ARTICULATOR Spring 2015 Volume 19, Issue 4
RMDC15
WRAP-UP Starting the Spring Fresh, Plan for the Future 6 2015 RMDC - A Record Breaking Show 8 Trimming the Team: A Management Challenge 10 Choosing a Dental Practice Model An Important Part of Strategic Planning 18 A Permanent Solution to a Temporary Problem 22 OSHA Requirements for the Dental Office 28
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ARTICULATOR MDDS
Connections for Metro Denver’s Dental Profession
Volume 19, Issue 4
MDDS Articulator Editor Brandon Hall, DDS Associate Editor Jeremy Kott, DDS
Creative Manager & Managing Editor CT Nelson Director of Marketing & Communications Jason Mauterer, CDE MDDS Executive Committee President Larry Weddle, DMD President-Elect Ian Paisley, DDS Treasurer Sheldon Newman, DDS Secretary Nicholas Chiovitti, DDS Executive Director Elizabeth Price, MBA, CDE, CAE Printing Dilley Printing The Articulator is published bi-monthly by the Metropolitan Denver Dental Society and distributed to MDDS members as a direct benefit of membership. Editorial Policy All statements of opinion and of supposed fact are published under the authority of the authors, including editorials, letters and book reviews. They are not to be accepted as the views and/or opinions of the MDDS.
mddsdentist.com
Spring 2015
Inside This Issue:
RMDC15 Wrap-Up ..........................4
RMDS15 Wrap-Up: A New Hope .......... 16
Member Matters ..............................5
Choosing a Dental Practice Model An Important Part of Strategic Planning....... 18
Starting the Spring Fresh, Plan for the Future .............................................6
A Permanent Solution to a Temporary Problem ........................................ 22
Member Connections ............................7 Event Calendar ...................................... 26 2015 RMDC - A Record Breaking Show...8 OSHA Requirements for the Dental Trimming the Team: A Management
Office............................................28
Challenge ...................................... 10 The Dentist’s Business Plan and Personal Nonprofit News ...................................12
Financial Plan Must Coincide .........33
Pathology Puzzler ..............................14
Classifieds.............................................35
The Articulator encourages letters to the editor, but reserves the right to edit and publish under the discretion of the editor. Advertising Policy MDDS reserves the right, in its sole discretion, to accept or reject advertising in its publications for any reasons including, but not limited to, materials which are offensive, defamatory or contrary to the best interests of MDDS. Advertiser represents and warrants the advertising is original; it does not infringe the copyright, trademark, service mark or proprietary rights of any other person; it does not invade the privacy rights of any person; and it is free from any libel, libelous or defamatory material. Advertiser agrees to indemnify and hold MDDS harmless from and against any breach of this warranty as well as any damages, expenses or costs (including attorney’s fees) arising from any claims of third parties. Inquiries may be addressed to: Metropolitan Denver Dental Society 925 Lincoln Street, Unit B Denver, CO 80203 Phone: (303) 488-9700 Fax: (303) 488-0177 mddsdentist.com ©2011 Metropolitan Denver Dental Society
MESSAGE TO OUR READERS:
CALL FOR ARTICLES – SUBMIT YOURS TODAY!
T
he Articulator belongs to you, our readers. Share your indepth subject knowledge, events and accomplishments with the Metro Denver dental community. By submitting articles, photos, happenings, etc. to us for consideration, article submissions are open to members and vendors in the Dental community.
Please submit your articles, photos, etc. to CT Nelson, Managing Editor, at creative@mddsdentist.com.
MDDS NEWS
RMDC15
WRAP-UP Larry Weddle, DMD, MS
I
’d like to start by saying “Bravo!” to the MDDS staff, members and volunteers for the record-breaking 2015 Rocky Mountain Dental Convention. A snowy Wednesday didn’t stop attendees from packing the Thursday morning Opening Session or the MDDS Awards Gala & President’s Dinner that evening. The Friday Night Party and the After-Party were huge hits. Our attendance this year nearly crested 9,000 and it all happened seamlessly. Thank you! I would like to extend a special thanks to everyone who participated in the Metro Denver Dental Society’s Awards Gala & President’s Dinner. This is our first year doing this event during the RMDC and I couldn’t have been more pleased with the turnout. I’d like to offer one more shout out to the sponsors before I get into the meat and potatoes of the event. Thank you to Accounting & Tax Resources Inc., American Orthodontics, Benco Dental, BVB General Contractors, Cain Watters & Associates, Carr Healthcare Realty, Cornerstone Dental Solutions, Fortune Management, Joe Architect, Rocky Mountain Orthodontics, Summit Accounting Solutions, Topline Management and UMB Bank. The Gala was held in the stunning lobby of the Ellie Caulkins Opera House. After the cocktail reception, guests enjoyed dinner while the ceremony commenced. I opened up with a few introductions, including my mother who came all the way from Alabama, and then turned over the mic to CDA President Dr. Brett Kessler and CDA Executive Director Mr. Greg Hill. Next up was our Awards Emcee, Mr. Charles Loretto of Cain, Watters & Associates. The following is a list of all the awards presented and recipients:
The MDDS in Partnership with KIND Humanitarian Award was presented to Dr. Anil Idiculla. The Service to the Society Award was presented to Dr. Jerome Greene. The Chairman of the Year Award was presented to Dr. Nelle Barr. The Volunteer of the Year Award was presented to Dr. Nicholas Chiovitti. The Honus Maximus Award was presented to Dr. Charles Danna by Dr. Larry Weddle. The MDDS Exemplary Staff Member Award was presented to Ms. Shelly Fava. It was truly a pleasure to host this inaugural ceremony for our Society and honor so many admirable individuals. I’m told over 150 people joined us that evening! Once the clapping and waterworks subsided, guests hit the dance floor to enjoy local favorite, Digital Pocket. What a privilege to get to kick off the first day of our Society’s premiere event, the Rocky Mountain Dental Convention – I can’t wait to be a guest at Dr. Ian Paisley’s dinner at the 2016 RMDC!
The ADA Golden Apple Award was presented to the Metro Denver Dental Society by the ADA 14th District Representative Dr. Gary Yonemoto. Outgoing Board Member Awards were presented to Dr. Anil Idiculla and Dr. Karen Foster. The Outgoing Editor Award was presented to Dr. Carrie Seabury. The Past President Award was presented to Dr. Mitchell Friedman.
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Outgoing Chair Certificates were presented to Dr. Nelle Barr, Dr. Karen Franz and Dr. Anil Idiculla.
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Articulator
Spring 2015
MEMBER MATTERS Metro Denver Dental Society's Awards Gala and President's Dinner– 1-27-15
New Members, Welcome!
The Gala was held in the stunning lobby of the Ellie Caulkins Opera House
The Honus Maximus Award was presented to Dr. Charles Danna by Dr. Larry Weddle.
The ADA Golden Apple Award was presented to the Metro Denver Dental Society by the ADA 14th District Representative Dr. Gary Yonemoto.
MDDS in Partnership with KIND Humanitarian Award presented to Dr. Anil Idiculla.
The Chairman of the Year Award was presented to Dr. Nelle Barr.
mddsdentist.com
The Volunteer of the Year Award was presented to Dr. Nicholas Chiovitti.
The Past President Award was presented to Dr. Mitchell Friedman.
Dr. Larry Weddle, Dr. Alex Park, Ms. Elizabeth Price, Dr. Gary Yonemoto, Dr. Carol Morrow and Mr. Greg Hill
Dr. Raed Ammari Dr. Eleonora F. Balota Dr. Jessica A. Barron Dr. Alexandra W. Bassett Dr. Carolyn D. Boettger Dr. Curtis L. Broeker Dr. Matthew D. Carlston Dr. Helen B. Chase Dr. Suzanne L. Delima Dr. Catherine A. Fermelia Dr. Raymond B. Graber III Dr. Anahita Gupta Dr. Clifton L. Harris Dr. Christopher S. Henes Dr. Fawzi A. Hijazi Dr. Katherine M. Hungate Dr. Thomas L. Jorgensen Dr. Yasamin Kasiri Dr. Roopi K. Kattaura Dr. Sophia Khan Dr. Mostafa Koperly Dr. Nidhi R. Kotak Dr. Jesus M. Machado Dr. Hani M. Marogil Dr. Kimberly A. Marshall Dr. Cara C. McCallum Dr. Rebecca S. Misner Dr. Christopher R. Morris Dr. Anas A. Najm Dr. Scott A. Novak Dr. Kenneth W. Ostrov Dr. William P. Paini Dr. David R. Randolph Dr. Amanda J. Shaffner Dr. Ethelyn G. Thomason Dr. Homer R. Warner Dr. John L. Weber Dr. LaShica M. Young
Mr. Rudy Wolf, Ms. Julie Collett, Ms. Elizabeth Price, Dr. Avani Khatri and Dr. Gary Field
Ms. Terri Poulos, Dr. David Klekamp and Dr. Michael Poulos
Articulator
Spring 2015
5
REFLECTIONS
STARTING THE SPRING FRESH, PLAN FOR THE FUTURE By Brandon Hall, DDS, Editor
I
Here it is, spring of 2015, my first issue as Editor of
This is a wonderful time to be a dentist, I truly believe that. Technology
MDDS and the Articulator. Feels a little weird, but
is becoming so advanced and vital to our diagnosis and treatment. Plus,
that’s normal when something’s new right? Kind
it’s just plain fun to use. The public is becoming more aware of their
of like a new house, new baby or a maybe that new
teeth and gums. And wow, the baby boomer generation is retiring and a
dental handpiece. Takes a little while get used to it but
lot of them need dental work. The need for us is there and always will be.
we’ll come around soon enough. For this intro piece, rather than get into a lot of prose, I’ll just introduce myself and tell you
For me, this year will be the year I look at giving back. Personally, but
what I hope to bring to the pages of the Articulator and to the thoughts
especially professionally. I haven’t done enough in my years as a practice
of readers.
owner with providing my gift of dentistry to those who need it. That will change. Getting my team on board and having a vision with how we’d
I’m a Midwest guy. Born and raised in Iowa. Yes, I know, the Bachelor
like to be philanthropic is on my “to-do list.” I can share that journey
is from there. I get it. He’s a good looking farmer. Not all of us are
with you as we become more acquainted.
farmers but most of us are good-looking (wink, wink). I was raised in a healthcare family (dad a physician, mom a nurse) and knew I wanted to
I’ve also had a few mentors along the way: my dad first and foremost,
get into healthcare in one way, shape or form and here we are.
but also others such as my childhood orthodontist and Dr. Brett Kessler. If you don’t already have one, find a mentor. Find someone you can just
I’d like to say in my short career of nine years, I’ve been through it
talk to about dentistry and life. It helps a bunch. We become so isolated
all. From a nightmare associateship right out of school, to corporate
sometimes and it’s not healthy.
dentistry and now to a private practice owner of four years. I’ve seen
things that most people see in a long career. I’ve been depositioned for
In the future issues of the Articulator, I hope to give you a fresh
a boss’ divorce and had an IRS agent show up at the office I used to work
perspective and provide something enjoyable for you to read. Our
at. I’ve fired some staff members, even had some just up and quit on me
previous editor, Dr. Carrie Seabury, certainly had a way with words and
for no reason. I’ve seen plenty of tears. Some tears of joy, some tears of
those are some tough shoes to fill, but I’ll do my best. I appreciate any
pain. I’ve had countless days of staff and patient drama. I’ve been there.
and all feedback.
You aren’t alone. It’s part of the profession.
I encourage everyone to continue their dedicated readership of the There were nights when I started my practice that I didn’t know if I could
Articulator. Not only that, but please support MDDS, the MWDI, the
do it anymore. A few nights I laid in bed in tears asking myself if I had
advertisers and all the people who help make it happen. There are great
made the right decision about not only starting a practice but going into
CE opportunities at MWDI that you shouldn’t ignore. Great speakers
dentistry. However, when you go through the valleys and failures you
that are coming here to give very inexpensive CE that normally costs
appreciate the peaks and successes much, much more. And you LEARN.
several thousand dollars elsewhere. Improve your skills, improve your
Having a fear of failure makes you want to succeed even more. Yet, I’ve
relationships with your team members and fellow dentists. Let’s all stick
failed many times. So don’t beat yourself up for things. It happens.
together and make our dental community a better place.
I think it’s important that we see where our profession has been, where it is now and most importantly, where it’s going. We need to keep our eyes open when it comes to insurance companies, corporations and the government. Do not let third parties dictate our ability to “be dentists.” Let’s not lose this. Let’s stand strong and let our voice be heard. We’ve spent too much money and worked too damn hard no to.
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Articulator
Spring 2015
MEMBER CONNECTIONS
MDDS New Member Welcome Event – Interstate Kitchen & Bar (Febuary 18, 2015) Thank you to Carestream Dental and Outreach Marketing Solutions, LLC for sponsoring this event.
A packed MDDS event at Interstate Kitchen & Bar
Dr. Alexandra Bassett, Dr. Angela D. Bernedo Pantigozo and Dr. Ashley Roark
Dr. Cameron Pangborn, Ms. Lauren Beckman and Dr. Eric Beckman
Ms. Cara Friedman and Dr. Ian Paisley
Dr. Brett Kessler and Ms. Ali Lindauer
Dr. Nelle Barr, Ms. Terry Fritz, Ms. Kim Arrigoni and Dr. Larry Weddle
See the Rockies Opening Weekend for ONLY $5.00*. *$20 total ticket price, includes $15 to be used on food, beverage or merchandise!
REGISTER FOR BOTH ONLINE at mddsdentist.com
The Colorado Convention Center with iconic Blue Bear peeking in
Dr. Gurinsky’s hygienist roundtable
Attendees entering the Expo Hall at the 2015 RMDC
Hands-on with lasers and pig jaws
2015 RMDC - A RECORD BREAKING SHOW Michael Scheidt, DDS, MS – 2015 RMDC Chairman
T
hanks to all who attended the 2015 RMDC and were part of the largest attendance in RMDC history. Special thanks to all of you who volunteered to assist with the planning and execution of this super MDDS event.
Our Convention Arrangements Committee, Programming Committee; Exhibits Committee, Exhibitor Host, Speaker Host and Greeter Chairs all did an excellent job in each of their special roles of meeting development as well as providing their invaluable assistance during the meeting. The lectures by premier dental educators from around the country, along with hands-on learning at the Convention Center and The Mountain West Dental Institute made for another great learning experience. Our exhibit floor was also busy, with over 230 exhibitors. The MDDS Awards Gala and Presidential Dinner for Dr. Larry Weddle on Thursday night was excellent, with much deserved recognition given to our volunteers and staff. (See page five for details) The Friday Night Party was truly an exceptional fling, as our professional DJ
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bought a record number of people to the dance floor with his great music mix and video show. Dr. Nelle Barr, President of the Metro Denver Dental Foundation and her Foundation Team, brightened up the dancers with glow bracelets sold to benefit the Foundation; as did her highly successful coat check service. If you missed the After Party at Chole, you missed an exciting time at our "After Hours LoDo event" with a dance floor, friendly mingling and our own bottle service. Wow! I am so very pleased to have participated as this year's Chair of the RMDC and so very grateful for all of the MDDS staff support including that of Elizabeth Price our Executive Director and Shelly Fava our Director of Convention & Events. It takes a great number of people committed to their profession and to their own professional growth to accomplish a successful regional dental convention like ours. I know that many more of our members would like to contribute, but for one reason or another just forget to make that volunteer call. You owe it to yourself and to the development of your professional relationships here in Metro Denver to join us in putting on RMDC 2016. Hope to see you all next year.
Articulator
Spring 2015
Testing new products in the Expo Hall
Getting a close-up view
Hands-on in Dr. Olmsted’s endo course
The Pacific Dental Services bus
Getting some hands-on instruction
Friday Night Party selfie
A packed house in The Dawson Academy course
The Friday Night Party
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OFFICE MANAGEMENT
TRIMMING THE TEAM: A MANAGEMENT CHALLENGE
By Teresa Duncan, MS
I
magine that your garden has a plant that is growing strong and is different than the other fragrant flowers. You’ve inspected it and you’ve determined that although it may look like one of your other plants, it’s slowly beginning to overtake them. It is taking up valuable space and nutrients in your garden. At this point you have probably decided that it is a weed and it needs to be pulled.
most taxing type of employee. Plenty of fears come to mind – each with its own intensity.
Now think about your weakest link in the office – you know who it is. If he or she isn’t in the office currently, I’ll bet that you’ve had one in your career. You identified her (let’s stick with the female gender for simplicity’s sake) as a weed a long time ago. You most likely have multiple stories to attest to her “weediness.” The effects of her tendrils and negative growth have been felt by not only your team but yourself. Why then are you allowing her to grow stronger every day? The paycheck is oxygen to this weed and you are keeping it alive. Again - YOU are keeping it alive.
Our minds immediately go to the scariest scenarios….what if she tells the neighborhood I fired her? What if I can’t handle all the tasks she used to perform? I have a question for you – what if she leaves tomorrow? All the same questions but you’ve eliminated the need to actually fire this person. Let’s be honest – that was the most painful part of this equation.
Fear can keep you from dismissing this
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• Fear of not being staffed adequately without her • Fear of badmouthing your practice if your community is small • Fear of patient perception of your staff turnover • And the largest fear of all – fear of change
Let’s think about this then as if she quit on her own. How will you handle the fear of being staffed adequately? You will ask your team to pitch in short-term. And please emphasize ‘short-term’ for no team member wants to think that their load
just increased permanently. Let’s look for a replacement using a well-written advertisement and in the meantime, consider hiring a temporary employee. Here comes the painful part – you will be staffed inefficiently, but this short-term discomfort is well worth the benefit of pulling that weed. What about your reputation in the neighborhood? I bet it will be just fine. Many people realize that when a litany of hate and complaints come from a person there is usually another side to the story. If your former employee was ‘weedy’ with you then chances are she was this way to others. I really believe that people consider the source when they hear malicious words. Have faith in people and believe that they will see her as you did – weedy! Many a doctor has told me that they worry how a large amount of turnover looks to their patients. Patients are used to seeing staff members move on – not just in your office but in their physician’s, stylist’s and in their own offices. You’ll be amazed and then amused at how many times a patient will tell you “I’m so glad she’s not here anymore – what a rude person she
Articulator
Spring 2015
was!” Should you ever hear that from a patient, please stop and take the time to discuss their experiences with your former employee. This could be vital to uncovering mistakes that could still impact your practice. The last fear that you’ll handle is fear of change. Again – imagine that your weed quit and you will have to face this head on with no preparation. Nothing like trial by fire! But truly this is what separates the leader from the follower. As the leader of your practice this is the perfect time for you to show your team that although you’ve been thrown a curveball you have plans to handle it. Whether your employee quits or is fired, you’ll need to address the team. Call a meeting – a short one. Explain that Weedra is gone and let them know that you are working to replace her as soon as possible. Here’s a sample of how you could handle it: ‘As you can see Weedra is no longer a part of our practice. The official story to our patients is that she has found another opportunity and we wish her well. Internally, I want you to know that I’m working now to find a replacement that will help us take this office to the next level. Short-term we’ll all have to work together because I’m sure we’ll have surprises over the
mddsdentist.com
next few weeks. But I want you to know that I don’t expect this to be a long process. I want to find the right person and I want to move this practice forward as soon as possible.’ Your team may surprise you and be relieved by the change. I’ll bet that’s the case – usually the last person to see the damage caused by this toxic employee is the dentist. But you’ll spot her more quickly now, won’t you? This change represents new opportunity for you and your team. You’ll feel new motivation when you realize you won’t hear “that won’t work” or “patients will never go for that” and other deflating words. Imagine your ideas and initiatives greeted with “tell me how to do that” or “yes, we can definitely make that happen.” That’s what you deserve to hear – encouragement and enthusiasm. Let’s keep your office garden beautiful and growing strong. No more weeds! About the Author Teresa Duncan is President of Odyssey Management, Inc. and is an international speaker that focuses on recapturing and maximizing revenue opportunities for dental offices. She also coaches managers to elevate their practices to successful heights. She can be reached at Teresa@OdysseyMgmt.com.
Articulator
Spring 2015
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NONPROFIT NEWS
13th Annual Give Kids a Smile Day5 (Febuary 6, 2015)
S
ince the American Dental Association began the Give Kids a Smile program in 2003, it has gone from a one-day event, to local and national events year-round. Dentists and dental professionals volunteer time and services to treat and educate children throughout the United States. Each year approximately 450,000 children benefit nationwide from GKAS. MDDS would like to thank all of you that volunteer your valuable time and resources to give our Denver area kids something to smile about!
9News reporter Ms. TaRhonda Thomas broadcasting a live interview with Dr. Avani Khatri from the MWDI
Giving kids smiles at the University of Colorado School of Dental Medicine
FOX31 news reporter Mr. Dan Daru reporting live from the University of Colorado School of Dental Medicine
Dr. Lindsay Compton with a smiling patient
Dr. Alfaiyaz Ibrahim giving a demonstration to a little patient
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Dr. Michael Petersen taking a group shot with volunteers and students at the University of Colorado School of Dental Medicine
Articulator
Spring 2015
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Articulator
Spring 2015
13
PATHOLOGY PUZZLER PATHOLOGYPUZZLER WITH DR. JOHN SVIRSKY
A
59 year old white female was seen initially by a local dentist in March 2012 with an uneventful oral examination. Her past medical history was reviewed and included medical management of chronic fatigue, fibromyalgia, hormone replacement therapy and a herniated disk. Her medications include Vicodin®, Flexeril®, estradiol, probiotics, Fiberpsyll®, Savella®, Zomig®, Amerge®, Vitamin D, Calcium, Dehydroepiandrosterone, Magnesium citrate and fish oil.
Figure 1
Figure 2
Figure 1: A 1cm by .8cm elevated lesion with a papillary appearance of the left buccal mucosa. Figure 2: A Velscope picture showing lack of fluorescence in and around the lesion.
On October 6, 2012, at her next appointment the patient presented with a raised lesion of the left cheek of four weeks duration, secondary to a cheek bite (according to the patient). (Figure 1) Prior to this appointment the patient saw a physician who recommended that a dentist evaluate. The dentist at
this appointment did an incisional biopsy. Which of the following should be included in a differential diagnosis? 1. Fibroma 2. Lipoma 3. Papilloma 4. Peripheral giant cell granuloma 5. Pyogenic granuloma 6. Salivary gland tumor 7. Traumatic ulceration 8. Verrucous carcinoma A Velscope® photograph (Figure 2) is attached showing the lack of fluorescence. Does this change your opinion or help diagnose the lesion? The answer is, No! Answers on pg. 32
Reprinted with permission from the Virginia Dental Journal Volume 90 Number 2
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RMDC WRAP-UP
RMDC15
WRAP-UP: A NEW HOPE By Brandon Hall, DDS, Editor
I
t’s over already?! Well here we are, another RMDC
get face time with those restorative specialists I work with on a day-to-
has come and gone. And wow, it certainly was a great
day basis. I also find it extremely helpful to take CE classes with those
meeting. It’s my sixth RMDC since I’ve been living in
doctors. This helps us to stay on the same page in our team approach to
Denver and I will say they continue to improve year
comprehensive patient care.
after year. I cannot wait until next year’s RMDC and
our great people, facilities and wonderful things the city of Denver has
Does your team participate in RMDC? If they do not, why not? If they do, do you feel like there is good information for all team members (front office, hygienists and assistants)?
to offer.
Yes. You have to understand that I am the newest doctor in a long
then the ADA meeting in the fall. It will a big year for
the dental community here in Colorado. We’ll be able to showcase all
There seemed to be a renewed sense of optimism in the air this year. Numerous vendors and exhibitors mentioned to me the exhibit hall seemed to be the busiest they’ve seen it in almost 10 years. That’s great news! To wrap up things from the RMDC, I asked a member dentist, Dr. Nick Poulos, and an exhibitor, Craig Gibowicz from Henry Schein, some questions regarding their experience at this year’s meeting. Here’s what they had to say:
came into an office where the entire team (front desk, hygiene, assistants, and doctors) had been going to the meeting together for many years. It didn’t take long for me to see the great value in this tradition. I always get great feedback from the various courses our team members take, and I can always feel the boost in energy the following week when everyone is excited to begin integrating their newly acquired knowledge into our routine patient care.
Dr. Nick Poulos – Periodontist at Poulos and Somers
What would you like to see differently at RMDC in the future?
In your experience, how did this year’s RMDC compare to previous meetings?
multitude of events which accompany the conference after hours. There
The biggest issue I see is not so much with RMDC itself, but with the are so many things I look forward to every year at the convention… The
Very similar. I have been a regular attendee (and
CDA New Dentist Happy Hour, The MDDS Presidential Gala, various
volunteer) at RMDC since I moved back to Colorado
alumni events and vendor sponsored parties, Friday Night Party, after
six years ago. One of the things I appreciate about the meeting is the
party, after after party etc. The biggest problem is that I can’t be in
consistency. I always know what to expect year-to-year.
more than one place at the same time. I have to pick and choose the
How do you feel RMDC is important when it comes to your relationship with dental vendors and exhibitors? What about other dentists and specialists? I like spending time in the exhibit hall checking out the newest
events I attend and end up suffering from FOMO (fear of missing out) regretting those I had to skip. I wish there was either more time, or better coordination between the various entities putting together these great events.
our patient experience the best it can be. I also appreciate the chance
If you fast forward 10 or 20 years, how do you envision RMDC and its role in the dental community?
to socialize with the vendors outside of an office atmosphere at events
I hope that it remains the largest (and most highly regarded) dental
technology, learning about new products and looking for ways to make
like the Friday Night Party. As a surgical specialist, it is always great to
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established periodontal practice here in Denver (Poulos and Somers). I
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convention in the region. I think that the future of the RMDC is closely
Articulator
Spring 2015
tied to the future of organized dentistry. As the landscape of dentistry
Not exactly sure and my first reaction is to say it will be very different.
transitions more and more away from the solo practitioner and towards
But I also thought that 10 years ago and it really is the same today as
a group and/or corporate model the net effect on involvement in
it was then, just products have changed to more technology centered.
organized dentistry (and associated events) remains an unknown.
With local dental organizations running these state conventions, there
Mr. Craig Gibowicz – Field Sales Consultant at Henry Schein As an exhibitor, how do you feel the RMDC is important in your relationship with dentists and the dental community? How about your company, Henry Schein? RMDC is a great way to strengthen existing relationships as well as start new ones. Seeing clients outside of their office is a good way to connect with them. This is just not for individual reps but for Schein as a company as well.
will always be a need for them. Some have said that state meetings will be a thing of the past but I disagree. It’s a time for people to come together to support the local dental offices and local dentists and local dental organizations. These are all vital to advance dentistry in Colorado.
What’s your favorite thing about being a part of RMDC every year? Seeing clients outside the office and getting to know them on a different level.
What’s something you wished was different or changed for the better? Continue to focus on bringing in top notch speakers to have attendance continue to grow. Dealers like Henry Schein are huge supporters of dental organizations and local dentists need to be reminded that when they invest in buying products from us, they are also investing in their
How has this changed over the last 10 years? It really has not changed much. Even with all the electronic ordering these
local dental association.
days, relationships and personal interaction is what this industry was built on.
If you had a crystal ball and could fast forward 10-20 years, how will RMDC look in regards to exhibitors and their roles at the convention?
Because we just never know...
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PRACTICE MANAGEMENT
CHOOSING A DENTAL PRACTICE MODEL AN IMPORTANT PART OF STRATEGIC PLANNING By Michael Perry, DDS
I
n my experience as a practice management consultant and practicing dentist, most private practice dentists don’t see themselves as operating within a particular practice “model.” Dentists often evolve into their practice model through random opportunity, market pressures, or other circumstances. Often the model a dentist works in is the only one that he/she knows and understands. Stages vs. Models Stages of practice refer to times in a dentist’s career. The CDA defines stages 1 through 4 describing phases from the dental student to the prospective retiree. I have often labeled stages of private practice another way: survival, growth, and fulfillment. Survival is the time when a private practice dentist is burdened with debt. Growth is the time when the practitioner’s priority is practice expansion. Fulfillment is when the practice becomes “turnkey” and is facilitating a doctor’s definition of success. Models of private practice are defined in this article by a dentist’s relationship with third party insurance. A model is determined the percentage of treatment a doctor is providing under contracted insurance. If a dentist has no direct contracts with any dental benefit company and only processes insurance via “indemnity” relationships, I call this a Pure Fee-for-Service model. In my experience, this model exists in approximately 10% of California practices. The remaining 90% of California practices have contracts that demand fee reductions for individual services (PPO) and/or contracts that pay a doctor a fixed periodic rate for taking care of patients’ dental needs (HMO). PPO plans include Delta Dental plans, Denti-cal, and many others. HMO plans are often referred to as “capitation” plans. Practices that are pure PPO or HMO are rare if they exist at all. It is likely that all private practices have at least some “cash” patients. A practice that obtains a portion of its patients through insurance contracts is sometimes called a “hybrid” practice. The level of remuneration varies significantly between insurance plans. Rules that restrict treatment options and outside charges to patients also have wide variations. These variations, in a sense, create an almost infinite number of model variations. For the purposes of this article, I will describe four common models, each with different types and levels of third party affiliations.
Common Models Model 1: Hybrid – 2/3 Fee-for-Service, 1/3 PPO. This has been a typical model in many areas of California. In this model, the dentist has often had a single contract with Delta Premier. Years ago, it was not uncommon for a dentist utilizing this model to have one fee schedule. It was common for “UCR” fees to be the same as those demanded by the contract with Delta. Today it is more common for dentists to have multiple fee schedules: one for each PPO and one for their noncontracted patients. Model 2: Hybrid – 1/3 Fee-for-Service, 2/3 PPO. One ADA survey showed that, nationally, 40% of private practice dentists have three or more PPO contracts. Model 3: Hybrid – 1/4 or less Fee-for Service, 3/4 or more PPO and/ or HMO. This model is more common in urban areas with greater population densities. Model 4: Pure Fee-for-Service. Practices utilizing this model have one fee schedule. Most still process insurance on patients’ behalf and take assignment of benefits when possible. To my knowledge, there is no available statistical evidence that shows what percentage of the market is encompassed by each model. The trend in recent years has likely been toward a decrease in the percentage of Model 1 practices, and an increase in Model 2 and Model 3 practices. There has likely been little change in the percentage of Model 4 practices. All of this has been due, at least in part, to changes in the dental benefits marketplace. Delta Premier has become less common in the California market while Delta PPO, Delta’s lower fee product, has become more common. Overhead Variation Practice overhead percentages vary significantly between these common models. These variations occur, in large measure, in the area of “variable costs” as opposed to “fixed costs.” The brunt of variable overhead in most practices is in staff costs and supplies. In general, the greater percentage of PPO-HMO (managed care) activity, the greater the variable costs per dollar produced. Managed care patients are usually treated for lower fees than indemnity or cash patients. For a practice that treats managed care patients to match a level of net profitability achieved by a pure fee for service practice, more patients have to be treated per unit of time, more staff will be needed, and more supplies will be used. (Continued on pg. 20)
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(Continued from pg. 18)
Variations in Staff Configurations Staff configuration is the grouping of individuals with the appropriate skill sets to work synergistically toward care for patients and success of the business. Plan rules and levels of remuneration vary widely among managed care plans. Having stated that, there are general rules that exist to help practice owners configure their staffs in an optimum way. Common sense dictates that the prudent business owner wants to achieve the best possible balance between staff costs and staff performance. The balance point for each of these common models differs.
• Supply costs increase proportionally with production. (Managed care patients are treated at lower fees, necessitating higher production to achieve the same profit level.)
In my experience, if one assumes that a private dental practice in California has a solo dentist/owner and a patient flow requiring the services of one full time hygienist, the appropriate staff configuration for each of these common models is:
• Leadership abilities between dentists vary significantly.
Model 1: (2/3 Fee-for-Service, 1/3 PPO) 1 highly trained business office employee 1 moderately trained “rover” 1 moderately trained registered dental assistant (RDA) 1 moderately trained registered dental hygienist (RDH) Staff Cost = 27% to 31% of collections Model 2: (1/3 Fee-for-Service, 2/3 PPO) 1 highly trained business office employee 1 moderately trained business office employee 1 highly trained RDA CHOOSING A DENTAL PRACTICE MODEL – 3 This resource is provided by the CDA Practice Support Center. Visit the Web site at cdacompass.com or call 866.232.6362 1 moderately trained dental assistant (DA) 1 moderately trained RDH Staff Cost = 30% to 35% of collections Model 3: (1/4 or less Fee-for Service, 3/4 or more PPO and/or HMO) 1 highly trained business office employee 1 moderately trained business office employee 1 moderately trained rover 1 highly trained RDA 1 moderately trained RDA 1 moderately trained RDH Staff Cost = 33% to 40% of collections Model 4: (Pure Fee-for-Service) 1 highly trained business office employee 1 part time bookkeeper (8 hours/month) 1 moderately trained DA 1 part time sterilization technician (20 hours/week) 1 moderately trained RDH Staff Costs = 22% to 25% of collections Variables to Profitability Between Models If a doctor/owner sets a goal of $200,000 annual net profit before retirement plan contributions and principal debt reduction, variations would exist between models to achieve that level of profitability. Some of the most significant variables would be:
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• Profitability is proportional to the quality of the PPO & HMO contracts in a practice. (Different contracts have different fee schedules and capitation rates.) • The ratio of fees to overhead varies among geographic areas in California.
• Clinical abilities between dentists vary significantly. • The model of practice in place has a significant effect upon staff costs. Production required for an annual net profit of $200K Taking into consideration the above variables, the approximate production required to achieve an annual net profit of $200,000 would be: Model 1, hybrid (2/3 Fee-for-Service, 1/3 PPO) Required annual production = $800,000 Model 2, hybrid (1/3 Fee-for-Service, 2/3 PPO) Required annual production = $1,000,000 Model 3, hybrid (1/4 or less Fee-for Service, 3/4 or more PPO and/ or HMO) Required annual production = $1,333,000 Model 4, (Pure Fee-for-Service) Required annual production = $572,000 In general, the greater the proportion of PPO-HMO dentistry in a practice, the more production is necessary to achieve a given level of profit, and the less time is available for patient examinations, treatment planning, and case presentations. Each private practice model has its commensurate strengths and weaknesses. Once a model is in place, however, there is usually significant risk and strategic planning involved in switching to a different model. In my experience, most dentists let a practice model choose them. It is far better for a dentist/owner to strategically choose his/her model as part of the practice vision creation process. Utilizing this method, the practice model becomes one the many chosen elements on a doctor’s path to the fulfillment stage of private practice. About the Author Dr. Michael Perry received his DDS from USC. He practiced general dentistry for 35 years, retiring from clinical practice in 2014. He is currently the Director of Practice Management at the California Dental Association.
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CLINICAL
A PERMANENT SOLUTION TO A TEMPORARY PROBLEM By Dave Andrus, CDT
C
rown and bridge cases that have to be returned to the laboratory to be remade or adjusted are expensive, frustrating, and if not corrected can be detrimental to the dentist-laboratory relationship. The focus of this article will be the seemingly innocuous provisional and the surrounding issues that can have significant impact on the success or failure of a case. We will attempt to explain what can go wrong, why it goes wrong and how to fix what goes wrong by looking at four primary phases that are inherent to the crown and bridge process; Preparation, Impression, Temporization and Dental Laboratory Fabrication of the Final Restoration. We will look at common materials and techniques which are used in this process and make suggestions that will allow them to work for us instead of against us. I often tell my clients if something isn’t right once, it’s an anomaly. If the same thing isn’t right a second time it’s a pattern and needs to be addressed. The all familiar “three strikes and you’re out” rule has an application to dentistry; in that if a restoration has a small adjustment here or there, it can still be highly successful. Small problems, however, are often accumulative and two, three or more small problems can become significant enough that a restoration will not be successful the first time it is tried in the mouth. Tooth Preparation: The primary issue we will address in this section is the proximal contacts on the teeth adjacent to the preparation. These aspects of preparing a case for a crown may seem rudimentary and tedious; however, when over looked, they can wind up contributing to a case being returned to the lab for adjustments. When a tooth is prepared, there may not be an appropriate path of insertion for a crown. This is often true if restorative dentistry has been done which involves the proximal surfaces such as fillings, crowns or veneers. The complications seen in a dental lab abound because these proximal contacts are frequently overlooked and not refined after nicking them while prepping or not refining them with an appropriate rotary instrument. Diamond bur marks on proximal contacts of adjacent teeth on the stone model give the laboratory technician a false reading when fine tuning the contacts of the crown. Coarse surfaces create more drag on the ribbon used to indicate how tight the contact is and can result in light or open contacts in the mouth. Green or white flame shaped stones make it easy to get a smooth proximal surface in the mouth. Diamond burs and other grinding choices with straight sides should be avoided because they tend to create gouges on proximal contact surfaces. Path of insertion issues, while not limited to, are particularly common and usually more significant with implant cases where a tooth or teeth have been missing often for extended periods of time allowing adjacent teeth to drift toward the edentulous area. It is common in these situations for the proximal contacts of adjacent teeth to have a significant angle toward the restoration site, instead of parallel to or slightly angled away providing an appropriate path of
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insertion. If these proximal surfaces are not corrected before the impression, it leaves the technician two options; make contacts that are less than ideal or attain permission to adjust the contacts on the model. Often an implant will require both adjacent contacts be adjusted creating a difficult seating appointment. In this case as well as any situation, it is extremely helpful to the lab to have instructions on the prescription to relieve as necessary or have a preference noted on the prescription to avoid making it necessary to contact the dentist which can delay the production of the restoration. Impressions: The all-important requirement of an impression is that it accurately represents the hard and soft tissue in the patient’s mouth. First and foremost we must have accurate impressions including accurate capture of the margins. The impressions with the clearest margins I have seen from clients, barring the use of a laser, are from clients who use a double retraction cord technique often implementing #000 first then #00 or #0 cords. The viscous gels do not work as well as string packing because they can leave a residue in the impression which distorts the stone dies at the margin. An important factor to note is that all impression material disinfectants are a contaminant to die stone. The result of this contamination is often seen on the occlusal/incisal surface of the stone die, sulcus area surrounding the die and the cusp tips of the teeth on the stone model. Subsequent pours in the same impression will not be affected as much because the contaminant will be removed or significantly diluted after the first models have been removed. Disinfectants leave the affected area of the stone soft and powdery as if the stone had never been mixed with water and will have a corresponding area of powdery stone in the impression. To avoid this, impressions should be placed prep side down on paper towel and aloud to dry after disinfecting liquids have been used in the dental office. Impressions are commonly left to dry sitting prep side up, which allows the disinfectant to settle and dry in the low areas of the impression. If the effects of the contamination are not caught in the laboratory, the crowns will typically not quite seat all the way and the margin accuracy will be compromised. Disinfecting the impressions in the laboratory can re-wet and rinse away some of the dried disinfectant, but may not completely eliminate the problem. One situation that makes it very difficult to get rid of the dried disinfectant is in a triple tray where a patient has bitten through to the middle mesh layer. The disinfectant can saturate the mesh making it impossible to completely remove, which will tend to distort the occlusal surface of the upper and lower model where the bite through occurs. The laboratory can sometimes equilibrate the models but often all the posterior teeth will be affected leaving no unaffected occlusal surface from which to attain accurate vertical dimension or excursive movements. Some laboratories prefer no disinfectant be used in the dental office to avoid these problems. Bite Registrations: If you are not taking a bite registration on every case, you absolutely should for three (3) reasons.
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Spring 2015
• It gives the lab a way to confirm their articulation is accurate. • If the occlusion is off when you try the permanent crown in and the bite has not been used or trimmed incorrectly, you can accurately define the problem as having occurred in the lab. • If the occlusion is off and you try the bite on the model and find the models are articulated correctly, the problem most likely lies in your office. Beware, however, blockout and die spacer paint may make the bite not fit on the model well and could make it seem that the lab did not use the bite when in fact they may have. If the bite registration is not used correctly, it can be a hindrance instead of a help. Only a small part of a bite registration should be used in the laboratory (Figure 1). A section of the bite that spans across the occlusal surface of the prep, onto the marginal ridges of the adjacent teeth spanning the buccal and lingual cusp tips of the prep and contacting the opposing hard tissue of the opposing arch should be left after trimming the bite registration (Figure 2). The detail replication of most bite materials is extremely good, so much so that if there are depressions on the teeth or prep such as open margins of a filling or deep fossa in the adjacent and opposing teeth, or interproximal areas, the bite material can replicate this detail in the form of a thin ridge, protrusion or flash. When Figure 1: An appropriately trimmed PVS bite registration with only enough material to the bite is placed on the models, confirm the articulation is accurate. these protrusions usually can’t fit in the depressions on the stone model and are likely to prohibit the bite from intimately adapting to the stone models rendering an inaccurate articulation. All the protrusions must be cut off of a bite registration with a sharp blade. The amount of material needed Figure 2: Eliminating unnecessary material from the bite registration allows a clear view to create usable bite registrations to confirm the upper and lower models are is only about the size of a articulated accurately evidenced by the intimate contact to the PVS bite. temporary crown. The material can be placed in the patients mouth in two ways; 1) expressed on the prepared tooth then have the patient close or 2) have the patient close then express registration material onto the prep, filling the space so the material contacts the adjacent and opposing teeth. Bite materials that are very flexible and don’t break while being trimmed or used are preferred. In this author’s opinion, the contraindicated materials are as follows: • Mousse type, because they break while trimming or even fitting them onto a model leaving nothing to work with. • Wax bites of any kind because they are impossible to trim without distorting them. It is also impossible to tell when the models have reached the correct vertical dimension, because wax gives under pressure and is permanently deformed.
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• Acrylics of any kind are contraindicated because these materials have an excessive shrinkage factor of about 5% according to testing in our laboratory, leaving an acrylic bite nearly impossible to accurately fit onto a stone model. Consider this, if a molar has been prepped which measures 10mm from the mesial and distal marginal ridges, an acrylic bite registration that spans the preparation site could hypothetically have 0.5mm shrinkage when measured mesial-distally making it completely irrelevant as an accurate bite registration. The significant shrinkage of acrylic bite registrations tend to chip and abrade the incisal/occlusal surfaces of stone dies when placed on a stone model because they are so hard and ill-fitting. Small chips and abrasions on the stone dies can result in inaccurate dies and ill-fitting crowns that have a slight rock to them and/ or slightly open margins. A properly trimmed acrylic bite should be trimmed so only the occlusal surface of the preparation and only a very small depression left by the opposing teeth should remain. While the technique is accurate, the extreme shrinkage of the material renders the bite in a practical application almost useless. The most common concern from dentists, who have historically used acrylic bites or have been taught that they are the most accurate, is that all other materials are softer and can be compressed during the process of articulating the models yielding an inaccurate articulation which has been the opposite of my experience. Articulating large cases is a process I don’t delegate because it is a very sensitive and crucial Figure 3: Cross section of a temporary crown which was made on a stone model, removed, step in the success of a case. finished to eliminate any external restrictions then glued onto the model it was made on with cyanoacrylate (super glue) and cross sectioned to demonstrate the effects of temporary crown shrinkage.
Temporization: With the current technology, it is impossible to make a temporary material that doesn’t shrink. Given this fact, there are some techniques that can be applied to help insure temporaries fit well and are accurate.
Let’s first look at the challenges shrinking temporary materials Figure 4: Abrasion marks on stone die from present. Temporary crowns are the shrunken temporary crown being placed on it before internal adjustments were made. fabricated directly on a prepared This same dilemma will cause a host of tooth, removed, finished, problems in the mouth. adjusted and cemented. The primary issue arises because the temporary is fabricated directly onto the prepped tooth, even the slightest shrinkage will result in a tight fitting temporary which cannot seat for the following reasons. • The temporary has gotten smaller creating a tight fit. • Any burr marks or under cuts on the prep will be replicated in the intaglio surface of a temporary and can be distorted when the crown is removed compounding the issue of a tight fitting temporary. • Temporary cement with an added film thickness which has not been compensated for is used inside the temporary crown. Tests conducted in our laboratory on stone models have demonstrated the effects of shrinkage of temporary crowns leaving them so tight that the margins (Continued on pg. 24)
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(Continued from pg. 23)
are open .1mm to .4mm when placed back on the stone die they were made on (Figure 3). The common method of fabricating a temporary crown has no compensation for the shrinkage of the crown or the film thickness of the temporary cement (Figure 4). The simple solution is to relieve the axial walls and the occlusal surface inside the temporary crown leaving the margins intact and sealed. The temporary crown should have a passive fit on the prep and not require force for the margins to seal. (Figures 5 and 6) Because temporary crowns are flexible, it is possible to have the patient bite on the temporary and force the crown, which is too small, down on the prep leading one to believe the temporary crown is properly seated even if the inside has not been relieved. However, doing this can expand the crown applying pressure on the adjacent teeth, orthodontically moving them which can result in open contacts with the final crowns. When finishing the contact areas of a temporary, it is important to remove any bulge or height of contour apical to the actual contact point on the proximal surfaces of the temporary so these areas will not apply pressure and movement to adjacent teeth resulting in open contacts on permanent crowns (Figure 7). If the proximal surface is not trimmed and smoothed well, flash can be sheared off during the seating process and lodged in the contact during cementation of the temporary crown, which can create a tight contact and orthodontically move the teeth creating an open contact with the permanent crown. Bridge temporaries are especially susceptible to the shrinkage of temporary materials, because one or more of the abutment teeth can be orthodontically moved toward the edentulous area. The most common internal adjustment made on permanent bridges is on the inside axial walls of the abutments next to the pontic, because the temporary bridges shrink in length (Figure 8). The simple and quick step of relieving the inside of each abutment of the temporary bridge until it seats without resistance can help solve the infuriating issue of “rocking bridges.” An easy way to determine if a rocking bridge is because the temporary shrunk and was too short is to look inside the abutments on the temporary. If there is burn through of the cement on the axial walls of the abutments furthest away from the pontic(s), you may have orthodontically moved one or more of the abutment teeth. The smallest prep usually loses the “shrinking temporary war.” There are also techniques that should be implemented in the laboratory that can also insure accurate fitting bridges, which I will detail in my future article entitled “The Push Me Pull You Bridge.” Temporary crowns that have not been internally
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Figure 5: A cross sectioned temporary crown which was not relieved internally. Note, the thick cement layer on the occlusal and margin areas and the burn through on the axial walls. This temporary was too small circumferentially to completely seat which is evidenced by the un-uniform thickness of the temporary cement.
Figure 6: This temporary crown was properly relieved before cementation demonstrated by theeven cement layer on the intaglio surface of the crown, allowing the margins to seat.
relieved and cemented on a prepared tooth can rebound. Have you ever wondered why a patient’s temporary crown can be high after leaving the dental office when everything was fine before they were dismissed? By nature, a temporary crown is flexible and when a patient bites on a flexible temporary crown that has been filled with temporary cement it will expand and many stay in place for a while. But some will rebound leaving the occlusion high requiring another office visit for adjustment. Taking the temporary out of occlusion may solve the immediate issue but can allow the prepared tooth or teeth to super-erupt creating a more significant occlusal adjustment issue when seating the permanent crown. Lab Fabrication of the Final Restoration: The fourth variable is what happens in the dental laboratory. It is generally accepted that if the crown fits the model, the lab has done their job. I agree with one caveat, the model must be an accurate model. There are many errors and omissions that can be made in the lab that will compromise the quality and accuracy of a model. I will cover the prominent ones by describing what you would see in the dental office and what the potential causes can be with the presumption of an accurate impression. Inconsistent marginal fit of crowns • Inconsistent water/powder ratio in the die stone and/or the basing stone • Not allowing the stone to set overnight before working up the model • Stone sealer too thick • Die trimmed wrong
Figure 7: The heights of contours on the proximal surfaces of this temporary crown are apical to the proximal contact. Bulges such as these can apply enough pressure on the adjacent teeth to orthodontically move them resulting in open contacts when the permanent crown is tried in.
• Casting investment expansion ratios wrong • Margin on metal frame polished off Inconsistent Proximal Contacts • Contact model made of plaster or different stone than models are made of • Powder/water ratio not consistent on model and/or bases on pinned models • Too heavy or light from lab
Figure 8: This temporary bridge was made on this model, trimmed externally, cemented backon the model with cyanoacrylate and cross sectioned. The effect of the bridge shrinkage is clearly evident where the axial walls of the abutments are binding against the outside walls of the preparations. This is a model of an actual case which resulted in a three unit PFM bridge having to be remade because the bicuspid prep was orthodontically tipped distally creating a rock in the permanent bridge.
About the Author Dave Andrus, CDT has been a technician for 36 years with a broad background in the dental laboratory arena as well as the operatory. Dave has served on the editorial board of the National Association of Dental Laboratories for their Journal of Dental Technology; a peer reviewed publication, is a past president of the Colorado Dental Lab, for the past 30 years and has owned Diamond Dental Studio, a five person lab, for 28 years; along with Andrus Technologies, a research and development company and is dedicated to the advancement of the dental industry as a whole.
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Be sure to check out the RMDC HANDS-ON COURSES being held at the:
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APRIL 2015 April 3 Straightforward Ultrasonic Debridement – Ms. Cynthia Fong & HANDS-ON A Simplified Approach to Ultrasonic Instrumentation – Ms. Cynthia Fong Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 Lecture course: 9:00am – 1:00pm Hands-on course: 2:00pm – 4:00pm (303) 488-9700
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April 11 HANDS-ON Adhesive Dentistry and Direct Composites Made Easy – Drs. Gerard Krugel & Chad Anderson Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 9:00am - 4:00pm (303) 488-9700 April 12 MDDS Afternoon with the Rockies Coors Field 2001 Blake Street Denver, CO 80205 2:10pm - 5:10pm (303) 488-9700 April 16 Feed the Foundation Chinook Tavern 6380 South Fiddlers Green Circle Greenwood Village, CO 80111 6:00pm - 9:00pm (303) 957-3272 April 22 CPR & AED Training Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 6:00pm - 9:00pm (303) 488-9700
MAY 2015 May 2 HANDS-ON Exdontia Techniques – Dr. John Alonge Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 8:30am - 4:30pm (303) 488-9700 May 8 Oral Pathology & Biopsies – Col. Theresa Gonzales Mountain West Dental Institute 925 Lincoln Street, Unit B Denver, CO 80203 9:00am - 4:00pm (303) 488-9700 May 30 MDDS Annual Spring Family Friendly Event Lowry Beer Garden/Wings Over the Rockies 7577 E Academy Blvd, Denver, CO 80230 11:00 am - 1:00 pm (303) 488-9700
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REGULATORY
OSHA REQUIREMENTS FOR THE DENTAL OFFICE
By Karson Carpenter, DDS
A
small business such as a dental office has a
in the workplace. In dentistry, these include disinfectants, restorative
multitude of legal requirements that must
materials, acids, cleaners, impression materials, etc. This Standard requires a
be met. While they all are important, none
written chemical safety plan, material safety data sheets for each hazardous
is more important than OSHA compliance,
chemical/product, labeling of these potentially hazardous products and
because it not only makes your facility safer for
training of employees who are exposed to them.
all who work there, but eliminates your exposure to costly and embarrassing fines.
There is often considerable misunderstanding as to what OSHA regulates and many confuse OSHA requirements with infection control recommendations. OSHA, in fact, is concerned with only one thing--the safety of employees. OSHA, which is an acronym for the Occupational
OSHA has recently adopted the Globally Harmonized System (GHS) for chemical safety. It takes an international approach to hazard communication, and will be phased in over the next two years in the United States. Present requirements are that all employees must be immediately trained on this new regulation.
Safety and Health Administration, was formed through an act of Congress
Bloodborne Disease Pathogens Standard
and its requirements are federal law. OSHA does not care if the hazard is
Because dental office employees are exposed to blood and saliva every day,
from a chemical, a bloodborne pathogen, an electrical device or a fire. The
this Standard is an extremely important one. Requirements include having
only concern it has is the protection/safety of the worker, and this includes
a written Exposure Control Plan, providing the Hepatitis B immunization
all employees in the dental profession.
at no cost to exposed employees, and making available personal protective
To begin your compliance efforts, choose someone to be your Compliance Director. A trusted and organized dental assistant, hygienist or officer manager is suggested; by having an accountable individual, progress can quickly be made. Next, assign your Compliance Director to review and implement one step at a time, using the following outline: Hazard Communication Standard
equipment (mask, gloves, safety eyewear, long-sleeved protective clothing). In addition, employees must have inter-departmental meetings at least annually to consider safer medical devices. As with all OSHA regulations, training is paramount. Employees must understand the modes of transmission for bloodborne diseases such as Hepatitis B, Hepatitis C and HIV. They must also know what to do in the event of a needle stick or other exposure incident and have access to proper follow-up medical care.
The Hazard Communication Standard deals with hazardous chemicals
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mddsdentist.com
(Continued on pg. 30)
Articulator
Spring 2015
Take 5 and Make Colorado Healthier! It’s our profession’s time to shine! Enroll as a Medicaid provider and Take 5 new patients or families today. For the first time, adults are now covered by Medicaid in Colorado. This means that an estimated 300,000 Colorado adults will be seeking dental treatment. They need you – and in fact their well being depends on it. Make a pledge to Take 5. Join your colleagues and make a commitment to address the needs of those served by Medicaid. On July 1, the full benefit for the Colorado Medicaid Dental Program will be available to patients and includes a $1,000 annual benefit, in addition to a full denture benefit. DentaQuest will administer the Colorado Medicaid Dental Program, and will provide regional field representatives to personally assist dentists, help with Medicaid enrollment, and educate your staff on best practices for efficient billing and patient management. DentaQuest administers dental benefits in 28 states. Visit cdaonline.org/Take5 and join the list of CDA members committed to caring for the new population of patients in Colorado. Questions? Call the CDA at 303-740-6900 or 800-343-3010. 29
(Continued from pg. 28)
Electrical Safety
Medical and First Aid
Electricity is such a normal part of everyday life that is often overlooked as being
This part of the OSHA regulation does NOT dictate what type of medical
potentially dangerous. Everyone has experienced a minor shock, but may fail to
drugs and/or equipment you have in place for patient medical emergencies, as
realize that severe shocks can cause death. Dental facilities make considerable
is often thought. Remember that OSHA regulations are only concerned with
use of electrical devices including autoclaves, instrument washers, ultrasonic
employee safety. The requirements include having medical personnel available
cleaners, model trimmers, lathes and curing lights, as well as a host of others. It is
to provide emergency care if needed or to have an employee(s) trained in first
important that no extension cords be used, that plugs and cords are checked for
aid available during working hours. A first aid kit should be available for self-aid
wear/ intact insulation and that plugs match their outlets (e.g. three-pronged).
as well as CPR microshields or other barrier devices to use when performing
In addition, cords should not be twisted around each other, but should run in
resuscitation. Remember to have emergency numbers posted on the phone and
parallel, and circuits/outlets must not be overloaded.
to have an eyewash station installed for flushing of the eyes.
Ionizing Radiation
Fire Safety
OSHA regulations require an employer to evaluate their facility for any
OSHA requires fire safety training. This training must include reviewing a list of
potential radiation hazard and provide employees with the appropriate training
all flammables in the workplace and their possible ignition sources. Employees
and monitoring equipment. The only source of ionizing radiation in a dental
must also know what their responsibilities are in the event of fire and the location
office is radiographic equipment. While some states require the wearing of
of a safe meeting place after evacuation. Having an accessible fire extinguisher
radiation badges by dental workers, others do not. It is recommended though,
and training employees on its proper use is also required.
that workers who take radiographs (assistants and hygienists) wear monitoring badges, since there is no such thing as a totally safe dose of ionizing radiation.
Recordkeeping
Means of Egress
include employee medical records, records of training, environmental
Every building is required by law to contain adequate exits that allow for
monitoring records (results of nitrous oxide and radiation testing) and material
escape of all occupants in case of fire or other emergency. There must be at
safety data sheets archiving. Employees have a right to access these records and
least two of these means of egress in every building. Exits must have no locks
they must be allowed to do so within 15 days of their request.
or fastening devices that may prevent free escape and must be clearly visible and conspicuously marked with illuminated or glow-in-the-dark signs. Non exits need to have similar signs that state “Not an Exit.” In the event of power failure,
As in so many other areas, proper recordkeeping is mandatory. Requirements
Summary OSHA requirements for dental offices are nothing more than a safety program
reliable emergency lighting must also be available for all exits and signs.
for its employees. By appointing a Compliance Director and making him/her
Walking and Working Surfaces
advisable to consider a commercially prepared program to guide them through
This part of the OSHA regulation is often called the housekeeping standard.
the process.
It requires all rooms and passageways to be kept clean, orderly and sanitary. All aisles and hallways must be kept free of debris/clutter and floors must be kept clean and dry. Additionally, stairways must have railings/guardrails and any ladders used must be OSHA approved. Ventilation Ventilation in the dental office is very important, as a variety of potentially hazardous substances can become airborne and cause illness or injury. To
accountable, rapid progress can be made. If their time is limited, it may be
About the Author Dr. Karson Carpenter is a graduate of the University of Michigan School of Dentistry and has been practicing dentistry since 1982. He is a member of numerous professional organizations, including the American Dental Association and the Michigan Dental Association.
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Spring 2015
Presented by Ms. Cynthia Fong, RDH, MS ATTENTION STRAIGHTFORWARD HYGIENISTS
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Articulator
Spring 2015
31
PATHOLOGYPUZZLER WITH DR. JOHN SVIRSKY (from pg. 14)
Looking at the clinical photograph, I felt that it was a 1.0 cm by 0.8 cm lesion with a verrucous/papillary appearance. Based on the clinical picture, I thought all but the papilloma and the verrucous carcinoma could be excluded. A fibroma would have a smooth surface texture and be of normal mucosal color unless being chewed (then the surface of the fibroma may have white areas). Fibromas are normally hyperplasia secondary to trauma rather than a true tumor. A lipoma, like the fibroma, would have a smooth surface texture and be normal mucosa color if deeper and a yellowish coloration if superficial. They are far less common orally than fibromas. A papilloma would have this surface texture but normally do not reach this size. Now with the association of oral cancer and human papilloma virus, the “fear index “ of a clinical diagnosis of papilloma has gone up. However one papilloma does not HPV make. A number of patients are undergoing HPV saliva testing, but I am not in favor of this. The percentage of the population that is HPV positive is high compared to the small number of people with HPV related oral cancers. Saliva tests give patients a reason to worry about an outcome that is impossible to predict. I feel the same way about whole body scans to find occult lesions. More unnecessary surgery will be done to find things that will never be a problem.
Verrucous carcinomas are the lesions most closely associated with human papilloma virus type 16. This lesion is typically found in men with an average age of 65-70. A lesion of this size should have an excellent prognosis since it was diagnosed early and was only a centimeter in its greatest dimension. This case was submitted by Dr. Stanley Kayes, a general dentist in private practice in Haymarket, Virginia.
Figure3: Histologic picture showing parakeratin clefting
A peripheral giant cell granuloma (PGCG) would not be considered since this lesion only occurs on tissue that is on or near the gingiva. Also the surface of a PGCG could be ulcerated but not papillary. A pyogenic granuloma has the same clinical appearance as a PGCG but can occur anywhere. New lesions are vascular (granulation tissue) with surface ulceration and as they mature they become the color of normal mucosa (more fibrous). They actually become a fibroma when fibrosed. A traumatic ulceration is usually flat and at times has a hyperkeratotic “collar”. They would not have a papillary surface texture. The ulcer has a brown, necrotic appearance. The lesion turned out to be a verrucous carcinoma (VC) (Figures 3&4) which in reality is an exophytic squamous cell carcinoma. This lesion appears to be an early VC since it is small, well circumscribed and has a verrucous/pebbly surface appearance.
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mddsdentist.com
Figure 4: Histologic picture showing a broad rete ridge with dysplastic changes
Articulator
Spring 2015
FINANCE MANAGEMENT
THE DENTIST’S BUSINESS PLAN AND PERSONAL FINANCIAL PLAN MUST COINCIDE By Edward Leone Jr, DMD, MBA, RFC
D
r. Jones has been operating his newly purchased
$1000 permitted), no loan provisions permitted, distributions prior to age
general dental practice for close to a year at
59 1/2 will incur a 10% penalty plus taxation at ordinary income marginal
this time. He still has much to do regarding the
rate, a distributions under some conditions will avoid the 10% penalty on
completion and monitoring of his business plan
the amount withdrawn, phase out for deduction of contributions made by
and his personal financial plan for that matter. However, he
married couples filing a joint federal tax return with a partner covered by a
is currently faced with a decision which will impact both
work place qualified plan occurs at AGI between $183,000 to $193,000.
planning modules at this time. The issue is retirement planning. Clearly the earlier one starts, the more likely it is that an effective plan will evolve. Not
Simple IRA
only that, the opportunity to mitigate some of Dr. Jones’s income tax burden
Many regulations are similar to the Traditional IRA regarding early
is an important motivator at this time.
Retirement planning for a dental practice has impact on the dentist, practice employees and their families. Employee retention and wealth building for the dentist owner are key considerations in a plan design. Let’s consider the choices available in the qualified plan menu since the tax savings implications on contributions and earnings are important factors for Dr. Jones and his staff. These retirement savings plan options are regulated under ERISA and IRS rules. Traditional IRA Annual Contribution permitted for 2015 $5,500 or 100% of compensation
distributions. Maximum contribution by employee is $12,000 with a potential for employer match of up to 3% of compensation which is optional or a straight 2% of compensation which is mandatory and not to exceed $16,000 combined. 401K Employee contributions to a 401K for 2015 are set at a maximum of $18,000 or 25% of compensation. The catch up for those over the age of 50 is $6,000. The employer may make a contribution in the form of a % of compensation match, but this is discretionary from year to year. Loan provisions are not permitted but hardship distributions may be accomplished.
up to that amount (catch up contribution for those over the age of 50
mddsdentist.com
Articulator
Spring 2015
33
CLASSIFIEDS Job Board Looking for a dental hygienist with skills that are above and beyond to help grow your practice? At the Community College of Denver, our graduates are well-versed in patient education, radiology, and complex patients with extensive periodontal needs. We are also providing our hygienists with advanced skills in salivary testing, laser pocket decontamination, and adjunctive oral cancer screening tools to add additional services to your office. We maintain a comprehensive list of current and former graduates that are seeking both full-time and part-time positions, and would love to help match your practice with a hygienist that will fit your needs. Please feel free to contact us at anytime to discuss - Michelle.Kohler@ccd.edu, 303-365-8334, Interim Director of Dental Hygiene, Community College of Denver.
Ortho Practice for Sale with CTC Associates: New, beautiful, high tech, spacious Orthodontic practice for sale in Colorado Springs. This practice offers private consultation room, large imaging room, 5 operatories, digital imaging and paperless charts, with plenty of room to expand. Contact Marie Chatterley with CTC Associates at (303)249-0611 or marie@ctc-associates.com. ADS Precise practices for sale: Colorado & Wyoming including Denver, Boulder, Cheyenne, Cody, Casper, Westminster, Arvada, Englewood, Aurora, Lakewood, Littleton, Parker, Greenwood Village, Ft. Collins, Colorado Springs & South, Mountains and Western Slope. For detailed information on practices for sale visit www.adsprecise.com or call Jed Esposito MBA, CVA or Peter Mirabito DDS, FAGD at 888-886-6790. We specialize in Practice Sales, Practice Appraisals, and Partnerships.
Real Estate
Announcements & Services
General Practices for Sale with CTC Associates: Practice listings along the Front Range in Denver, Arvada, Lakewood, Littleton, Castle Rock, Colorado Springs, and Fort Collins. Additional opportunities available in Montrose and throughout the eastern mountains. We also have opportunities in New Mexico, Utah, Idaho, Wyoming and Hawaii. For a summary of each current practice opportunity, go to www.ctc-associates. com or call Larry Chatterley and Susannah Hazelrigg at (303)795-8800.
Transition Services with CTC Associates: For more information on how to sell your practice or bring in an associate, or for information on buying a practice or associating before a buy-in or buy-out please contact Larry Chatterley and Susannah Hazelrigg at (303)795-8800 or visit our website for practice transition information and current practice opportunities www.ctc-associates.com.
Visit mddsdentist.com/classifieds to place an ad.
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