows the team to discuss each procedure and any anomalies in the schedule. Furthermore, meeting first thing ensures that everyone has an idea of what is going on in each room thus allowing them to plan accordingly. It also highlights any opportunities to fill open appointments with patients who are already coming in for treatment.

Having an understanding of how to book patients and a coordinator to keep things flowing will have everyone ready to tackle the day with confidence and a smile.

If you’ve been in dentistry for more than 10 minutes, you know the different types of patients and how they get you off schedule and exhaust every ounce of your patience. Most patients are awesome, and you enjoy their visits, but lighten up for a minute and identify these “special” patients:

1. Talkative Tammy- Talkative Tammy is usually very nice and compliant with homecare. However, she never stops talking the entire time she’s in the office. She even talks with instruments in her mouth, and if anyone else enters the operatory while she’s there, she’ll talk with them for thirty minutes. You barely get her teeth cleaned and she leaves you so out of sorts and off-schedule that you don’t know which way is up!
2. High Maintenance Mary- High maintenance Mary is the patient who, when you look at her chart, has an entire page listing her dislikes and preferences. Some of her necessities include rinsing with mouthwash before and after the procedure, no lying back, earphones, covering her eyes, no power scaling or x-rays, applying lip balm throughout the procedure, etc. The list is truly endless, and so are her demands. High maintenance Mary is an extremely particular patient who makes you see double while trying to keep a smile on your face!
3. Grumpy George- Grumpy George is a tough nut to crack. He’s always mad about everything. If kept waiting even 1 minute past his appointment, he loses his mind. He never answers questions because he merely grunts, and he won’t be pleased with any treatment you provide. When George leaves, you need some soothing tea and encouragement.
4. Always Late Larry- Always late Larry is usually quite pleasant, but always significantly late. He phones 10 minutes after his appointed time and says he’s “5 minutes away”. There is no such thing as 5 minutes away in dentistry. Five minutes is always at least twenty. He’s good at the game too. Even when you put on his appointment card that his appointment is at 3:30 when it’s really at 4 pm, he arrives at 4:30. Always late Larry leaves you exasperated and off schedule.
5. Disorganized Debbie- Disorganized Debbie forgets everything. Often, she’s forgotten that she has an appointment. If she remembers her appointment, she’ll run into the office in the nick of time looking like she just leaped out of bed. She’s probably forgotten to premed and hasn’t brushed her teeth. She digs through her purse the entire appointment looking for something or stays on her phone talking and texting. She must also visit the restroom before and after the appointment. Disorganized Debbie is a human tornado leaving you in her wake and shaking your head.

While not an exhaustive list, all offices have their classifications. Seminars dealing with difficult patients can’t even touch these cases. Fortunately, there usually aren’t too many in each practice, and these patients make us appreciate the great ones even more.

Tetracycline staining is the most difficult intrinsic stain to treat with bleaching because it’s very tenacious and results vary. Following are some guidelines to achieve optimal results while providing realistic expectations:

1. Tetracycline-stained teeth take longer to bleach than unaffected teeth, and the process can take 2 to 12 months to reach optimal results.
2. Like “normal” teeth, tetracycline-stained teeth will lighten until they reach a plateau regardless of technique or product used. They will never become “white,” but they can lighten dramatically and look very nice when compared to the initial shade.
3. The first few days of bleaching will usually produce noticeable whitening followed by no observable change for about one month. Therefore, patience is required.
4. 10% carbamide peroxide worn in custom trays nightly is the method of choice for bleaching tetracycline-stained teeth. Carbamide peroxide remains active for 6 to 10 hours and delivers the bleach over a longer period than hydrogen peroxide. Using a strength over 10% doesn’t change the speed of whitening measurably, but it does increase sensitivity.
5. As with unaffected teeth, existing restorations will not change color with bleaching. Therefore, the patient must be advised that new restorations may be necessary after the bleaching process to match the new shade of their teeth.
6. Tetracycline staining takes an extended amount of bleaching over time to achieve the desired results, so sensitivity must be considered. A low concentration of carbamide peroxide (10%) and a proper fitting tray is imperative. Potassium nitrate 5% which is found in over-the-counter desensitizing toothpaste is very helpful in managing sensitivity. The patient can brush with the desensitizing paste and/or wear it in the bleaching trays for 15 minutes daily to treat and prevent sensitivity.
7. The patient must be made aware of the reality of bleaching tetracycline-stained Treatment takes longer, there is an ongoing cost, and the results vary.
8. Many practitioners and patients choose the “single arch treatment” approach treating one arch at a time. Most patients prefer to begin with the upper arch. This plan can be more cost effective for the patient, and it also serves as a great motivator when comparing the bleaching arch to the untreated arch. Furthermore,  sensitivity is reduced, wearing one tray versus two is easier on the TMJ, and it’s more comfortable for the patient.
9. Bleaching is recommended before any other treatment such as veneer placement because the shadow of tetracycline-staining can show through veneers. Sometimes, after the bleaching is complete, the patient is satisfied with the results and decides against veneers.
10. The bleaching process may have to be repeated over the years. It’s difficult to predict, but many patients do have to repeat the bleaching process after five It may or may not take as long with subsequent sessions.
11. As with all bleaching, the cervical third of the tooth is the most difficult to whiten, and the blue-gray staining is more difficult to whiten than the yellow-brown

Bleaching tetracycline-stained teeth aren’t impossible, but it takes time, dedication, and patience to achieve the best results. The cost is far more than bleaching “normal” teeth, but it’s not ridiculously expensive. As long as the patient is realistic and compliant, it can be very beneficial and life-changing.

Oral appliances include braces, space maintainers, retainers, overbite correction appliances, expanders, and devices to help cease oral habits. They are used to correct, treat, or prevent conditions related to the upper and lower jaw, teeth, and tissues. Some of these devices are cemented on the teeth, and some are removable. If an appliance is removable, it’s best to remove it while eating. The appliances are durable, but they do have to be treated with care to be successful in treatment. Therefore, many foods should be avoided during treatment to keep them in working order and efficient.

Ice- Chewing ice is very detrimental and can destroy appliances, and even ice with a softer consistency isn’t safe to chew. Ice can bend wires, break or loosen brackets, and damage palatal expanders, overbite correction appliances, and retainers.

Hard food - Hard pretzels, tortilla chips, jerky, pizza crust, uncooked carrots, and nuts can bend wires, break rubber bands, break brackets and tubes, and loosen cement holding the appliance(s) in place.

Hard Candy- Hard candy can stick to the appliance(s) and coat the teeth in sugar for prolonged periods. If chewed, it can break or loosen brackets, loosen cement, bend or break wires, damage tubes, and retainers.

Sticky candy- Gummies, caramels, taffy and any other candy of this sort can bend wires, loosen cement, break or loosen brackets, and destroy retainers. These candies also surround the teeth with sugar for an extended amount of time.

Foods with a high sugar content- Although these foods don’t need to be avoided altogether, cookies, cakes, puddings, and other desserts can linger around the appliance(s) constantly coating the teeth with sugar. It’s best to rinse with water after consuming sweet treats and limit consumption.

Foods high in starch- Starchy foods such as pasta, potatoes, bread, popcorn, and cereals are hard to remove from oral appliances because they are sticky when consumed. They get embedded in the appliance(s) and constantly saturate the teeth with sugar. Popcorn kernels also break, bend, and damage mechanisms.

Suckers and sour candies- Suckers are terrible for teeth with or without appliances. They last for far too long and attack the teeth with sugar byproducts. They are detrimental to oral appliances because they stick to devices and can cause damage. Sour candies are also horrible for teeth, tissue, and oral devices because they are acidic and can cause deterioration of the teeth.

Gum- Gum seems harmless, but it can cause a dental apparatus to malfunction. It sticks to everything and gets intertwined with the appliance(s) and can become a place for plaque to hide. Also, gum can bend wires.

Wearing an oral device is usually for a limited time and although inconvenient, avoiding these foods is a must. It only takes one piece of candy or food to break or damage the appliance and many orthodontics charge fees for fixing or replacing the device. Eating these foods and candies can become expensive and delay treatment. Once the appliance(s) is removed, you can celebrate in moderation with “forbidden foods.”

Assisted hygiene refers to a schedule in which a hygienist operates out of two operatories and sees patients every 30 minutes with the help of a designated assistant. The assistant stays with the hygienist the entire day, and the two switch off between operatories treating patients. The hygienist performs therapeutic scaling, irrigates periodontal pockets, measures gingival and periodontal health and disease (pocketing, recession, bleeding points, and exudate), removes plaque, calculus, and stains, applies antimicrobial agents, provides patient education, and administers other treatment deemed necessary. The assistant seats patients, updates medical histories, takes x-rays, polishes teeth, makes recare appointments, applies fluoride, dismisses patients, and performs other duties within the scope of state law.  Many practices operate successfully on an assisted hygiene schedule, but before transitioning, explore why the change may benefit your practice.

First, assisted hygiene shouldn’t be used to offset missed or last-minute cancellations. Holes in the hygiene schedule are usually due to problems with patient management. When patients begin de-valuing your services by missing appointments, it’s time to reevaluate how easy it is for them to reschedule. Never be dishonest with patients, but allowing multiple choices after they repeatedly cancel or no-show sets the stage for more of this behavior. There are valid reasons patients miss appointments, but with a chronic offender, it’s best to limit choices for rescheduling. Also, make staying on schedule a priority and don’t make a habit of keeping patients waiting. If patients are kept waiting on a continuous basis, they will no longer respect your time because you’re failing to respect their time.

Second, evaluate your patient base. Many generational practices have patients who have been with them for fifty years or more. It may be very difficult to transition from the hygienist spending the entire appointment with the patient to the appointment being split between the hygienist and an assistant. It’s not impossible, but tradition plays a role in this scenario, and certain patients will expect an explanation as to why there’s a new appointment protocol. Patients are accustomed to spending time with an assistant while seeing the dentist, but many don’t expect to see an assistant during their prophylaxis.

Third, are you incorporating assisted hygiene to increase hygiene production? Using assisted hygiene to help increase production while practicing as a DMO can be tricky. It’s very difficult to make a decent profit while participating in reduced fees programs. However, increasing production by incorporating a soft tissue management program and stressing more frequent recalls for patients with certain conditions can benefit from assisted hygiene. Also keep in mind that converting to assisted hygiene means that a dedicated assistant for the hygienist is imperative, and more instruments and supplies will be necessary.

The most important part of whether assisted hygiene will work in your practice depends on the hygienist and the assistant. Is the hygienist willing and capable of handling such a schedule? Will there be an assistant who is dedicated to the hygienist? A hygiene assistant is different than a dental assistant. The hygiene assistant can’t be “borrowed” to assist the doctor because this type of schedule is extremely tight, and getting off schedule is disastrous. As long as you’re honest with yourself and adopt assisted hygiene for the right reasons, it can be beneficial for your practice.

Has your dental practice ever filed a medical claim? While not a common occurrence in dentistry, there are instances where filing a dental claim on a patient's medical insurance is permissible. Furthermore, filing medical insurance can be very helpful to the patient and profitable for your office.

Procedures that may be covered include:

• exams/consultations
• Sleep Apnea appliances
• TMD devices
• Appliances used in breaking habits- e., thumb sucking
• Orthodontic appliances
• Some surgical procedures
• Periodontal surgery
• Bone and tissue grafts
• Some implant surgeries
• Traumatic injury cases
• Biopsies
• Interim prosthesis during trauma cases or after radiation or chemotherapy
• Final prosthesis after trauma
• Crowns, bridges, and other removable and fixed prosthesis following cancer treatment

Filing a medical claim is nothing like filing a dental claim, and even the most skilled insurance coordinator will have much to learn. There are many seminars on processing medical claims live and online. Your dental rep should be able to locate these resources for you. Basically, four steps are crucial to getting the claim paid quickly.

Step one is ensuring that the dentist is properly credentialed. This credential is granted through the Council for Affordable Quality Healthcare (CAQH) and isn’t the same as being a participating provider in a medical insurance company’s network.

Step two is filing the claims electronically. Paper claims aren’t permitted which usually isn’t a problem since most offices file electronically anyway.

Step three is obtaining preauthorization before proceeding with treatment. In dentistry, preauthorizations can be time-consuming and inaccurate. However, with medical insurance, preauthorizations are often required. There are clearinghouses portals online that make preauthorizations quicker and less of a headache.

Step four is using the proper format. Delivery of treatment won’t change, but chart notes and reporting information in the patient’s electronic records will have to be in the correct format. In addition, clinical notes are legal documents and must be written by the doctor and no other team members.

The entire dental team should be on board with this process. Although it will be a bit of a learning curve, mastering the art of filing medical claims successfully in the dental office will be beneficial to your patients and your practice.

It’s that time of year again! Halloween is coming, and all ghosts and goblins are ready to be inundated with sugar! If eaten in moderation, sugar is harmless barring other health issues. The problem is that it’s very addictive and overindulging can cause health issues. What’s more enticing than a plastic pumpkin filled with all sorts of gooey sweets?

How do parents pry the pumpkin full of goodness from their child’s death grip? First, the candy must be surrendered to mom or dad the minute trick-or-treating is over. As difficult as this will be, it’s the only way to get control of the situation.

Second, remove all the hard and sour candy. Hard candy continuously bathes the teeth in sugar, and sour candy is very acidic. Eating acidic candy is very detrimental and causes damage to the teeth. It’s far better to chew a piece of softer candy and swallow it quickly. Suckers can last upwards of ten minutes, and that’s far too long to be in the mouth.

Third, allow the child a maximum of two pieces of candy per day. One piece in the morning after a healthy breakfast and one piece in the afternoon after school is enough. Let them choose which piece they want to eat because it will show them that they have a choice in the matter. After consuming, have them rinse with plain water. Eating candy coats the teeth with sugar and causes a very acidic environment. Brushing while the mouth is acidic can harm the teeth.

Fourth, be diligent with home care. A proper oral hygiene regiment is important throughout the year, but especially during the holidays. Brushing with a fluoridated toothpaste at least twice per day and flossing at least once per day is crucial. It may also be beneficial to add an over-the-counter fluoride rinse for children over five. Consult with a dental professional before beginning any fluoride treatment at home.

By using these tips and being firm and consistent, all ghouls will be happy and healthy, and Halloween will be a screaming success!

National Dental Hygiene Month is celebrated in October each year and is dedicated to the recognition and celebration of dental hygienists for their position in the dental community and commitment to raising awareness of proper oral hygiene.

This year, the focus of dental hygiene month is on the Daily 4 campaign which launched to help incorporate the four daily habits that improve the oral and overall health of the public. The Daily 4 consists of brushing, flossing, rinsing, and chewing.

• Brushing- Placing the brush at a 45-degree angle to the gums, gently move back and forth in short strokes. Brush all outer surfaces first, then inner surfaces, and the chewing surfaces last. Place the brush vertically to clean the inside of the upper and lower front teeth using up and down strokes. The American Dental Association (ADA) recommends brushing twice per day with a size appropriate soft-bristled brush and fluoridated toothpaste for two minutes. The tongue should also be brushed with a toothbrush or tongue scraper.
• Flossing- The ADA recommends flossing once per day to eliminate plaque and food debris not removed through brushing. Plaque that’s left on the teeth can mineralize and become a hardened deposit called calculus and requires a dentist or hygienist for removal. The lingering plaque also causes tooth decay.
• Rinsing- There are other structures inside the mouth other than the teeth that require attention. Rinsing with a product that’s approved by the ADA can help eliminate organisms that cause gingivitis and decay from the teeth and the soft tissue in the mouth. There are many excellent rinses on the market that are dedicated to different needs. Dental professionals recommend rinses based on patient
• Chewing- Studies have shown that chewing sugarless gum can help with many oral Chewing increases saliva flow which dislodges food and other debris and neutralizes acid. Some gums contain helpful ingredients that fight dry mouth syndrome, demineralization, and other issues. However, if a patient experiences Temporomandibular Disorders (TMD), chewing gum may not be advised.

For further information regarding the Daily 4, visit http://www.adha.org/daily4 where you’ll find many resources for your office to celebrate Dental Hygiene Month by encouraging excellent oral health.

The abuse of opioids in the United States is astounding. All doctors are being monitored closely in regards to prescribing opioids, and dentistry is no exception. In mid-August 2018, the Center for Opioid Research and Education (CORE) released new guidelines based on the number of opioids necessary in relation to the procedure. Also, the number prescribed will vary depending on the situation and the invasiveness of the procedure.

These guidelines refer to common procedures and suggest that the first drug of choice should be OTC acetaminophen and/or ibuprofen. These two can be used in conjunction on an alternating basis and work very well in this manner.

Following is the maximum number of opioids that CORE recommends with respect to the specific procedure:

• Wisdom tooth or impacted tooth extraction – (15) 5mg oxycodone
• Surgical extraction- (12) 5mg oxycodone
• Routine tooth extraction- 0
• Implant placement- (10) 5mg oxycodone
• Periodontal bone graft and regeneration- (6) 5mg hydrocodone
• Soft tissue graft- (10) 5mg oxycodone
• Osseous procedure- 0
• Tooth resection/ root amputation- 0
• Apicoectomy- (4) 5mg oxycodone

These guidelines can be confusing for the dentist because they don’t want their patients suffering. However, they are merely recommendations at this point. The bottom line is that CORE wants all clinicians across the board to stop prescribing more opioids than they deem truly necessary.

Attention to oral health should begin the minute your baby is born because bacteria starts forming in the mouth from day one. Your child will also go through many oral developmental stages, so it’s important to be prepared.   Following is a guide to help navigate the transition from zero to thirty-two teeth.  

Birth- Tooth Eruption-

• Gently wipe your baby’s gums with a clean, damp washcloth after feedings and at bedtime
• Wash the cloth after each use
• Don’t use any pastes or gels for cleaning the gums

Tooth Eruption-3 years

• Gently brush your child’s teeth with an age-appropriate brush that’s approved by the American Dental Association (ADA)
• Use a gel “toothpaste” formulated for infants and toddler’s that are approved by the ADA
• Don’t use any toothpaste formulated for kids or adults
• Don’t use any product with fluoride until around age two and follow the directions to the letter
• Begin flossing when their teeth are in contact with one another
• The first dental appointment should be around age two

4-6 years of age

• All primary teeth should be present
• At four, your child can start brushing their teeth with your guidance
• Use an age-appropriate toothbrush and fluoride toothpaste approved by the ADA
• Floss for them until age six. Then, they can use over-the-counter flossers designed for children
• Primary front teeth will loosen around 5-6 years
• The first adult molars (6-year-old molars) will begin to erupt behind the last tooth in each quadrant
• They should be going to the dentist for cleanings and exams every six months and receiving proper brushing instruction, x-rays, fluoride treatments, and sealants on permanent molars
• At six years old, it may be prudent to add an over-the-counter fluoride rinse under very close supervision. Consult with your dentist

7-12 years of age

• Developmental changes are taking place
• Your child will have a “mixed dentition” which means that they have baby and adult teeth in their mouth at the same time
• Orthodontic appliances are likely
• During this period, power brushes are helpful because of orthodontics and having different sized teeth
• It’s imperative that they see the dentist every six months or as recommended
• It’s very common to have poor oral health during this stage, so remind them of the need to brush and floss at least twice daily
• An over-the-counter fluoride rinse is usually necessary due to poor oral hygiene
• Sealants are highly recommended and placed by your dentist or hygienist
• Around age seven, they should have the manual dexterity to brush and floss on their own, but you should still check after them

13-16 years of age

• All permanent teeth should be erupted by age fifteen except for the third molars (wisdom teeth) which may or may not erupt until age 16-20
• Your child will become more and more independent, but their oral hygiene may not be so great
• It’s often difficult to keep up with brushing and flossing because of their age and shifts in their attitude. Sometimes, it’s best to have the dental team talk with them and encourage them to stay diligent with their oral care
• They must be seen by a dentist every six months or as recommended
• An over-the-counter fluoride rinse is most likely necessary
• It’s highly probable that they will be going through some type of orthodontic treatment
• Sealants are recommended and placed by your dentist or hygienist

17-Adult

• During this time, your child has most likely finished orthodontic treatment and is in the maintenance phase. Retainers must be worn until further notice from the orthodontist, or the teeth will relapse
• If recommended, wisdom teeth are usually ready for extraction
• Going off to college is in the near future, and oral hygiene usually declines
• Include toothbrushes, toothpaste, and over-the-counter fluoride rinse in their essentials and care packages
• Although tricky due to scheduling, make sure they have a dental cleaning and exam every six months

There will be difficulties along the way, but being a good example to your child with your oral care routine will instill proper habits that will last a lifetime.

Have you considered joining a practice as an associate dentist? Many clinicians prefer to accept a position in an established practice instead of having their own because of student loans, the expense of owning a practice, and the responsibility associated with being the owner. Following are some tips to help with your decision:

• Consider all offers- There are often many associate opportunities available in the field of dentistry, and each should be reviewed Make a list of pro’s and con’s and trust your instincts. Take some time to observe the office you’re considering. While the interviews and introductions may be fantastic, seeing the way the office runs in a day to day setting is important.
• Make meeting the team a priority- The dental team will be your support system, and it’s crucial that you meet each person and observe their You’ll also want to observe the behavior between the senior doctor and the team. Again, the interview can seem awesome, but you can tell a lot about a doctor and their team by the way they interact with patients and one another.
• Never gossip or speak negatively about the senior dentist or the team- If you have a legitimate problem with a team member, it’s best to go to that person and resolve the issue. If you have an issue with the dentist/owner, sit down with them and hash it out. Be honest and direct, and never get defensive. If the doctor gets defensive, alter your approach and make sure you’re handling the situation properly.
• Diagnosing will most likely be tricky- diagnosing for some practices goes one of two ways. Under-diagnosing is a real problem, and you may find yourself in an office where periodontal disease isn’t diagnosed or treated, decay isn’t dealt with until it’s advanced, and the equipment isn’t the latest and greatest. You may not even realize it’s happening at first, but it’s not a lost cause. The practice may need an overhaul, and you’ll need to decide whether it’s worth staying. Over-diagnosing is the opposite end of the spectrum. You may begin working in an office where you’re expected to suggest treatment plans that aren’t entirely necessary or procedures based on cosmetic versus restorative needs. This type of practice rarely changes, so you may have to keep looking. Staying in either situation without improvement is detrimental to your career. There are plenty of offices that fall somewhere in the middle and deliver excellent care without practicing supervised neglect or unethical dentistry.
• Be prepared to ask for what you need (within reason)- You may have had state-of-the-art equipment at your last practice or in school, but your new office equipment may be less than ideal. You’ll have to take into consideration the age of the practice and the location. Rural settings may not have the most up-to-date equipment and instruments, but that doesn’t mean that you can’t achieve excellent results. If the equipment is truly unusable, you may need to have a heart-to-heart with the senior dentist. Most likely, they are fully aware of the necessary Approach this situation by being honest, non-threatening, and ready to discuss how specific improvements will increase doctor/team satisfaction, patient comfort, and production.
• Have a signed contract in place- never accept a position without a contract that you and your attorney have read and understand. If you make counter offers or changes, ensure that they’re in the contract before signing. A signed document protects all parties and outlines all aspects of your role in the practice.
• Beware the “sink or swim” office- in some practices, you may be thrown into the water and left to sink or swim. Whether you’re an experienced doctor or not, you must have support and encouragement. Don’t be afraid to speak up and ask for what you require to succeed and become an asset to the office.

Choosing the best fit for you will take some investigation. If an office is pressuring you to decide after a short period, it’s probably best to keep looking. Don’t get discouraged because the perfect setting for you is out there, and you’ll be glad you took the time to find a practice in line with your goals and standards.

Have you reached a point in your career where you’re considering adding an associate? While the thought can be unnerving, the following guidelines can help make the transition more comfortable and exciting.  

Guidelines for the senior doctor-

• Prepare the team for the new associate well in advance. Skipping this step isn’t an option. While recognizing that it’s your practice, your team has a stake in the practice too, especially if they’ve been with you for a number of years.
• Welcome the new doctor into the practice with open arms. Don’t talk about them in a negative way to anyone-especially your team.
• If the candidate is a new grad, expect to take on the role of mentor, and be patient while they adjust. Demonstrate procedures in a calm and non-threatening manner. Remember, you were new to the practice of dentistry once upon a time.
• Jealously is not permitted. Patients must be shared unless a patient requests you, and you’ll also have to accept that some may prefer the new dentist. However, the new doctor should be expected to bring in new patients to build their patient base.
• Consider an open house meet and greet. Don’t be afraid to introduce them to patients and the dental community. This gathering should be positive and uplifting. Don’t keep the news a secret.
• Have a contract in While this seems like common sense, some doctors fail to include this step. A signed contract is crucial to protect all parties.
• Give it time. A new grad or even a clinician with tons of experience needs time to acclimate. A new grad may need a lot of hand-holding, so offer guidance and support on a daily basis.
• Never compare the new dentist's skills to your own or any other clinician. Everyone has strengths and weaknesses. Keep an open mind, and you may find that you compliment one another nicely.
• Be very careful in setting monetary and other professional goals. Give the new grad a full year before deciding on production expectations, and the experienced clinician at least six months. When the year or six months has passed, sit down with them and make realistic goals based on skill level, professionalism, and quality of work. Also, invest in the entire team by supporting continuing education, fun trips, and activities.
• Be fair in scheduling procedures. Don’t expect the new dentist to be bogged down with simple fillings and hygiene exams. They need to be challenged and Communication is key, and you should sit down with them every week or as needed to go over any questions, problems, or comments.

Hiring an associate should be an exciting time for you, your team, and your practice. While it can be a daunting task, following the guidelines can make for a smooth and positive transition.

The eruption of your infant’s first tooth is a pretty big deal. However, it can be an uncomfortable process for you and your baby unless you’re prepared. The following chart gives an estimated timeline for primary tooth eruption and serves as a guide in getting through this developmental stage easier.

Most infants begin teething around 4-7 months, but this time frame may vary. Symptoms and intensity of pain may also differ from child to child. Common symptoms include but aren’t limited to: slight fever (less than 101 degrees Fahrenheit), swollen and tender gums, drooling, crying and being irritable, sleeping and eating pattern changes, runny nose, and gnawing on objects.

While teething can be very uncomfortable for the infant, it generally doesn’t make them ill. The following symptoms don’t usually occur during teething: severe rash, high fever, congestion, cough, uncontrolled vomiting, and uncontrolled diarrhea. If these symptoms arise and persist, contact your pediatrician immediately.

When trying to soothe your baby and ease teething pain, the key is to be versatile. What works for one baby may not for another. Traditionally, anything cold (not frozen) is essential in decreasing inflammation and assists in producing a numbing effect. Many devices on the market are approved by the American Academy of Pediatrics (AAP). Choose teething aids that are approved by the AAP and make sure to clean them after use. Look for large pieces without small parts that can pose as a choking hazard. Your pediatrician may also prescribe acetaminophen or ibuprofen if the pain is intense.

There are two products that the AAP doesn't recommend. The first one is a very trendy teething device. The apparatus is made with amber beads that are strung into a teething necklace. Baltic amber (fossilized tree resin) is used and is supposed to release oil into the bloodstream to decrease the pain. These claims aren’t proven, and the beads are a choking and strangulation hazard.

The second product which isn’t recommended by the AAC is numbing gels containing benzocaine. These over-the-counter gels were used frequently and rubbed on the gums to provide comfort. However, the Food and Drug Administration has concluded that benzocaine shouldn’t be given to children under the age of two.  Also, topical medicaments wash away quickly because of saliva flow and are swallowed which can be dangerous.

Teething can be a difficult time in your child’s life. However, being prepared and choosing proper teething aids will facilitate the developmental process. Before you know it, your baby will have a mouthful of pearly whites!

Dental Malpractice is the fifth and final topic in this blog series dedicated to confusing legal issues encountered in the practice of dentistry. We’ll focus on the definition of malpractice, and reasons you may find yourself in a lawsuit.

Malpractice is a legal term describing a professional individual’s failure to deliver the standard of care because of ignorance or outright negligence. For a case to be considered malpractice, there must also be long-term injury, disfigurement, loss of normal function, or death. If the ruling is in favor of the patient, a monetary settlement is usually paid by the dental professional in question. Although rare, with one in seven malpractice cases being dental related, it can happen to even the most proficient and successful practitioners.

Reasons for a case of malpractice:

• Failure to diagnose, treat, or refer an obvious cancerous lesion, periodontal disease, decay, periapical abscess, or periodontal abscess
• Long-term or irreversible nerve damage resulting in loss of taste, disfigurement, or numbness
• TMD caused by treatment
• Wrongful death directly related to any procedure
• Negligent delivery of anesthesia causing injury or death
• Failure to evaluate and consider the patients’ medical history resulting in injury or death
• Extraction of the wrong tooth/teeth
• Complications due to negligence of any kind
• Failure to secure a signed informed consent or performing treatment outside of the signed informed consent
• Inappropriate behavior while a patient is sedated

While the reasons for malpractice suits are plenty, studies show that most cases are a result of tooth extractions where the patient wasn’t given an informed consent form. This signed documentation gives the dentist permission to perform the procedure after providing the patient with a complete understanding of why the procedure is necessary, methods by which the procedure will be carried out, the procedure itself, and the benefits and risks of following through with treatment.

Avoiding malpractice is absolutely the best approach. Have informed consent documentation in place and only proceed when signed.   Educate patients and take the time to listen to their expectations, and don’t abandon them after treatment. Review medical histories every single visit, review treatment plans, and diagnose and treat all patients as though your license depends upon it.

Firing a patient- Yes, it’s possible part two is the fourth topic in this blog series dedicated to confusing legal issues encountered in the practice of dentistry. Part one described why dismissing a patient might be necessary. Part two will discuss how to properly and legally end the doctor-patient relationship because if done improperly, a case of malpractice or abandonment can be made. Following are steps to end the relationship smoothly thus preventing legal issues.

1. Send a certified letter with a return receipt- A simple phone call will not suffice in this instance. A certified letter with a return receipt must be sent to the patient. Because laws vary by state, you should consult with your attorney, but basically, the letter should contain:
   • Date of termination
   • objective and non-threatening language stating the reason for dismissal
   • a reasonable amount of time you’ll be available for emergencies
   • the patient’s current condition, any treatment plans, and consequences of not seeking care
   • willingness to forward any x-rays or records. Records and x-rays can’t be withheld due to non-payment in most states
   • information about finding a new dentist such as the local dental society. Don’t give specific dentist’s names
   • financial balance intentions

2. Never dismiss a patient due to age, race, sex, religion, or disability. Also, never terminate a patient who is in a life-threatening situation, extreme pain, bleeding profusely, or has extreme swelling.
3. If the patient’s insurance coverage is an HMO, DMHO, or capitation plan, you can’t refuse care until the third-party payer is notified and the patient is reassigned.
4. If a patient is seeing a doctor in a group practice, termination must include every doctor in the practice.
5. HIPPA rules and regulations must be followed to the letter. When records are sent to another dentist, the patient must sign a Release of Records Authorization. If records are sent by traditional mail, send certified with a return receipt. If emailing, the patient must give written consent to transfer records via email and notified that the information is sent through an unencrypted format on an open and unsecured e-mail unless you use a HIPAA-compliant secured service. You may charge up to 75cents per page, but it may be wise to refrain from charging any fees for processing in this case.
6. If refunding any money to the patient, a Release of Liability or All Claims must be signed by the patient. These documents should contain a clause protecting you, your practice, and team members from defamation and slander. Furthermore, the clause should prohibit the patient from speaking and writing anything negative regarding your practice or your employees.
7. Inform all team members of the separation. All team members must be made aware of the dissolution. No doctor or employee of the practice should refer to the patient improperly amongst themselves or to any other practice or patient. When speaking of the patient, state that there were administrative differences which couldn’t be resolved.

A quick word on abandonment. Abandonment occurs when a dentist terminates a patient without providing the patient sufficient time to select another practitioner or refuses to complete or follow up treatment for no valid reason. Don’t operate in this manner because doing so can easily result in a case of malpractice.

Before deciding to fire a patient, reconsider and decide if it’s worthwhile to sit down one on one and see if it can be avoided. Make sure all reasonable efforts to resolve issues have been exhausted. If termination the only solution, consult with your attorney and follow all instructions to avoid any legal consequences.

Firing a patient is the fourth topic in this blog series dedicated to confusing legal issues in the practice of dentistry and outlines dismissing a patient from your practice. The dissolution can be at any time deemed legitimately necessary before, during, or after treatment. The first part of this blog will cover why releasing a patient may be necessary. Part two will discuss how to dissolve your relationship with a patient ethically and legally.

Legitimate ethical and legal reasons you might dismiss a patient from your practice:

1. The payment agreement was not fulfilled by the patient- Once a treatment plan has been agreed upon, the financial arrangements should be defined and explained to the patient by the team member dedicated to financial arrangements. Some patients are very clever and quite successful in delaying payments. Therefore, they must understand what dollar amount is covered by their insurance (including co-pays, maximums, and deductibles) and the dollar amount that they will owe. UCR (usual and customary rates) should also be made clear. Working with a third-party financing service for your patients is beneficial because you get paid immediately, and the debt is managed between the financier and the patient. If a patient consistently doesn’t pay on time or not at all, you have a strong case for
2. The patient repeatedly cancels, no-show’s, or is chronically late for scheduled appointments- Unfortunately, this occurs more often than necessary. New and established patients should be fully aware of your cancellation, no-show, and late policies. In fact, it should be stated in writing along with other office rules and guidelines and signed by each patient. Be very specific about the policy and state the consequences of disregarding your valuable time.
3. The patient becomes physically or verbally hostile or violent towards the doctor and/or team- this is a very serious violation of patient-doctor/team trust and respect. Regardless of the reason, a patient must never be permitted to become violent or abusive in any If this unfortunate situation occurs, it must be handled swiftly and with authority. This behavior should always result in automatic dismissal.
4. The patient refuses to comply with home-care instructions and compromises the outcome of treatment- Great lengths are taken to assure a successful outcome for every patient during and after procedures. If a patient refuses to perform prescribed homecare and/or recommended appointment frequency, it may be time to part ways.
5. The patient lied or willingly gave misinformation on their health history- Patients should never lie or be misleading about their health history. While some may not be upfront about their weight or whether they floss every day, giving false information or leaving out critical information (diseases, allergies, joint replacement and other surgeries, daily medications, heart abnormalities, etc.) that can be a health risk for the patient or the dental team is indefensible.
6. Trust has been broken between the patient and the doctor- If for whatever reason something has occurred to break the doctor/patient trust, it’s time to sit down one on one and decide if trust can be regained. If not, an amicable separation is in order.
7. The patient is exhibiting prescription drug abuse- The drug abuse may be a result of drugs you prescribed responsibly, or the patient is obtaining legal or illegal drugs from another source. Nevertheless, drug abuse is very serious and shouldn’t be tolerated.
8. The patient won’t accept diagnostic record gathering or necessary treatment- It’s imperative that you be permitted to collect diagnostic data such as radiographs, periodontal charting, clinical charting, diagnostic models, etc. If a patient declines the gathering of pertinent diagnostic material, diagnosis and treatment planning will be practically impossible. Even if a patient agrees to diagnostic records, they may still refuse any treatment necessary for alleviating their issue. In this case, patient education is key, and the team should be well versed and confident in educating the patient. If a patient fully understands the importance of diagnostic tools and all available treatment options have been discussed, and they still won’t comply, it’s time to consider a parting of the ways.
9. The patient is physically attracted to the doctor or a team member- Although awkward and embarrassing, this does happen from time to time. Occasionally it’s a harmless non-sexual flirtation, but other times, it’s borderline sexual harassment. Even if it seems innocent, there’s a very thin line, and if crossed, the outcome may become disastrous. Prevent this scenario by not engaging in inappropriate banter and be prepared to dismiss the patient early in the relationship.

Stay tuned for the second part of “Firing a Patient” where we’ll discuss how to successfully and legally ask a patient to leave your practice.

Supervised Neglect is the third blog in this series dedicated to some of the confusing legal aspects of the dental profession.

Supervised neglect is when a doctor routinely examines a patient who exhibits symptoms of a disease or problem, but the patient is not aware of the situation and its progress. Sadly, supervised neglect occurs often by excellent and caring clinicians who mean no harm in treating patients. However, it can be very serious, and every attempt should be made to avoid this slippery slope.

There are many reasons supervised neglect occurs, and that’s why it’s important to keep the lines of communication open. Each patient should be apprised of their condition, treatment options, cost, time involved, risks, and benefits of proceeding with treatment versus doing nothing. Surprisingly, no treatment is a treatment option. Remember, the patient can only make an informed decision if they’ve been advised of and understand their oral status.

Why does supervised neglect happen?

• Fear- Doctors fear telling their patients bad news. They don’t want to upset them and dread their reaction.
• Responsibility- Often, doctors and team members feel responsible for the status of their patients. The patient’s oral health routine is a very important part of success or failure. If the patient has been informed of their condition, it’s their responsibility to maintain their oral health.
• Little to no support- Depending on the clinical setting, doctors and hygienists may not receive the support they need to treat patients properly or refer them to a specialist.
• Rejection- Some clinicians have difficulty discussing certain aspects of patient care because they fear that the patient will reject their recommendations.
• Betrayal- Seeing patients on a regular basis for many years often makes them friends and family. Some doctors presume that if given distressing news, the patient will feel that they’ve been betrayed.
• Assumptions- perhaps the biggest reason for supervised neglect is clinicians making assumptions. The most common assumptions are: the patient can’t afford the treatment, the patient is too old to care or spend the money, and guessing what the wants of the patient. Second guessing people is not ideal because you never truly know their thoughts and life status.

Supervised neglect can be avoided by being consistent with diagnosis, treatment, and patient education. Doing so will help in keeping legal ramifications away from your practice.

Informed Refusal is the second blog in this series dedicated to some of the confusing legal aspects of the dental profession. Before diving into informed refusal, we’ll begin with its counterpart, Informed Consent.

Informed Consent is permission (usually written) given by a patient to a doctor acknowledging their diagnosis and awareness of all recommended treatment options so that they can make an informed decision. The document also contains information such as cost, time involved, possible consequences, prognosis, risks, and benefits.

On the other hand, Informed Refusal is a patient’s right to refuse a part or all of the proposed treatment and alternative treatment options. Many sources maintain that refusal forms don’t protect practices from legal consequences. For the most part, if the doctor performs the appropriate action using the standard of care, makes the patient aware of everything related to treatment, and has a signed document, they’re less likely to face legal consequences. Although patients have the right to refuse diagnostic record gathering and proposed treatment, they can’t permit substandard care. Also, the clinician shouldn’t allow themselves to deliver inadequate therapy.

Whatever the patient’s reason for refusal, (economics, fear, inconvenience, or denial) as long as all bases are covered, it’s less probable to be brought up on malpractice charges. Covering all bases includes complete patient education, signed documents, providing standard of care, and meticulous record keeping. It’s also wise to consult with a malpractice attorney for guidance and to secure properly worded documents for patients to sign.

In continuing with the second part of this blog, we’ll discuss some of the factors and variables in regards to standard of care (SOC).

While some professionals feel that SOC defines what is minimally required, others believe that clinicians should strive for excellence in care. Treatment based on SOC depends on several factors and variables as follows:

• Location- The location of the practice dictates the SOC. In rural areas, there may be few dental practices and fewer specialists. Therefore, treatment that would normally be referred to a specialist may be performed by a general dentist. However, this is not to say that the care will be sub-standard. Rather, the general dentist will have a greater responsibility, and the SOC may be different.
• Medical Conditions- The patient’s medical condition may guide SOC. Depending on the severity of their health condition, the patient may not be able to withstand ideal treatment. Therefore, a minimal and less invasive procedure might be more appropriate.
• Economics- The patient’s inability to pay for a procedure is a very common occurrence. Even with insurance, the remaining balance can be overwhelming. In this instance, the patient and the doctor may have to take a step back and develop a plan that will allow for treatment within the patient’s budget. This doesn’t necessarily mean that the patient’s dental health is being neglected; it means that both parties are realistic in providing the best treatment with the available funds.
• Continuous Evolvement - SOC continuously evolves due to new technology, improved materials, and current court rulings. As updated information becomes available, the doctor is responsible for incorporating necessary and progressive methods into the practice as deemed safe and practical.
• SOC Dictated by the Patient- On the flip side, patients may try to convince the dentist to override their needs and address their wants. Patient-driven care can easily lead to costly aesthetic overtreatment and negligence of proper oral health.

It’s wise to have the best interest of the patient as a top priority. Base treatment on sound judgment, do no harm, use evidence-based techniques, and meticulously document each visit. Taking into account that most practitioners view ethics, morals, and values in high regard, practicing within the standard of care is second nature.

The next topic in this blog series is Informed Refusal (treatment refusal). Informed refusal pertains to a patient declining procedures even after being informed of the consequences of not receiving the proposed treatment.

Standard of Care- The Gray Area of Dentistry is first in this blog series dedicated to some confusing legal aspects of the dental profession. In this litigious society, care must be taken to ensure that all phases of treatment are delivered with the highest of standards based on the needs of the patient. Standard of Care, Informed Refusal, Supervised Neglect, “Firing” a Patient, and Malpractice will be included in this series to help navigate the murky waters in preventing and handling a legal situation in your practice.

Standard of care (SOC) by definition is a written explanation outlining actions, rules, or conditions regarding the care of a patient. SOC in dentistry is principles taught by accredited dental schools and accredited hygiene programs and describes standards carried out by the profession.  SOC is determined by each state, and most dentists and hygienists don’t understand its meaning or how it’s determined.

In 1998, a landmark case defined SOC as follows:

• Maintain an acceptable degree of education and skill comparable to doctors in the surrounding area
• Use reasonable care and diligence during treatment
• Be aware of new materials, techniques, and advances, and implement as deemed necessary and prudent
• Use the best judgment in carrying out treatment and apply scientific-proven knowledge
• Pursue techniques and education exercised by good standing members of the profession
• Apply approved and safe methods
• Educate the patient on their condition, introduce all applicable treatment plans, and advise as to what could happen if they accept or reject the treatment plan

In part two of this blog, we’ll explore some factors and variables of the standard of care.

Body modification is the process of purposely altering the body to achieve a certain look or physical feeling. Some body transformations are viewed by society as normal and beneficial such as orthodontics, conventional plastic surgery, Lasik eye surgery, and ear piercing. Alternatively, there are modifications of the body that are considered odd and disfiguring. Following are some of the more unusual things people do to alter their mouth.

• Gap Band- A gap band is an elastic rubber band usually purchased through a website that is placed around the two front teeth to “close the gap.” The space may close, but there can be many complications. Moving teeth correctly is difficult and precise and takes place over a specific amount of time. Proper orthodontic treatment is orchestrated by an orthodontist who has many years of formal education and experience. If teeth move too quickly or at the incorrect angle, permanent damage can occur to the blood supply, connective tissue, and nerves surrounding the tooth leading to possible tooth loss.
• Dental Grills & Gold “Caps”- Grills are ornamental covers that fit over the top or bottom front teeth. They are made of gold, silver, non-precious base metals, or jewel inlaid precious metal. Gold caps are cosmetic gold teeth that fit over a single tooth. Kits are available to purchase online that allow consumers to gather the requested information, and an online lab will create the grill or cap. Some are removable (recommended), and others are glued onto the teeth/tooth (not recommended). Because a dentist is normally not involved in these processes, grills and caps are placed over existing teeth without any preparation to allow for the extra space needed for the appliance. The result is that they are ill-fitting and bacteria can grow rapidly between the device and the tooth causing decay and/or periodontal disease. Grills and caps fabricated with non-precious metals can cause serious metal-allergic reactions.
• Mouth Piercing- Mouth piercing is fairly common in various places in the mouth (tongue, gingiva, frenum’s, and uvula). Even if the piercing is done in an establishment that offers the service, having it done can lead to infection, excess bleeding, tooth damage, nerve damage, aspiration of the barbell or ring, keloids, Hepatitis B or C, and even HIV.
• Tooth Tattoos- A tooth tattoo is an image printed onto a crown before it’s cemented permanently into the mouth. The crown is fabricated in a dental lab and is cemented on a tooth that a DMD or DDS has properly prepared.
• Tooth Modification- Tooth modification is very extreme. It’s hard to predict who might perform this service because removing healthy tooth structure in this manner is something most dentists wouldn’t consider. In this process, the front teeth are reduced dramatically thus providing sharp points on the biting surfaces. This action is irreversible and would require major rehabilitation to restore the teeth back to ‘normal.’ Another popular alteration is creating fangs to the canine (eye-teeth) with composite material added to the biting Fangs are more conservative and easily reversed.
• Tongue Forking- Tongue forking is an extremely invasive procedure where the tongue is split vertically down the middle giving the appearance of a snake’s tongue. As with piercing, even if the consumer is going to a legitimate studio, care must be taken to avoid diseases, permanent damage, and life-threatening consequences.

The bottom line- any process that involves the patient or anyone else who is not a doctor performing an extreme procedure in an unsterile environment and with unsterile instruments should think twice before proceeding.

Believe it or not, school is back in session which means it’s time to get back into the routine. While summer is a time to be carefree and have fun, the school year brings structure and a hectic pace. Part of the transition is resuming proper personal care including oral health.   

Therefore, how do parents get their children back into the groove? When it comes to oral health care, here’s a checklist of things to consider to aid in resuming the daily schedule easily:

1. Supplies- Just like pens, pencils, and backpacks, kids need the right tools when performing oral health care. A new toothbrush, floss, toothpaste, fluoride rinse, mouthwash, and any other aids are in order. If your child is in orthodontic treatment, other devices may be necessary such as a power brush or an irrigation device.
2. Lunch & Snacks- It’s prudent to review your child’s lunchbox and snacks. Start the year off right by packing healthy food and snacks in their lunchbox such as fresh fruits and veggies that can be dunked into a healthy dip. Seemingly good snacks, such as dehydrated fruits, should be eaten
3. Regular Bedtime- Although it doesn’t seem directly related to oral health care, sleep is very important. With exhaustion and improper sleep patterns comes the probability of clenching and grinding the teeth. When short-lived, bruxing and clenching isn’t too problematic. However, if it becomes a long-term habit, it can be very detrimental. Stress the importance of sleep and reasonable bedtimes to your child.

Going back to school doesn’t have to be a dreaded experience. As long as you’re prepared, the new schedule won’t be too difficult to integrate, and the entire household will be in sync and happy.

Do you have patients pre-rinse before each dental procedure? If not, it may be time to add this simple step to the appointment because it greatly reduces cross-contamination of harmful microbes. Today, we’ll discuss who, what, and why rinsing right before treatment is beneficial.

Who- The patient being treated should rinse with an antimicrobial product for 30 seconds before the procedure. By swishing beforehand, the number of microorganisms present in the mouth is reduced thus decreasing the number of contaminants entering the patient’s bloodstream. Furthermore, the treatment site heals better and with fewer complications.

What- During any procedure in a dental office, splatter and aerosols come out of the patient’s mouth and contaminate everything and everybody in the treatment room.  The Centers for Disease Control (CDC) reports that utilizing antimicrobial pre-rinses decrease the level of microbes. The CDC also recommends at least one of the following ingredients in the mouthwash to diminish contaminants:

• Chlorhexidine gluconate
• Povidone Iodine
• Alcohol and essential oils
• Cetylpyridinium chloride

Why- The amount of aerosol that comes out of the patient's mouth while drilling, power scaling, polishing, and using any other aerosol producing instrument is astounding. This aerosol contains harmful bacteria, fungi, viruses, and biofilm that contaminates everything and everyone in its path. Providing mouthwash beforehand significantly reduces the number of harmful contaminants for the patient and the clinicians.

Providing mouthwash before treatment is extremely cost-effective and simple. It may seem like one more thing to add to the appointment, but the benefit far outweighs the minimal time and effort.

Toothbrush, toothpaste, and floss are given to most patients at their prophylaxis appointment, but are clinicians overlooking a key element in homecare? Mouth rinses are available in every store and are usually chosen by the patient based on TV commercials or ads on mobile devices. While using mouthwash isn’t a replacement for brushing and flossing, it can be a helpful adjunct to the oral health routine. Rinses are relatively inexpensive, easy to use, and take around 30 seconds. They flow into hard-to-reach areas and have ingredients based on varying mouth conditions. Becoming familiar with mouthwashes is important for the dental team so that they’re ready to recommend a product based on the patient’s diagnosis.

Therapeutic and cosmetic are the two types of mouthwashes. There are sub-categories for each type, and some are over-the-counter while others are prescription only. Children under the age of six shouldn’t use mouthwash because of underdeveloped swallowing reflexes which could lead to ingestion of the product. If a doctor recommends a rinse for a child six and under, extreme care must be taken to avoid ingestion unless the doctor recommends swallowing the product.

Therapeutic rinses contain active ingredients that help control plaque, halitosis, gingivitis, and reduce the incidence of caries. These active ingredients include chlorhexidine gluconate, essential oils with alcohol, peroxide, fluoride, and cetylpyridinium chloride. Chlorhexidine gluconate and essential oils with alcohol assist in controlling plaque and gingivitis. Peroxide is useful in whitening rinses. Fluoride is an excellent choice in helping to prevent decay. Cetylpyridinium chloride is used to treat halitosis. All of these are sold over-the-counter except for chlorhexidine which is by prescription only. Cosmetic mouth rinses are mainly used to freshen the breath and do little to assist with serious mouth conditions.

One other crucial factor when considering mouthwashes is whether they have earned the American Dental Association’s (ADA) Seal of Acceptance. This seal assures that the product is safe and effective based on scientific evidence and approval from the ADA Council on Scientific Affairs.

As with toothbrushes, toothpaste, and floss, it’s best to educate the patient as to why adding mouthwash to their home regiment is essential.  Once the benefits, ease of use, and cost-effectiveness are pointed out, the patient should see that adding this step at home is beneficial to their oral health.

Reusable medical devices such as high-speed, slow-speed, electric (cordless), endodontic, and surgical handpieces should be cleaned and properly sterilized after each patient use. This includes all parts of the handpiece (nosecone, head, and motor) and attachments (reusable contra or prophy angle). In fact, any intraoral device that can be removed from air or waterlines should be cleaned and sterilized according to the Centers for Disease Control (CDC), the American Dental Association (ADA), and the manufacturers of such devices.

Studies have found that the internal gears of handpiece motors can become contaminated during a procedure and, as a result, may contaminate the rest of the handpiece. Therefore, using an unsterile device could lead to cross-contamination between patients. Surface disinfection and immersion in a chemical germicide isn’t acceptable. Chemical vapor and autoclave sterilization are the only approved methods.

Most handpieces sold today can withstand heat and chemical vapor sterilization. Handpieces that can’t tolerate the process may be retrofitted to allow for sterilization. The FDA has very clear guidelines regarding the use of older devices that can’t be cleaned and sterilized properly. If in doubt as to whether or not a device can be sterilized safely, the FDA provides a searchable database online of devices that can tolerate the procedure.  

Buying multiple handpieces can be expensive, but following the manufacturer’s directions can ensure that they have a long lifespan. Cleaning and lubrication is the most important part of keeping the device in great shape and ensures durability and top performance.

Mandatory sterilization of handpieces is controlled by each state dental board. As of this writing, it’s mandated in the following states: Florida, South Carolina, Virginia, Ohio, Oregon, Indiana, Kansas, Missouri, New Mexico, and Washington State. It’s estimated that most states will require proper sterilization at some point, so it may be wise to go ahead and make the investment. Being compliant now will help with the transition and keep the practice running smoothly.

As discussed in part one of this blog series, forensic dentistry is a fundamental part of forensic science. Forensic dentists know as Odontologists, aid in the identification process of the deceased and the living. Part two of this blog will discuss bite mark analysis in the living in relation to crime solving, and with heroes who perish because of their high-risk career.

A bite mark is the pattern teeth make when they come together, also known as occlusion. Everyone has a unique bite which can be reproduced and compared. Criminals can be identified from the bite mark they’ve left on a victim. Additionally, high-risk employees such as military personnel, firefighters, police, EMT’s, and search and rescue teams usually have their bite registration on file in case of a deadly consequence. Their premortem and postmortem registration can be examined, and a positive ID made.

With criminal investigations, bite marks are left on victims in instances such as rape, homicide, assault, domestic violence, elder abuse, self-defense, and infanticide. The marks on the victim are compared with the suspect's bite registration for a positive ID. Odontologists commonly evaluate evidence, consult, and testify in court as an expert witness.

Some odontologists specialize in bite mark analysis and identification and must follow rigorous guidelines and standards for analysis developed by the American Board of Forensic Odontology (ABFO). Additional education, experience, and training are required as well as proficiency with digital imaging.

Forensic dentistry is a fundamental branch of forensic science using dental experience in recognition of human remains and evaluation of the bite. A forensic dentist is a DMD or DDS who have furthered their education and specialize in the field of forensic dentistry.

Part one of this blog will be focused on tools such as clinical exams, radiographs, DNA, and Ameloglyphics in the examination of the deceased. Part two will explore the use of bite mark analysis in the living and post-mortem.

Comparison of fingerprints is the first step in the identification process.  However, fingerprints are often destroyed by decomposition, trauma, or fire. With natural disasters such as tornados, hurricanes, tsunamis, and wildfires, the odontologist joins the recovery team to investigate when fingerprints have been destroyed. Furthermore, caskets can become unearthed due to floods, and bodies may have to be re-identified.

The assessment of the deceased when fingerprints aren’t available begins with charting existing and missing teeth. Special attention is given to implants, unusual restorations, bone patterns, and any anomalies that would help with a positive ID. Radiographs are also taken and compared to premortem dental records if they exist. The age of the individual is determined based on eruption patterns and occlusal wear.

Another way Odontologists authenticate findings is by retrieving DNA from the pulp chamber for cross-matching and with a relatively new process called Ameloglyphics. Ameloglyphics is a promising new approach that involves studying the enamel rods of the tooth which are like fingerprints in that they are unchangeable and very resistant to destruction.

Although forensic dentistry is quite an odd job, it has become more commonplace with the number of television shows dedicated to the identification of victims and crime scene investigations.  This specialty is held in high regard with helping families put loved ones to rest, and in the prosecution of criminals.

When considering a dental implant, you may have experienced some sticker shock if you’re not aware of what’s involved in the process. Three pieces are normally used in the entire implant procedure, and they include the fixture, the abutment, and the restoration (crown). Even if your insurance covers implants and restorations(crowns), the average fees can range from $2500- to $5000 for the completed project. With most plans maxing out at $1500-$2000, you can be left with a pretty hefty remainder. 

First of all, the implant itself consists of two segments which are the fixture and the abutment, and because it’s considered a surgical event, it’s usually performed by a  periodontist or an oral surgeon. The fixture is screwed into the bone where it becomes integrated and acts as the root of the tooth. The abutment protrudes from the gumline and serves to secure and support the restoration (crown). Sometimes the specialist positions the abutment, and sometimes it’s placed by your dentist. The fixture and abutment are made of titanium as a result of it being a lightweight, strong, and long-lasting metal. Titanium is the choice of metal because the implant is a prosthesis that’s integrated inside of the body, and therefore, must be medical grade. The fee for the fixture and abutment varies between $1500-$3000.

The third portion of an implant is the restoration (crown) and is usually performed by your dentist after the implant has been established for a designated period. As soon as the specialist gives the clearance,  it’s time to fabricate a crown on top of the abutment so that the “tooth” is functional in your mouth. An implant crown is usually more expensive than a regular crown because your dentist may have to purchase special materials and instruments to install it properly. The cost of the restoration (crown) of a single implant can be anywhere from $1200-$2000.

There are some other factors to examine when thinking about an implant because, at times, surgeries such as a bone graft or a sinus lift are necessary to ensure a successful outcome. A bone graft is required on the lower jaw and upper anterior jaw when there’s insufficient bone to support an implant. Cadaver or synthetic bone is normally used, and the price varies from $500-$3000. A sinus lift can be mandatory on the upper jaw in the posterior if the bone is inadequate or if the sinuses are low and encroaching on the bone. The sinus is “lifted” to make room for bone to be inserted between the upper jaw and the sinus cavity. The charge of a sinus lift fluctuates between $500-$3,000. As with the bone graft, cadaver or artificial bone is commonly used. Additional expenses you may incur are radiographs and occasionally, a CT scan.

Although typically uneventful, an implant is a complex surgical method usually including a specialist and your general dentist. Years and years of education and experience go into the whole operation, and you’ll want clinicians who are proven to deliver excellent results. Although in reading this blog, it may seem that the bottom line can be upwards of $8000. However, the entire price of an implant and restoration is generally between $2500-$5000. Price discrepancies depend on where you live and if the additional surgeries are required

Who is a candidate-

• Patients presenting with simple to moderate malocclusion cases. When choosing this method, personal information will be submitted on a website, and a starter kit will be provided which identifies if the patient is a suitable candidate.
• Patient must be 12 years of age or older, and all permanent teeth must be erupted.
• Patients who don’t want to physically see an orthodontist every 4-6 weeks for evaluation and adjustments.
• Patients who are seeking orthodontic treatment at least 60% off traditional therapy.

Who isn’t a candidate-

• Children under the age of 12 with mixed
• Patients with a complex malocclusion and cases requiring surgery.
• Patients with moderate to severe decay and/or periodontal disease.
• Patient’s with dental implants. Although not impossible, each case will vary.
• Patients who need constant in-person supervision.

What is at-home orthodontics?

• A series of trays (aligners) are manufactured using a series of 3D printed models. These aligners are mailed to the patient over a period of months or all at once to guide the teeth into proper alignment gradually. Specific instructions are given as to when to advance to the next tray.
• The trays (aligners) are clear and tight fitting. They must be worn continuously except for when eating, drinking, and practicing oral hygiene.
• Although the patient won’t be physically seeing the orthodontist monthly, companies who offer treatment ensure that each patient is paired with a state licensed orthodontist or dentist who will evaluate their medical history, models and/or 3D scans, and photographs. Furthermore, these licensed professionals are available throughout treatment to assist the patient with any questions or problems.
• Some dental insurance and FSA’s (Flexible Spending Account) will contribute to the cost.

Where do these treatments take place?    

• Oddly enough, most if not all of the treatment happens in the privacy of the home. In some cases, the patient may have to visit a satellite office for a 3D scan of their teeth.

How does at-home orthodontics achieve straighter teeth?-

There are three steps to acquiring the perfect smile:

1. The patient receives a starter kit in the mail which includes supplies to make an impression of their upper and lower teeth. The patient may also visit a satellite office, if they are close in proximity, for a 3D scan of their upper and lower teeth.
2. After receiving the impressions and/or 3D scans, the manufacturer fabricates a series of aligners that are designed to move teeth gradually. These trays may be mailed all at once or every 4-6 weeks.
3. When optimal results are achieved, the patient moves onto a maintenance phase where they will wear trays usually at night to keep teeth from shifting. Many times, these trays can double as bleaching trays so that the patient can whiten their teeth as well.

What are the concerns when choosing to use this method of straightening the teeth? The ADA (American Dental Association) and the AAO (American Association of Orthodontics) don’t seem to be in favor for several legitimate reasons. The absence of radiographs with this approach before and during treatment is very disturbing. X-rays are extremely necessary to evaluate bone level, decay, and abnormalities detected only on film. Furthermore, it’s difficult to predict the manner in which the bone will respond to movement of the teeth and the appropriate protocol if the patient’s teeth aren’t responding to treatment. The bottom line is that the consumer should consult with a dentist or orthodontist before considering orthodontics at home.

Teledentistry is dental consultation, education, and treatment without the presence of a dentist using the aid of telecommunication and information technology. With dentistry being a hands-on process, how does teledentistry work without the patient physically being in a doctor’s presence?

Teledentistry began in the nineties by the U.S. Military to assist the troops stationed far from dental care. Digital images were captured during deployment in remote areas and transmitted to a dental specialist. These images were examined by a dentist and suggestions were given for the alleviation of pain. The patient would then be seen by a medic or surrounding dentist using the best available approach with limited supplies.

In the civilian world, teledentistry is becoming more popular because of some states in the U.S. passing legislation making it legal for specially trained hygienists and assistants to be supervised by a virtual dentist. Practicing in this manner is primarily being implemented to assist low-income families by creating access to affordable dental care while stressing preventative education. Teledentistry is also utilized throughout the world and even in third world countries where dental education and provision doesn’t usually exist.

With the passage of legislation, specially trained hygienists and assistants may provide basic therapy without a dentist’s direct or indirect supervision. Temporary clinics such as nursing homes, schools, or community centers are the setting for offering services such as prophylaxis, placement of temporary fillings, fluoride application, and other aid depending on the laws of the state. The provider of the assistance corresponds with the supervising dentist primarily by the internet. The interaction between the hygienist or assistant and virtual dentist consists of treatment planning and guidance throughout the appointment. Patients are referred to a participating dentist for more complex needs. While this type of delivery may be controversial, it can be very beneficial to those who otherwise wouldn’t have access to dental care as long as the provider operates within the laws of the state.

Going green is here to stay, so how does this environmental movement transition into the dental office? Below are some suggestions to help without draining your bank account.

1. Use non-aerosol products
2. Take advantage of your energy providers energy savings programs
3. Transition patient correspondence from mailed reminders to text messages or emails.
4. Wear eco-friendly scrubs
5. Use degradable plastic bags for patient bags
6. Install programmable thermostats
7. Use LED lighting where possible
8. Caulk all office windows or apply weather stripping
9. Consider using biodegradable supplies whenever possible
10. Label recycle receptacles to encourage recycling
11. Recycle all electronics (computers, batteries, computer parts, etc.)
12. Recycle traditional x-ray lead foil and solutions
13. Maintain air conditioning and heating filters
14. Encourage turning lights off when the room is empty (restrooms)
15. Use touchless faucets when possible and don’t leave them running while brushing or washing hands
16. Deal with companies who support conserving energy
17. Use fans to help circulate the air. However, practice caution when using fans in the operatory while creating aerosols.
18. Consult with companies who support going green when building a new practice or remodeling an existing office.
19. Utilize reusable products when possible
20. Don’t become overwhelmed by trying to go green all at once. Incorporating sensible little changes on a continuous basis will contribute to making your office environmentally friendly.

Being a Dental Hygienist for nearly thirty years has afforded me many encounters with patients which can be awkward from time to time. Following are some of the most unusual requests and questions I’ve witnessed over the years.

• Do you clean the instruments between patients? The answer is a resounding YES! Instruments are carefully transported to the sterilization area where they are placed in an ultrasonic cleaning device with an enzymatic cleaner. The ultrasonic action removes any debris on the instruments considering debris must be dislodged before the instruments can be sterilized The instruments are then placed in an autoclave where they are sterilized by pressurized steam.
• Upon entering the operatory, I’ve had patients request: no x-rays, no scaling, no polishing, and no flossing. What??? My sarcastic self wants to ask why they’ve come in for an appointment. Instead, I regain my composure and ask why they are refusing the proposed treatment. If I identify what exactly they fear or dread, I can explain why each step of the appointment is necessary, and some parts of the procedure can sometimes be shortened while still providing thorough treatment.
• I can’t lean back at all, so you’ll have to stand to clean my teeth. Again, my sarcastic self wants to tell them that it’s fine and I’ll stand on my head. After a few deep breaths, I inquire as to why they have to sit upright. There certainly are instances where a patient can’t lie flat, and that’s respected and honored. For the most part, if it isn’t a legitimate request, the reason for not wanting to lean back is fear and loss of control. Simply explaining to the patient that they are one of many patients treated daily and trying to treat them while they sit fully upright is detrimental to my long-term health. Some clinicians prefer to stand while providing treatment, but the patient is reclined. Treating patients fully upright can contribute to Musculoskeletal Disorders and end your career.
• I just want a cleaning today. I don’t need to see the doctor- In most states, an examination by the doctor after a prophylaxis is the law. There are some states in which hygienists can open their own practice without a dentist ever being present. Also, some states allow for a patient of record to be seen without a dentist being present if they have received an exam within 12 months and are appointed for a regular prophy. For the most part, the patient must be examined by the doctor.

Some other funny things patients have said:

• Upon handing the patient a sealed lip blam to use during the appointment they, in turn, ask me if I give the same one to the next patient. I smile and say, “No, this one is special for you to take home.”
• “Where does the stuff go that you suction out of my mouth?” After a chuckle, I inform them that the “stuff” first goes through a filtration and separation system and the remainder goes down the drain just like it does at home when spitting in the sink.

 Patients can be the source of some unusual requests and questions, but it certainly makes the office more fun. Oh well, it’s all in a days work.

Should you be concerned with etiquette in the operatory? Although it may seem to be a strange question, some clinicians aren’t even aware they’re violating the protocol of OSHA and HIPPA. Not all of the infractions listed below are HIPPA and OSHA requirements; they’re just plain rude. Here is a list of things to avoid in and out of the operatory:

• Leave your cell phone OUT of the operatory. A patient in the chair DOES NOT want to witness your conversation or text message. Furthermore, the patient’s appointment time isn’t an opportunity to catch up on emails or social media. Smartphones have enabled us to have the world at our fingertips, and it’s tempting to engage with the phone instead of the patient since there can be plenty of downtime during the appointment. Try engaging with the patient instead and educate them, make them comfortable, or just let them vent.
• Never blow your nose or cough in the presence of a patient. Excuse yourself and go to an area where you’ll have privacy. Even if the patient can’t see you, it’s not something anyone wants to hear, especially in a medical setting.
• Never have a heated discussion with a team member in front of a patient. Leave any cross words or even a calm discussion for later when it can be addressed out of the operatory and in privacy.
• Avoid conversations about religion or politics. Even if the conversation is agreeable, a patient in the next room may hear and find you being improper and unprofessional.
• Avoid conversations about patients with team members unless in a closed room away from any observers. HIPPA violations are very real and can end in fines and jail time. Additionally, ignorance of HIPPA laws can’t be used as an excuse.
• Pay special attention to the patient's personal information. When you have a chart in your possession, this information must be kept confidential. If anyone other than a team member gets access to another patient’s personal information, very serious consequences can ensue. HIPPA personnel will become involved and again, impose fines and in some cases, prison. These fines can be imposed per occurrence which means that you’re not facing one fine, but separate fines for each patient whose information is compromised. The front desk is a prime example of where opportunists might gather patient information. The reception area and front desk are very busy places with many things happening at once. Also, the communication in the front office includes credit card numbers, names, addresses, social security numbers, and insurance information.
• Don’t eat or drink in the operatory or in front of a patient. Keeping food and drinks in the treatment room can cause them to become contaminated. With the use of high-speed and low-speed handpieces, particles enter the air and land everywhere. Even at the front desk where contamination may not occur, eating in the presence of the patient is rude.
• Watch what you say outside of the office. It’s no surprise that people vent about the workplace. However, you never know who’s sitting in the next booth. Mixing in alcohol can also be a huge problem if it encourages you to talk louder and be more open. HIPPA exists outside of the dental office, and you absolutely can violate HIPPA guidelines and have to face the consequences.

Fun can still be had while treating patients, however, be sure to stay within reason of the rules and guidelines. The workplace will be safer and more pleasant for the team and the patients.

As the school year comes to a close, thoughts turn to no schedules, vacations, and kid’s camps. During the school year, schedules abound with everyone staying on task including paying close attention to personal grooming. When it’s time to prepare for “back to school,” many parents find that their child has been neglecting their oral hygiene with a trip to the dentist and receiving a bad report. This type of diagnosis can be avoided by following a few simple rules.

• Don’t let the routine fall by the wayside- Continue the normal routine regardless of it being summer break. It’s very easy to stay up late and sleep late while forgetting to brush and floss. Also, much more junk food is probably consumed leading to a greater risk of decay.
• Pack the necessary tools- Vacations are great because it’s a time to leave all the stress behind. However, make sure the toothbrush and floss aren’t left behind with the stress. While most children can pack their luggage by age 12-14, they are likely to skip the brush and floss. Give their packing a once over confirming the presence of oral hygiene supplies. Also, if you’re with the children on vacation, make oral maintenance a priority. Many times, children from six to fourteen and beyond are in some phase of orthodontics making brushing and flossing imperative. Another great idea for use all year round is an over the counter fluoride rinse.
• Going off to camp- Sending kids to camp is a time-honored Often, it’s the first time parent and child are separated. In this case, advice must be given and written to help the child remember to take care of themselves. A written reminder sent along can make the child feel less homesick and more likely to follow the rules. It’s also wise to pack extra toothbrushes and travel size toothpaste to be given to the counselors for safe keeping.

By taking some extra simple steps, your child can remain cavity free as the summer comes to a close. It will also be easier to resume the school year routine when the alarm clock sounds once again.

Dental offices are busy places where clinicians run from room to room with only seconds to spare. Occasionally, in all the confusion, team members and dentists aren’t on the same page regarding the patient’s treatment plan. As a result, the patient receives an employee’s plan and the doctor's opposing plan concerning the same treatment. This type of miscommunication is common in practice all over the world, and the one who suffers is the patient.

Usually, there are two reasons for an inconsistent treatment plan. The first reason is that the team and the doctor haven’t reviewed the plan together. The second reason involves the hygienist, assistant, or front desk team members not agreeing with the doctor’s prescribed plan.

If the problem is related to not being familiar the treatment plan, time must be set aside to review who’s in the chair, proposed treatment, areas on “watch,” and any other necessary facts to ensure the patient is handled professionally. A morning huddle is a good idea with the team and doctor’s attendance being mandatory.

The second cause of confusion with an existing treatment plan involves a team member who doesn’t agree with the doctor. While it may be difficult for clinicians with years of experience to accept, the only person who can legally diagnose and change proposed treatment in the office is the Dentist. Hygienists, assistants, and front office team members are not legally permitted to diagnose or change any doctor’s diagnosis or prescribed treatment.  

Disagreeing causes some team members to revise the dentist’s recommended treatment by justifying that they know what’s best for the patient or by making financial assumptions involving the patient. Following are some guidelines to help prevent and avoid this type of confusion and insubordination. Otherwise, the doctor’s treatment plan is devalued and suggests to the patient that the dentist is trying to take advantage.

Step one-

A team meeting lead by the doctor outlining the manner in which patients should be handled clinically is a great start. There should also be documentation of this protocol, and each team member must sign. If a team member refuses to sign, it may be time to part ways.

Step Two-

Incorporate scripts that teach each team member how to have conversations regarding treatment with the patient. Role-playing within the team can help with any awkwardness. Each team member must be familiar with the scripts and adhere to the wording.

Step Three-

Stick to the plan and always offer support. Avoid slipping back into old habits through continuous training.

Although difficult at first, devising and following through with a system outlining the proper way of presenting and following through with prescribed treatment plans will allow everyone involved to be on the same page.

As discussed in Part One of this blog, HPV is the leading cause of oropharyngeal (tonsils and base of the tongue) cancer. Oral cancer caused by HPV is very serious, and most patients aren’t even diagnosed until they present with symptoms because the symptoms are often painless and subtle. Physicians are enlisting the help of the dental profession in assisting with detection, diagnosis, and referral for treatment. In this blog, we’ll discuss the difficulty in diagnosis, symptoms, and treatments of HPV related oral cancer.

Difficult to Diagnose-

HPV is present in millions of males and females. In most cases, it clears on its own and treatment isn’t necessary. It rarely causes any symptoms making it very difficult to detect. There are many oral cancer detection kits on the market, but none are accurate in detecting HPV related cancers. Paying close attention to the patient’s medical history and any unusual lumps or lesions is imperative in helping with detection. It’s necessary to have a conversation regarding the seriousness of HPV related oral cancers and the availability of the HPV vaccine.

Symptoms-

Symptoms are rare, and if they do appear, it’s most likely that the cancer has been present for a while. While the symptoms listed aren’t necessarily linked to HPV oral cancer, it’s prudent to take detailed notes and have the patient return to your office if any of the following are present for two to three weeks or longer.

• A painless lump present on the outside of the neck with a duration of at least two weeks
• Numbness in the lips or mouth
• A persistent cough or coughing up blood
• A unilateral earache lasting for at least two weeks
• A recurrent ulcer or sore that doesn’t heal after two weeks
• A black, red, or white discolored patch on the soft tissue
• Difficulty in swallowing or the feeling that something is stuck in the throat
• Unilateral painless and inflamed tonsil. Both tonsils should be approximately the same size
• An ongoing sore throat or hoarseness

Treatment-

If oral cancer is suspected, it’s crucial that the patient is referred to an oral surgeon, periodontist, or an ENT immediately. Upon examination by a specialist, a laryngoscope or pharyngoscope may be utilized to explore the base of the tongue and tonsillar areas. A biopsy of the suspect tissue will be taken. Depending on the results of the biopsy, a treatment plan will be created which may include surgery, radiation therapy, chemotherapy, or all three. Sometimes, surgery is sufficient. With any treatment, reconstructive surgery may be necessary.

HPV related oral cancers can be prevented with the vaccine and safe sex practices. Although this discussion may be awkward, it’s necessary to educate patients and parents about the devastation caused by this growing crisis.

Human Papillomavirus (HPV) is a group of nearly two hundred different strains of viruses with most being harmless and not cancer causing. It’s the most common sexually transmitted disease (STD), and it can be present for many years before transitioning into cancer. More difficult to detect than tobacco and alcohol-related oral cancers which usually occur in older patients, HPV related cancers affect young adults. Oral cancer caused by HPV is very serious, and most patients aren’t even diagnosed until they present with symptoms because the symptoms are often painless and subtle. Therefore, physicians are requesting the assistance of the dental profession with detecting and diagnosing HPV related oral cancer.

HPV is the leading cause of oropharyngeal (tonsils and base of the tongue) cancer. The location of these cancers makes the dental team invaluable, and their role is two-fold. First, it’s important to perform an oral cancer screening at each recall appointment. Second, it’s crucial to talk with the patient (if over 18 years of age) or parent to inquire if the three-dose HPV vaccination series has been administered. The vaccination series is recommended for patients ages nine to twenty-six, and The Food and Drug Administration (FDA) recommends that males and females receive the first injection of the series between the ages of eleven and twelve. This timing coincides with tetanus and meningitis vaccinations.

A less awkward way to begin the discussion of HPV related oral cancers is to ask the patient or parent if they see their doctor for regular exams and if they’re current on their vaccinations. Furthermore, ask if their vaccination series includes the HPV prevention injections. The conversation can be approached while performing an oral cancer exam. Explain that the exam is to look and feel for any lumps or lesions because HPV is the leading cause of oral cancer.

While there is a lot of information concerning HPV and the vaccine, some of it’s negative concerning the side effects, and this puts the likelihood of getting vaccinated in jeopardy. Direct the patient to legitimate websites such as the Centers for Disease Control (CDC). There are also reputable pamphlets that can be handed out to patients.

In part two of this blog, we’ll discuss the difficulty in diagnosis, symptoms, and treatments of HPV related oral cancer.

Patients may be running a little late from time to time and that can be overlooked. Repeat offenders, however, can make office life pretty unbearable. You know the patients of which I’m referring. They are the ones that when you see their name on the schedule, you begin taking bets on just how late they’ll be or if they show up at all.

Running on time is paramount in any office, but in dental offices, the entire world revolves around the schedule, and one misstep can cause a snowball effect of disaster and you can’t recover. So, what can be done to finally get these patients on the same page and stop causing you to run behind, thus having to feel the wrath of each subsequent patient?

First of all, you should incorporate a form which each patient must sign. This document will be committed to a late or no-show policy for your office. It will describe policies regarding showing up on time or not arriving for the appointment and the consequences of each. The form should include that the practice respects the patient’s time and the patient should return this respect.

The document should clearly outline the consequences of a no-show such as a fee if they don’t indeed arrive but also a fee in they cancel within 24 hours of their appointment. If the patient does actually arrive late, more than 10-15 minutes, explain that they may not be seen at all or that treatment may be extremely limited.

If you do provide treatment when the patient is more than 15 minutes late, the treatment should not include a prophy. The appointment should be records (Xrays, Charting, and Doctor’s exam) only. If you perform a prophylaxis, the patient is likely not to return for the records portion of the appointment.

Once this policy is written and signed, it must be strictly adhered to. There’s no saying, “it’s OK this one time”. Although it may be uncomfortable at first, it’s imperative to get the policy written, signed, and Implemented to save time and missed appointment time.

The beloved cell phone has become a part of our lives, and some would agree that they’re a blessing and a curse. While mobile devices are awesome, having rules regarding their use in your practice is wise.

Develop a written policy devoted to what will and won’t be tolerated in the reception area and operatory, and have the patient read and sign the document. Having clear guidelines prevents having to address an offender. Also, posting signs stating “No Cell Phone Use” is helpful.

While waiting for their appointment, patients can create quite a scene while using their cell phone. A noisy app or conversation can become a real problem for others in the reception room. If the patient uses the device in the treatment room, a myriad of problems may arise. I’ve had patients try to conduct conference calls, take phone calls, and ask me to move out of their line of sight while attempting to text.  

Of course, phones may be utilized in the office, but be clear about the rules you’ve set. You may prefer that patients have their phones on silent mode while in the office and not permit taking phone calls or texts while receiving treatment. There are some exceptions where I’ve allowed patients to keep their phone with them and answer it if necessary during the appointment. Examples include a loved one in the hospital, moms of school-aged children, and any other unusual circumstance.

You must also remember that the rules apply to you and the team. Everyone’s phone should be out of sight and earshot.

Turning your room over to prepare for the next patient can feel somewhat like a pit crew experience. However, this procedure is crucial for the safety of everyone entering the operatory. After dismissing the patient, returning to the operatory must be seen as a field of numerous pathogens waiting to infect anyone in their path. Cleaning and disinfecting should be considered as important as sterilizing instruments and wearing Personal Protective Equipment (PPE).

Most offices use disposable barriers for surfaces such as light handles, air/water syringes, suction apparatus, headrest/chair, and computer mouse/keyboard. These barriers are simple to remove and replace, but what about all the other contaminated surfaces? When it comes to a surface disinfectant, look for these characteristics.

• Tuberculocidal- not only will this level of disinfectant kill TB, but it will also be effective against a wide range of pathogens such as HIV and HBV.
• Cleaner and Disinfectant- The same product should serve as a cleaner and disinfectant. A surface must be cleaned first, or it can’t be disinfected properly
• Must possess rapid contact (kill) time
• Excellent surface compatibility- must be compatible with multiple surfaces while not discoloring, staining, corroding, or producing other damage
• Must feature low-toxicity and be fragrance-free, and not be likely to cause allergies
• Must not require rinsing or leave a residue. Easy storage and satisfactory shelf-life is also essential

It’s very important to follow the manufacturers directions because failing to do so can cause the active ingredients in the disinfectant to become deactivated. If in doubt, your dental representative can offer suggestions and answer questions.

An Amalgam Separator is a device which traps amalgam fragments from dental office wastewater thus reducing the amount of amalgam and the mercury it contains from entering the sewage system. As of July 14, 2017, the Environmental Protection Agency (EPA) made a final ruling on the mandatory use of Amalgam Separators in dental practices because the field of dentistry is the leading source of mercury discharge into wastewater. The date of compliance for all dental practices is July 14, 2020. The use of an Amalgam Separator is thought to suppress at least 99% of potentially harmful mercury entering the public sewage system. Although most dentists don’t place it anymore, it’s still encountered daily in the treatment of teeth containing amalgam.

Amalgam separators use filtration, sedimentation, centrifugation, or a combination of these methods to remove the amalgam waste. The average cost of an Amalgam Separator is $800-900 with the installation running around $250-300. Operational cost per year is around $500.

You need to do your homework regarding Amalgam Separators. There are chairside models and central systems installed at the vacuum pump. The chairside models are easy to install and can be effortlessly connected by a team member. A Central System must usually be installed by a dental technician or a plumber. Some models use sedimentation tanks, and others operate with filters. The units that run on sedimentation tanks tend to operate with less expense. The ones that operate on filters can be very costly due to the expense and disposal of the filters. 

Maintenance is minimal and typically involves only replacing the container once it's full which occurs every six to twelve months depending on the size of the practice. The container must be sent to a certified amalgam waste company. If you choose a unit that has filters, the size of the practice will determine how often the filter will need to be changed. The model chosen must also be ISO-Certified (International Organization for Standardization) for effectiveness. However, most models exceed this standard.

There are some exceptions to the new EPA requirement. Practices such as Oral Surgery, Periodontic, Orthodontic, and Prosthetic don’t usually deal with amalgam and are exempt from mandatory use an Amalgam Separator.

Periodontitis is an ongoing infection which affects and destroys the soft tissues and bone supporting the teeth. Studies reveal that the bacteria that causes this infection lives in the saliva and can be passed from person to person. The pathway of transmission is believed to be among family members through kissing, sneezing, sharing glasses and utensils, and sharing food.

Technically speaking, the odds of contracting periodontal disease from another person is rare, but taking steps to protect yourself and your family is prudent. Following are some helpful tips:

1. If you are diagnosed with periodontal disease, complete all recommended treatment. Treatment greatly reduces the harmful bacteria living in your mouth.
2. After treatment, be faithful to your maintenance regiment. Keeping the harmful bacteria suppressed in your mouth is important.
3. Make sure each family member sees the dentist at least twice per year for prophylaxis and examination. Not only will this ensure optimal health, but also provide for early diagnosis if periodontal disease is suspected.
4. Encourage optimal oral hygiene habits for the entire family. Provide appropriate essentials such as toothbrushes, dental floss, mouthwash, and interdental aids.
5. Keep sharing glasses, utensils, and food to a minimum.

Having periodontal disease doesn’t mean you can’t have close contact with your family. Your dental professional can give you further instruction based on the level of disease present in your case.

The Centers for Disease Control provides handwashing guidelines for healthcare providers. While washing your hands may seem second nature, when dealing with patient care, you must correctly wash your hands to protect the patient and yourself against unwanted germs.

Hand hygiene refers to cleaning your hands by the following methods: regular soap and water, antiseptic hand wash, antiseptic hand rubbing with alcohol-based sanitizer, or surgical hand antisepsis. Even though you will probably be wearing gloves, it’s imperative to thoroughly clean your hands before and after donning gloves to reduce the spread of potentially harmful germs between yourself and the patient.

There are two approved methods for hand hygiene which include washing with soap and water or rubbing with alcohol-based hand sanitizer. Washing with a non-antibacterial soap is the least effective method, and alcohol-based sanitizers are the most effective. Washing with antiseptic soap lies in the middle. Generally speaking, if hands are visibly dirty, soap and water are recommended. However, if hands aren’t visibly soiled, alcohol-based sanitizers are in order.

Cleaning the hands should be done in the following instances:

• Before and after eating
• Before and after any contact with the patient’s intact skin
• After contact with blood, body fluids, mucous membranes, or open wounds
• After contact with any medical equipment surrounding the patient
• Before and after removal of gloves
• Before and after using the restroom

The CDC technique for washing with soap and water:

• Wet hands with room temperature water (continued exposure to hot water can dry the skin)
• Apply the manufacturer recommended amount of soap to the hands
• Rub hands vigorously together for 15 seconds while covering all surfaces of each hand
• Rinse thoroughly with water
• Use a disposable towel to dry the hands and use the same towel to turn off the faucet

When using an alcohol-based sanitizer, the CDC recommends applying the amount as directed by the manufacturer onto the hands covering all surfaces and rubbing at least 20 seconds or until the hands feel dry.

As a healthcare professional, you wash your hands and apply sanitizers many times per day. Keeping your hands in good shape is the best defense against spreading germs. Lotions and creams are permissible, and ones approved for use with sanitizing methods will protect your skin and not interfere with the sanitation process.

The first use of opioids goes back as early as 3400 B.C. and was given for pain management, illnesses, and anxiety. The need for opioids has always been present, and the problem with this treatment regarding abuse and addiction has also remained. Unfortunately, pharmaceutical companies have tried to develop effective drugs safely with little risk of abuse or addiction without much success of introducing a safer alternative.

In 2017, the U.S. Departement of Health and Human Services (HHS) declared a public health emergency directly related to addiction and fatal overdosing because of misuse of prescription and non-prescription opioids. More than 42,000 deaths were the result of an opioid overdose in 2016, and 40% of those deaths were the consequence of a prescription opioid. Even the President of the United States has gotten involved with the war on Opioid misuse, and as a result of this growing crisis, the American Dental Association (ADA) has announced a new opioid policy.

This new policy presented by the ADA is as follows:

1. “The ADA supports mandatory continuing education in prescribing opioids and other controlled substances.” It’s also recommended that the entire dental team becomes involved with this continuing education.
2. “The ADA supports statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain.” This statement is consistent with the Center for Disease Control and Prevention (CDC) guidelines. Most dental pain is of an acute nature, and studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are as effective or even more effective than opioids in the treatment of acute dental pain.
3. “The ADA supports dentists registering with and using prescription drug monitoring programs to promote the appropriate use of opioids and deter misuse and abuse.” Programs are available to dentists which monitor prescription drugs and patients who may try to abuse the system.

Although dentists comprise a small fraction of the total prescriptions of opioids written, the ADA fully intends to make practitioners aware of the epidemic and play their part in managing the war on abuse and death due to overuse.

The world of dentistry revolves around appointments which is great until something occurs that throws off the schedule. It happens inevitably, and when it does, is it acceptable to move a patient’s appointment? That depends on some very important guidelines which include proper training, communication, and follow through to ensure that the schedule flows properly and at maximum efficiency without offending and inconveniencing patients.

First of all, have a scheduling policy and make sure the entire team understands and follows it methodically. Most of the time, the front office will be in charge of appointments, but it’s a good idea to have the entire team on board. The schedulers should have a good understanding of how appointments work and how to schedule to maximize production while running on time. If the scheduling is done properly in the first place, moving appointments will be kept to a minimum.

Second, when scheduling patients initially, know what to say and how to say it so that if changing the appointment is necessary at a later date, it will be simpler. Ask the patient if it’s permissible to contact them regarding their appointment and the best way for them to be reached (phone, text, email). Explain that you may contact them as the appointment gets closer if it’s found that there’s a more convenient time for their schedule.

Third, keep detailed notes concerning any conversations with the patient about an appointment change. It’s also prudent to indicate if the patient mentions any days or times that are off limits. Keeping detailed records assures that unnecessary calls aren’t made which may irritate the patient. Correspondence should include information such as who called, when the call was made, and what appointment was offered. If it’s necessary to leave a message,  it’s imperative that the details are documented and that everyone is on the same page. For example, if you leave a message, make sure that the patient understands that they must contact the office regardless or the original appointment time will remain unchanged.

Fourth, verify that the detailed notes are read by whoever is phoning the patient. Save yourself embarrassment by knowing what the patient likes relevant to appointment days and times. Don’t tell them that you are calling because someone canceled last-minute because it’s negative. Tell them that you remember them saying that they prefer morning appointments and that you happen to have a morning opening. Saying something like this shows the patient that you are thinking of them and looking out for them as well.

Finally, don’t move the patient’s appointment more than once. Never continue to call patients to move their appointment. Also, if a patient does allow you to move their appointment, make a note of it and thank them when they arrive at the office.

“There is nothing that the dentist can do which will overcome what the patient won't do” is a saying in dentistry that’s so very true. While your dentist can treat you with excellent clinical skills, what you do or don’t do at home every day will determine the outcome of your dental health. What are your responsibilities as a patient regarding the success of your treatment?

1. First and foremost, make an appointment with your dentist and be seen on a regular basis. Many people are under the impression that they only need to be seen if they’re in pain when nothing could be further from the truth. Once discomfort is experienced, it can be too late to save the tooth. The best plan is to see your dentist for a cleaning and examination every six months or more frequently if it’s recommended. If your insurance only pays for a twice-yearly cleaning and exam and you’ve been advised by your dental team to be seen more frequently, please consider their suggestion.
2. When you make an appointment, it’s important to keep it even if it becomes inconvenient. Time tends to get away from us, so if you have to miss an appointment, make another one as soon as possible.
3. If restorative treatment becomes necessary, inquire about your options especially if the recommended treatment is out of your price range-even with insurance coverage. Sometimes, treatment can be done in stages as not to break the bank. If there’s only one choice of care and it’s outside of your budget, explore third-party financing options. There are several available, and many have decent interest rates and terms of service.
4. Follow instructions set by your care team. Your dental professionals should provide short-term and long-term instructions concerning maintenance of your oral health. More than likely, suggestions will include American Dental Association approved devices such as power(electric) toothbrushes, floss, water flossers, interdental aids, mouthwash, and toothpaste.
5. Once treatment is completed, it’s still important to visit your dental team twice per year or more if recommended to establish that your oral health is stable and doesn’t require further attention.

Dental professionals want nothing more than to keep their patients healthy and happy. Your relationship with them is paramount and if you’re not comfortable, seek an office where you feel you’re part of the family.

Once upon a time, the dentist was the financier for those patients who carried a balance for services rendered. Even with dental insurance, many patients have a balance after they’ve reached their benefit maximum.

Today, even if the patient's benefits are maxed out, it doesn’t mean they must wait for needed treatment or that the dentist has to carry the burden of financing. Furthermore, cosmetic procedures aren’t usually covered by insurance anyway, so the patient may have to be financially responsible for the entire procedure.

Most insurance companies allow a maximum amount of benefits per year and that maximum is around $1500-2000 which isn’t a lot in regards to dental treatment. Also, the insurance will only pay the usual and customary fees meaning that the carrier decides what fee the dentists (providers) should be charging for each service and they will only pay that amount.

By using a third-party for financing, the dentist (provider) gets paid immediately and doesn’t have to spend additional time and money trying to collect payments from patients. There are many third-party financiers, and some have attractive payment options such as interest-free periods and programs for those with less than perfect credit.

Becoming familiar with third-party financing is profitable for both the patient and the practice. Patients can progress with treatment without having to wait and risk worsening of the problem, and the practice can enjoy the increase in production without having to become the bank. Make an appointment with your business banker or ask your dental supply representative about third-party financing for your patients. You’ll be surprised at how easy the process is for everyone involved.

You probably haven’t given much thought to the mask you don before dental procedures. However, it’s quite important to have the facts when choosing products designed to keep you safe when exposed to pathogenic viruses and bacteria. Let’s explore the what, when, where, why, and how to choose and properly use a surgical dental mask.

What is a surgical mask?

A dental surgical mask is a barrier that protects the clinician from potential respiratory disease agents and is an FDA regulated medical device. Masks are composed of several layers of synthetic microfiber materials created to trap microscopic matter and are manufactured in a variety of sizes and shapes.

When is a surgical mask worn?

The Centers for Disease Control (CDC) recommends that a surgical mask be worn during procedures which produce aerosols, spattering, or splashing of blood or other bodily fluids. The mask must be disposed of after each patient, following one hour of continuous treatment, or every twenty minutes during a procedure producing a high level of aerosols.

The American Society for Testing and Materials (ASTM) specifies the performance of face masks and certifies the levels of mask type to be worn based on the procedure.

ASTM low barrier level 1 is used during procedures where there is a low concentration of aerosols, spatter, or fluids being produced. Examples are: patient exams, lab work, taking x-rays, applying fluoride, and disinfecting the operatory.

ATSM moderate barrier level 2 should be donned when there is a moderate concentration of aerosols, spatter, or fluids being produced. Examples include: Use of the ultrasonic scaler, hand scaling, rubber cup polishing, air polishing, use of a slow speed handpiece, placing a filling or sealant, placing a permanent or temporary crown, placing an inlay or onlay, taking impressions, and any other procedure which would produce moderate aerosols, spatter, or fluids.

ATSM high barrier level 3 masks should be worn where there is a high probability of concentration of aerosols, spatter, or fluids being produced. Examples include: ultrasonic scaling, air polishing, use of a high-speed handpiece, extractions, implant placement, any surgical procedure, and any other procedure which would produce a high-level concentration of aerosols, spatter, or fluids.

Where is a surgical mask worn?

A mask is worn on the face of the clinician and must cover the nose and mouth without actually touching the nostrils or the mouth. It’s attached to the head securely so that the clinician is comfortable and able to work effectively and safely. 

Why wear a surgical mask?

Dental aerosols are produced in the highest concentration within two feet of the patient being treated. Furthermore, the clinician is usually within this two feet and is exposed to the larger droplets and the remaining smaller nuclei droplets. These smaller droplets remain airborne for extended periods and can contain pathogenic viruses and bacteria.

How is a surgical mask used properly?

1. Wash hands before touching a clean mask.
2. Handle the mask for proper placement- the side of the mask which is facing up in the box is always the front of the mask. The pleats of the mask should be facing down when opened. The metal noseband is bent to the contour of the nose.
3. Hold the mask by the ear loops and place the loops around each ear.
4. Form the malleable metal strip to the shape of the nose.
5. Extend the bottom of the mask over the mouth and chin.

Some other factors to consider when choosing a mask include confirming that it has a high bacterial filtration efficiency (BFE), it doesn’t cause fogging of eyewear, and it’s made of a material that doesn’t irritate the skin or cause an allergic reaction. While it may take some time to find a mask which suits you and your team, most manufacturers offer samples so everyone can try different types and make an informed decision.

If you’ve been in dentistry for at least 25 years, you remember and may still sit on operator stools manufactured for everyone regardless of their size, height, leg length, shape, torso, or weight. Many clinicians sit on stools provided by the office and have never even heard or thought of ergonomic seating. Conventional seating taught operators to sit with their thighs parallel to the floor which flattens the healthy curve of the spine.  

Sit/stand positioning has become quite popular in many traditional offices. However, the dental office isn’t traditional, and sit/stand techniques must be altered to make it feasible to treat patients while keeping the spine in a neutral position. Studies have shown that adopting the sit/stand technique decreases time sitting, increases muscle activity, expends more energy, and reduces sedentary episodes. Individuals adopting this system report less fatigue, decreased low-back pain, less neck and shoulder pain, and increased productivity. Two options are available for clinicians to create a modified sit/stand technique: the stability ball and the saddle stool.

Stability balls have been utilized in exercise classes and physical therapy for many years and weren’t intended to be used as a seat. They started making their way into offices when it was determined that balls make the user sit up straighter thus maintaining the lumbar curve. If choosing a ball seat, it’s crucial to select a ball that’s appropriate for your weight, height, and leg length. Stability balls are better suited for a workplace other than dentistry where the user sits at a desk and has limited movement. The problem with using stability balls in the operatory is that they are large and treatment rooms are small. The other issue is that the ball must be inflated or deflated depending on the patient.

The second and probably better option for clinicians is the saddle stool. This type of seating promotes proper posture and is easy to maneuver around the operatory and the patient. The shape of the saddle places the pelvis in a neutral position. Western and modified English saddle stools are the two available varieties. Most practitioners prefer the modified English stool because the seat is wide with a slight rise in the middle allowing the operator to sustain a wide stance. The Western saddle has a prominent hump and is narrower which is better suited for those with a narrow pelvis and prefer a more narrow leg stance.

As with any new device, some discomfort may be experienced initially because sit/stand positioning engages different bones and muscles than traditional seating. However, prevention is key to maintaining a healthy and happy body. Furthermore, many companies will send a representative to your office making it easier to try different models before you purchase.

Musculoskeletal Disorder’s (MSD’s)  are progressive and degenerative conditions that affect two out of three dental professionals. Close to one-third of dentists are forced to retire early due to this disorder. The causes of MSD’s in dentistry are diverse, and symptoms include recurrent pain, inflammation/swelling, stiff joints, and dull aches in the neck, back, shoulders, wrists, hips, legs, knees, and feet.

Proper patient positioning techniques can prevent MSD’s and other types of chronic conditions in the dental field. Adopting this system is beneficial when taken into account that the operator is using other favorable equipment such as professionally fitted loupes and lighting, and ergonomic operator seating, such as a saddle stool.

Patient Positioning:

• Position the patient supine for treatment of the maxilla and semi-supine for treatment of the mandible.
• Instruct the patient to move to the end of the headrest after reclining
• Frequent movement of the clinician will mandate the patient rotate their head and move their chin to maintain a line of sight that is perpendicular to the surface of the tooth.
• An ergonomic dental headrest cushion that is held in place by a strap can be used to help with patient comfort and maintain proper orientation of the occlusal plane while being reclined during treatment. Choose a supplemental cushion that is designed for dental chairs.
• When treating the maxilla, the headrest should be adjusted so that the occlusal plane of the maxilla is 15 to 20 degrees backward in relation to the vertical plane. Use a contoured pillow made for dental chairs with the larger end of the pillow under the patient’s neck which positions the head back and chin higher.
• When focusing on the mandible, the headrest should be adjusted so that the occlusal plane of the mandible is around 30 degrees elevated from the occlusal plane. If using a contoured pillow, reverse the position used in the maxillary position with the large end being behind the patient’s head.
• Mandibular Arch 8-9 o’clock positioning is best for treating anterior surfaces of the non-dominant hand, posterior right buccal, & left lingual. The patient’s chin should be down and their head slightly away from the operator.
• Maxillary Arch 8-9 o’clock positioning is best for treating anterior surfaces of the non-dominant hand, posterior right buccal, & left lingual. The patient’s chin should be up and head slightly away from the operator.
• Mandibular Arch 10-12 o’clock positioning is best for treating the anterior surfaces away from the non-dominant hand, posterior right lingual, & left buccal. The patient’s head should be slightly toward the operator and chin should be down.
• Maxillary 10-12 o’clock positioning is best for treating the anterior surfaces away from the non-dominant hand, posterior right lingual, & left buccal. The patient’s chin should be up and their head toward the clinician.

Are you guilty of wearing your prescription glasses or readers without proper eye protection while treating patients? The Centers for Disease Control and Prevention (CDC) clearly states that all dental clinicians should wear protective eyewear that features solid side shields or a face shield during any procedure involving aerosols, splashes, or sprays of blood or bodily fluids. Furthermore, patients should also be provided proper protective eyewear and mandated to wear it during procedures.

Safety eyewear forms a protective barrier from microorganisms for the mucous membranes of the eyes which is important because infectious diseases can be transmitted through these membranes. By not shielding your eyes, you are at risk for introducing bacteria, viruses, and even fungi into your body.

These infectious microorganisms are introduced into the eye from direct splashes, aerosols, or droplets generated from patient treatment. Aerosols are the most common form of contamination for the clinician. These contagious particles may also invade by touching the eye with contaminated fingers or other contaminated objects.

The Organization for Safety and Health Administration (OSHA) mandates employers provide proper protective eyewear or face shield protection that complies with American National Standard Practice for Occupational and Educational Eye and Face Protection regulations (ANSI).

Some important factors regarding eye protection include:

• Safety glasses must be worn in the event of aerosols, blood splatter, body fluid exposure, or in the presence of chemicals.
• Intermediate level disinfectant must be utilized to clean the eyewear after each procedure if contamination is suspected.
• Masks with an attached shield and clip-on shields may be used in place of safety goggles.
• If you wear prescription glasses, goggles that fit over the prescription glasses are effective.
• Professionally fitted loupes may be used for eye protection.
• It’s prudent to try many different types of eye protection before making a final decision. Make sure that you choose a brand that’s anti-fog, fits well, and is marked to ensure it’s ANSI approved.
• Proper protection from UV light (curing light) must also be taken into consideration for the clinician and patient.
• Each patient must be supplied with proper eye protection and mandated to wear it during procedures.

Office equipment isn’t the only thing you need to be spending money on in your office. Your dental team is a very important resource and it’s critical for the success of the practice that they be treated as such. Spending money on the education of you and your team will definitely keep your office moving forward and ensure that your staff is engaged.

By providing continual training, efficiency and productivity of your team will increase immensely.

There are 3 main reasons why continual staff training is an essential element of long-term success for your practice.

1. Staff efficiency and productivity

Continual training gives staff the knowledge and skills necessary to do their jobs more efficiently and productively. Staff members are more likely to do well in their positions on a day-to-day basis if they are not struggling to complete tasks due to inadequate training. This increases staff confidence, which in turn increases productivity, creating higher profits for the practice. You’ll also find that a more confident and relaxed team will provide better customer service at every part of the patient’s experience—which, through repeat business and referrals, will also increase profits in the long term.

2. Staff motivation and “ownership”

Successful practices understand the value of a great staff member and his/her impact on practice growth. Every employee needs to be a productive and integral part of the practice. When team members are shown that they are a valued and vital part of a thriving practice, they feel a sense of ownership and personal responsibility in their daily work. For most people, the most motivating element of a particular job is believing that they are an important part of the team and that their contribution matters to the success of the practice. Giving your staff frequent opportunities to improve their work performance is the best way to encourage this sense of ownership and belonging. It also has the side benefit of maintaining a team atmosphere in which every staff member is understood to be highly valued.

3. Staff loyalty and retention

Continual training for employees offers a highly educated staff for dental practices. The training helps practices keep qualified individuals for advancement while offering new hires the opportunity to start their job off on the right foot. The doctor or practice administrator doesn’t have to look for qualified staff outside the practice when there is an opening in a higher position with more responsibility. Meanwhile, existing staff continue to build the skills and knowledge needed for additional responsibilities within their positions. The bottom line for your practice is less expense in staffing and hiring.

In short, initial and introductory training are only the beginning of a continual and ongoing process of skill-based learning for dental staff. You’ll need to evaluate your staff’s training needs on a routine basis to identify and acknowledge gaps and then find a training program that will help address those gaps.

Another consideration is the need for employees to retain newly learned skills through continual training. Just as it’s true that introductory job training isn’t all that’s needed for continued job success, it’s also true that learning new skills doesn’t lead to a good return on investment unless those skills continue to be adjusted for ongoing changes in the industry. We know that new technology and products can help dentists be more productive in the operatory; in the same way, new ideas and products to help the front office are always changing as well. Ideas and skills that were used in the past may not be as efficient and productive as what is available today.

Getting started with continual training

Virtual training is the most efficient and least costly way to train staff members. When training is offered online, the practice does not have to interrupt the work of a productive employee in order to train someone else. Even better, with virtual training, multiple staff can be trained at one time. It also offers consistency of training across the team to make sure each person is trained in the same way with the same information.

As a practice whose staff is engaged in continual learning, you’ll enjoy a competitive advantage over the majority of other dental offices in your community.

By developing your staff’s knowledge and skillsets, your practice will enjoy a significant return on investment through increased staff productivity, increased staff loyalty, and happier patients. And that’s a win-win for everyone involve

Resembling something out of a Hollywood blockbuster, ransomware is a very real threat to any business, hospital, practice, police department, or any organization that uses a computer to manage files and information. Ransomware is a type of malware that “prevents or limits users from accessing their system, either by locking the system’s screen or by locking the user's files unless a ransom is paid.”

Ransomware isn’t going anywhere anytime soon either. In March 2016, there were 56,000 ransomware incidents and $209 million paid to the criminals committing these crimes in the first quarter of 2016.  Furthermore, less than half of the victims of this corruption completely recover their data even with secure backups.

Ransomware is delivered by email with malicious attachments or links around 59% of the time. Clicking on a link in an email is far more dangerous than clicking a link on a website. The venomous software generates profit for attackers by encrypting a user or company’s files and demanding payment (ransom) to decrypt the affected files. These vicious applications can affect any computer, and the data breaches often go unreported or underreported.

What can you do to protect your practice from this type of disaster?

• Maintain secure backups- data backup must be secured, and shouldn’t be on the main network, or it’s also subject to encryption by the attackers. Offline storage or cloud-based services are great choices for keeping backups from being affected.
• Advanced email scanning- email is the simplest way for hackers to obtain access because emails are the least secure. Choose a service that provides substantial attachment transcription to protect yourself from viruses, phishing, and malware attacks.
• Network segmentation- Critical data computers should be separate from web browsing and personal email computers. It’s imperative that employees understand that the critical information computers are for business use only-no surfing the web or checking personal emails on these computers.
• Response plan- If a cyber attack does occur, knowing what and what not to do is crucial. Having a plan including information on who to call and where your secure backups are located is prudent. This plan should be kept in a secure place and reviewed yearly to help you recover quickly in the event of an attack.
• Team training- you and your team must be trained in this new age of cyber attacks. Only open email attachments that have been screened by a third-party filter. Never click hyperlinks (URLs) contained in emails. Employees or authorized users are the only people who should have access to your office computers.

The American Dental Association and the U.S. Department of Justice have additional information, and it’s prudent to review this information and be prepared in case your office is targeted.

The recare (recall) system in dentistry is the bread and butter of the practice, and it’s imperative that it be created properly and maintained to help the practice grow and thrive. Most offices today use dental software in all aspects of management from procedures and record keeping to billing and insurance. Furthermore, dental software includes components with regards to recare making it so much easier to handle than in days gone by where tracking appointments were managed on handwritten ledgers.

It should be office policy that each patient who comes in for an appointment has their next made whether it’s prophylaxis or restorative care. Recare is usually assigned to prophylaxis, but it should also be included in making restorative appointments. Reasons for making the following visit include:

• Filling the appointment book in the future allows you to know what openings remain for emergencies and last minute needs.
• Scheduling the next appointment at the end of each visit reiterates to the patient that their dental health is a priority.
• Making the next appointment ensures the patient that they have reserved time on the schedule, and thus, makes it a commitment.

What happens if a patient doesn’t make a recare appointment? Running reports of overdue and unscheduled patients provide the information you need to reactivate them easily. Once you have the list of patients who are due, communicate with them in multiple ways because people prefer to receive information differently.

Phone calls, texts, and emails should be made to the patient once a month until they schedule or they ask you not to contact them anymore. There are many automated services for emails and texts which makes the process simple. Also, emails and texts allow for the patient to contact the office after hours and in a non-threatening manner. The only reasons to cease correspondence with the patient are: they request you stop, they have moved out of the area or switched dentists, or they have passed away. Having a healthy recall system keeps the practice moving forward and active and should be an integral part of the day to day operations.

When you have an employment opening in your practice, how much thought do you give to hiring the right candidate? More often than not, the focus is placed on getting the position filled, and this can prove to be an unfortunate way to hire a new team member. There are many factors involved in choosing the right fit for your practice, and it’s well worth your time to carefully consider each interviewee.

First and foremost, think about why dentistry is your passion. What is it that gets you out of bed in the morning and makes you grateful to be in the dental field? When you and your team realize the “why,” not only will you find the right team member, but you’ll also take your practice to new heights.

Secondly, become familiar with your core values and make sure you and your team share these values. The “who” is very important because the entire office needs to have the same beliefs and be on the same page. Good or bad, your relationship with one another will extend to the treatment of your patients.

Lastly, ask the candidate the right questions. The “what” is equally important as the “why” and “who.” Being prepared for the interview with the right questions is imperative for locating the perfect individual. Pay attention to body language and listen to the answers given. Also, several working interviews are mandatory to determine if this person will mesh with everyone. Personality tests are very helpful and informative as well. Looking beyond the resume will ensure you make the right decision. Some pertinent questions are:

1. What skills and duties did you perform in your last position?
2. Why did you leave your last position and under what terms?
3. Have you ever been chosen to lead the team, and if so, how did the others respond to your leadership?
4. What would you say has been your greatest accomplishment and why?
5. Are you open to offering and/or receiving mentorship?

These are but a few recommendations. Sit down and think about the type of person you want by your side and don’t be afraid to weed out as many candidates as necessary. When you think you’ve found the right person, make sure it’s understood that they will be placed on a three-month probationary period. It’s not the end of the world if you hire the wrong person and if after three months, you find that the fit isn’t right, you can part ways without any drama. Also remember, people tend to be who they are, and while skills can be learned, a person’s values and culture are difficult to change.