AGD Impact
MEDICAL-DENTAL SYSTEMS INTEROPERABILITY
THE NEXT CRITICAL STEP TO IMPROVING COLLABORATION AND UNDERSTANDING
The Great Tax Battle of 2025 Prepare for a DEA Inspection
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Contents MEDICAL-DENTAL SYSTEMS INTEROPERABILITY THE NEXT CRITICAL STEP TO IMPROVING COLLABORATION
AND UNDERSTANDING
By Mark W. Jurkovich, DDS, MBA, MHI, MAGD
Tools that help healthcare clinicians sort through information are valuable and perhaps essential from an efficiency standpoint. Currently, physicians have tools that use various types of artificial intelligence that assist electronic health record systems in summarizing information, allowing physicians to have a more cohesive picture of patients. This is not common in the dental field at this time, but it is rapidly growing in medicine. How can dentistry take steps to make the profession part of the interoperability conversation? Self-Instruction article, 1 CE credit
How Will the Great Tax Battle
of 2025 Impact You?
By Wesley W. Lyon II, CPA, CFP®
Tax legislation promises to be a major focus next year because many individual tax provisions from the Tax Cuts and Jobs Act are set to expire Dec. 31, 2025, automatically raising income taxes for most taxpayers. The expiration of the act will force both political parties to negotiate or face backlash from the general public, as neither side plans to increase taxes on the middle class.
Gas or Electric?
Being from Detroit, I find it is easy to compare the auto industry to decisions in our dental practices. We always have many choices in life, from what we purchase to what we envision our future to be to how we live our lives. If you’re in the market for a car, you have the choice between purchasing one of the new electric cars or going with a gas model. My dear friend, AGD President-elect Chethan Chetty, DDS, MAGD, often refers to the pleasures of his Tesla, driving hands free as he entertains Zoom meetings.
There are pros and cons to both types of vehicles. High performance gas engines have been the mainstream in autos for over a hundred years. Electric vehicles have gained popularity in recent times. Both vehicles get you to the same place, sometimes a bit faster and sometimes slower. With gas, we have a concern for fuel costs, but electric vehicles take time to recharge over long trips. Depending on your circumstances, the decision of what to purchase is based on personality, political views, climate concerns and identifiable needs.
The same holds true for the type of dental practice you choose to purchase or create. There is no one-size-fits-all solution, and your individual situation dictates the choices that are right for you. Obviously, cost is one of the great influencing factors. Electric cars are the most expensive option now because there aren’t a lot of used options. With a used gas vehicle, you may pay less upfront, but you’ll be paying for fuel for the lifetime of the car. In dentistry, some young dentists’ finances may make it feasible to start a new practice right away. Some may look into purchasing a practice shortly after dental school. For others, it might make the most financial sense to work a while as associates.
Once you make your decision, you aren’t locked in. With cars, you can always upgrade the sound system, get a new coat of paint or add a security system. In dentistry, you can be happy with a basic armamentarium, or you can upgrade your practice with any of the latest amazing
technologies, such as in-house milling, CAD/CAM or a CBCT machine. And, if you’re ultimately unhappy with your car, you can always sell it, although you’ll probably take a hit because every car depreciates in value. At least dentists don’t have to worry about their business depreciating. When it is time to move on, there are many options available to a business owner, including selling outright or over time.
In both car buying and dentistry, knowing yourself is part of the process, but so is gathering information. Car buyers should know what a fair price is for the car they want. Dentists should be well versed in the latest procedures so that they can take advantage of all the latest wonderful technology and give their patients the best care. As always, our AGD is here to help with that. Continuous professional growth will help you achieve goals and navigate the path to your destination.
I like to tell my patients that what is most important in their treatment is a positive final result. The process may be challenging at times, but the goal is to arrive with comfort and happiness. It doesn’t really matter what type of car you drive — they all get us to the same place eventually. And it doesn’t matter what kind of practice you own as long as you and your patients are satisfied. The way you finally arrive is indicative of your own desires and fulfillment.
Personally, I want to wake up each morning to a life full of meaning. The knowledge I’ve gained over the course of my career has informed the knowledge of myself, and vice versa. I’ve found a balance that works for me and that allows me to enjoy work and life to the fullest. I encourage you to do the same — and enjoy the ride.
Timothy F. Kosinski, DDS, MAGD Editor
Editor
Timothy F. Kosinski, DDS, MAGD
Associate Editor
Bruce L. Cassis, DDS, MAGD
Director, Communications
Kristin S. Gover, CAE
Executive Editor
Tiffany Nicole Slade, MFA
Managing Editor Leland Humbertson, MA
Associate Editor
Caitlin Davis
Manager, Production/Design Tim Henney
Graphic Designers
Robert Ajami Eric Grawe
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Dental Practice Advocacy
AGD Representatives Named to ADA Ad Hoc Working Groups
AGD President Merlin P. Ohmer, DDS, MAGD, appointed the following AGD members as official AGD representatives to two ad hoc working groups of the American Dental Association’s Code Maintenance Committee (CMC):
• Brooke Elmore, DDS, MAGD, a member of AGD’s Dental Practice Council (DPC), and Guy E. Acheson, DDS, MAGD, a consultant to the DPC on matters relating to anesthesia, were both appointed to the CMC Ad Hoc Working Group on Anesthesia Codes. This group will focus on anesthesia codes
and prepare recommendations on issues raised by certain CDT Code action requests tabled during the CMC’s March 2024 meeting.
• Arlene O’Brien, DMD, FAGD, also a member of the DPC, was appointed to the CMC Ad Hoc Working Group on CDT Granularity. This group will focus on the industry’s needs and the impact of expanding the granularity of CDT Codes and prepare recommendations on several action requests that were tabled during the CMC’s March 2024 meeting.
AGD Attends Annual Conference of the Association for Dental Safety
By Cindy Kluck-Nygren, Manager, AGD Dental Practice
The Association for Dental Safety (ADS), previously known as the Organization for Safety, Asepsis and Prevention (OSAP), held its annual conference in Tucson, Arizona, May 29–June 2, 2024. Close to 400 individuals attended the meeting and represented multiple industries, including professional dental associations, federal regulatory agencies, dental manufacturing companies and leading consultants in the field of dental safety. Other attendees included dental professionals from private practice, public health and the military.
Darren S. Greenwell, DMD, MAGD, chair of AGD’s Dental Practice Council, was AGD’s primary representative at the meeting. “Attending this conference ensures AGD reaffirms its position as the leading advocate for general dentists within organized dentistry,” said Greenwell. “As the only professional association that exclusively represents the interests of general dentists, AGD is deeply committed to being at the table at meetings that have the potential to impact operations within the dental practice. Our involvement with ADS is especially important since it allows AGD to be among the communities of interest invited to participate in listening sessions convened to provide certain federal agencies with input to be used in updating their guidelines.”
This year’s ADS Annual Conference featured presentations from key opinion leaders who discussed dental infection prevention, occupational health, patient safety and more.
“AGD’s involvement in ADS is important since it ensures that general dentists’ points of view are represented not just during the conference, but throughout the year,” said Greenwell. “Our engagement with different members of the broader dental community, including ADS, is one of the most effective ways for AGD to advocate on behalf of its members.”
This year’s session marked the 40th anniversary of ADS, which is the only dental membership association for oral healthcare professionals that focuses exclusively on dental infection prevention and patient and provider safety. A key announcement during the meeting was the unveiling of the organization’s new name.
In a recent press release, ADS Executive Director Michelle Lee, CPC, commented that the “decision to rebrand to ADS represents an exciting milestone in our 40-year journey as an organization.” After careful consideration, OSAP “refresh(ed) its brand identity to
reflect better its values, vision and commitment to our members and stakeholders. The new name, Association for Dental Safety, encapsulates the essence of our organization’s mission and aspirations for the future.” The organization remains committed to maintaining its position as an infection prevention and safety leader within the dental community and to maintaining its organizational pillars of patient and provider safety, science-based learning, integrity, competent community and collaborative leadership.
The 2025 ADS Annual Conference will take place May 29–31 in Orlando, Florida. Visit myads.org for more information about the organization.
Advocacy
AGD Hill Day 2024: Advocating for Oral Health Legislation
By Sheida Takmil, DDS
As a general dentist working at Open Door Family Medical Center, a federally qualified health center in Westchester County, New York, I felt privileged to participate in AGD’s Hill Day this past May. Held in Washington, D.C., this event provided a crucial opportunity for the dental community to engage with policymakers and advocate for key oral health legislation. Drawing on my firsthand experience serving a diversely underserved population, I recognized the importance of the proposals discussed during Hill Day as they directly impact the health outcomes and access to care for my patients. The last time I was in Washington, D.C., was as a child sightseeing the historic monuments, so I was a bit anxious to return in such a different context. Thankfully, I knew my CEO, Lindsay Farrell, had met with many policymakers in the past, including Rep. Mike Lawler, whose staff I’d be meeting with. Before taking off, I sought advice from Farrell on how to highlight our organization in the context of the proposed legislation so as to garner bipartisan support. After landing, I learned a wealth of knowledge during the event itself, which was moderated by AGD President Merlin P. Ohmer, DDS, MAGD. We received a variety of lectures: Adam Barefoot, DMD, MPH, spoke on his role as chief dental officer of the Health Resources and Services Administration (HRSA); Natalia I. Chalmers, DDS, MHSc, PhD, chief dental officer of the Centers for Medicare & Medicaid Services, discussed Medicaid coverages; and Richard A. Huot, DDS, FAGD, emphasized the importance of advocacy. These speakers — as well as other AGD leaders and D.C. staffers — helped us prepare for our meetings with House and Senate representatives, in which we discussed the following bills:
Oral Health Literacy Act (H.R. 994/S. 403): This legislation seeks to enhance oral health education and literacy programs nationwide, empowering individuals to make informed decisions about their oral healthcare. This bill would authorize $750,000 per year over a five-year period for HRSA to establish an evidencebased education campaign to promote oral health literacy among vulnerable populations.
Dental and Optometric Care (DOC) Access Act (H.R. 1385/ S. 1424): This act aims to improve access to dental care, particularly for underserved populations, by expanding the scope of practice for dental professionals and enhancing reimbursement mechanisms for dental services. This legislation would prohibit dental insurance plans from setting the fees contracted doctors may charge for services not covered by the insurers.
Action for Dental Health Act (H.R. 3843/S. 2891): This legislation would reauthorize critical state grants to support dental health workforce initiatives in areas with dental health provider shortages through fiscal year 2028. Such initiatives include loan forgiveness and repayment programs, continuing education, and the establishment of new residency programs, to name a few.
Hill Day was a resounding success, with policymakers expressing receptiveness to the issues raised on behalf of general dentists nationwide. AGD will continue to advocate for the passage of these bills by mobilizing its membership and fostering partnerships to advance the cause of oral health nationwide. Hill Day served as a pivotal moment
for the dental community to amplify its voice and champion critical oral health legislation on Capitol Hill. By advocating for these bills, AGD reaffirmed its commitment to improving oral health outcomes and ensuring access to quality dental care for all.
This article originally appeared in the Fall 2024 issue of GP: The Journal of the New York State Academy of General Dentistry and is reprinted with permission.
Dental Practice Advocacy Survey Results: AGD Members’ Use of AI/AuI in the Dental Practice
By Cindy Kluck-Nygren, Manager, AGD Dental Practice
A 2023 AGD survey provides valuable baseline data regarding AGD members’ use of artificial intelligence/augmented intelligence (AI/AuI) in their dental practices. Survey respondents’ primary reasons for incorporating AI/AuI into their practices involved increased accuracy of diagnoses, enhanced patient education, higher case acceptance of treatment plans, and greater efficiency for both the dentist and staff.
In 2023, AGD’s House of Delegates adopted a statement on “Artificial Intelligence in Dentistry” that was developed by a Dental Practice Council subcommittee. AGD’s statement as well as the full 2023 survey results are available at agd.org/advocacy/ agd-priorities/agd-policies.
AGD President Merlin P. Ohmer, DDS, MAGD, presents the 2024 Legislator of the Year Award to Sen. Susan M. Collins.
My Rookie Year
By Clayton Sorrells, DDS
One day, you’re freaking out because you’re learning to do a Class I cavity prep, you keep burning the plastic tooth, and you have no idea how to move your hand while looking in a mirror. The next day, you are a full-blown dentist and have owned a practice for a year. The first year of practice ownership has been nothing short of incredible. I firmly believe I have the best staff and group of mentors. I have learned a lot about business, teeth and people in the first year of ownership, and my hope is that the things I have learned will help those who find themselves in a similar position.
Let’s start with something hard for me to say: I am not special. I say this because I am not the most outstanding dentist or practice owner. I still have a lot to learn, and my first year of practice was not perfect. I also say this because, if I can do it, you can, too. When I graduated, I met with the previous owner of the practice, Dr. Plyler, and he said, “If you show up, do the work and treat your patients well, your practice will be successful.” So, what did I do? Exactly that. I worked my butt off and challenged myself every day. I stayed late many days to learn just a little more about teeth or business. I reached out to people when I didn’t know the answer, and I wasn’t afraid to ask for help. Whether you are an owner or an associate, you need to do the same when you are a newly graduated dentist — show up, do the work and treat your patients well.
I learned that dentistry can seem isolating. When you are the solo dentist, a complex case can walk in the door at any time. And the most challenging statement that patient can make is: “Well, it’s up to you, doc — I trust you.” Well, that’s great, but I don’t know exactly what to do! When this happens, don’t be afraid to “do a hygiene check.” By this, I mean step into your office and call one of your mentors and friends. Dentistry is hard, and every patient and case is different. As a one-year dentist, I have not seen everything and do not know everything, but I know plenty of people who know a lot more than me.
My next piece of advice is to be kind to yourself. This statement means different things to different people. For me, being kind to myself means turning the computers on at the office on Sunday night, having my Keurig pod ready to go and laying my clothes out for Monday morning. These three simple things instantly put me in a good mood on Monday. If I receive a text message that says, “Dr. Sorrells, the hygienist is sick,” it’s OK. Why? Because the computers are on, my coffee is ready to go, and I know what I’m wearing. You need to find out what being kind to yourself means — the earlier, the better. You should play golf on your day off, do yoga, get your nails done or whatever takes the stress of the week off you.
If you have ever heard, “Don’t bring your work home with you” and thought, “You’re right. I will never do that,” then you’ve never been a small business owner. I have gotten much better at leaving my work at work, but, in the first six months, my wife knew how to run a dental practice just from how much I talked about it. If this is you, do not beat yourself up about it. Emily understood that this was a current, temporary scenario, and she knew (well, threatened) that it was not a forever scenario.
What did I accomplish in my first year? What I am most proud of — and you might roll your eyes — is that I made many people laugh. People are terrified of the dentist, so if you can make their visit not so terrifying, why wouldn’t you? Now, I did not make everyone happy. I could tell some people did not entirely trust me because I was a young dentist, which was OK. If you know the treatment you are presenting to the patient is the best possible, do not lose any sleep. Some people will inherently not trust you because you are young, and that is on them. We also modernized the practice by adding an intraoral scanner and text reminders. We changed practice management software and the way we submit insurance claims. We added financing options to offer more dentistry to more people. We bought a lot of new equipment to make things more efficient. I say “we” because this was a group effort. I would not have survived without my staff, mentors, friends and family.
This first year of ownership was fueled by many of the people I spoke with while in dental school about buying a practice who said, “Hmm. I probably wouldn’t do that. I would look at being an associate first.” It was not easy, but I give so much credit to Dr. Plyler and his wife, Julie, for setting me up for success. I was reflecting on my first year yesterday, and this adage came to mind: “If they tell you that you can’t, it’s probably because they can’t.” ♦
Clayton Sorrells, DDS, is a new dentist and previous AGD chapter president at Louisiana State University School of Dentistry. To comment on this article, email impact@agd.org
Creating a Transgender- and Nonbinary-Inclusive Dental Office Through Cultural Competence
By Drew Smith, DDS, MS, MA
This column is a collaboration between AGD and the American College of Dentists.
Transgender and gender nonbinary (TGNB) people often face barriers to healthcare, and many feel alienated and misunderstood in healthcare settings, including the dental office.1,2 As dentists, we have a responsibility to treat all people equally and with dignity and respect, regardless of their gender identity. While most dentists recognize the societal disadvantages TGNB people face, we have limited knowledge of gender nonconformance and its impact on the oral health of the TGNB population. As healthcare professionals, we must become aware of the barriers to care this population faces and create an inclusive dental environment by developing cultural competency in the delivery of care to TGNB patients.3
About the TGNB Population
Currently, over 1.6 million adults and youth (ages 13 and older) identify as gender nonconforming in the United States.4 TGNB people identify with a gender different from their biological sex. Understanding TGNB people begins with comprehending that biological sex and gender identity are separate constructs. Sex is based on anatomy and biology, while gender is both psychological and social and is the sense one has of being male, female or gender nonconforming.5,6,7 Most people identify as cisgender — that is, their gender matches their biologic sex — while TGNB individuals identify as a gender that does not match their sex assigned at birth. Gender identity is a person’s internal experience of gender, or “who you know yourself to be,” and develops over time. Non-cisgender identities include a broad spectrum, including transgender, nonbi-
nary, gender neutral, agender, pangender, genderqueer, two spirit and third gender, along with a combination of any of these categories.8,9 TGNB individuals face disproportionate levels of discrimination and violence, including elevated incidences of job loss, eviction, bullying, physical and sexual assault, homelessness, incarceration, familial rejection, depression, suicidality and denial of medical service. They are also subject to increased prevalence of substance abuse, alcohol misuse, tobacco use and high-risk sexual behavior, often stemming from the discrimination, stigmatization and transphobia they face.2,3
TGNB Oral Health Issues
From an oral health perspective, heightened stress levels, risky sexually behaviors and hormone therapy all contribute to increased susceptibility to certain oral health concerns for TGNB people. Stress, often related to the discrimination TGNB people face, increases cellular inflammation, which may contribute to periodontal disease, bruxism, temporomandibular disorders and myofascial pain, and aphthous stomatitis.6 Risky sexual behaviors increase the incidence of sexually transmitted infections such as human immunodeficiency virus, human papillomavirus, and herpes simplex virus types 1 and 2, which often have oral manifestations.6 Hormone therapy may affect the periodontal condition through tissue inflammation and changes in bone density.10
While many TGNB people face significant risk factors that predispose them to oral disease, they often face social and structural
barriers to oral healthcare, including educational, income and employment disparities.3,11 Another barrier is related to a lack of healthcare providers, such as dentists, who are sensitive to transgender health issues, including mental health, trauma histories and health concerns specific to this population.12 Oral healthcare providers are often unaware of their health needs, and many dentists are unprepared and/or uncomfortable treating TGNB patients. Many TGNB patients also report being treated poorly due to discriminatory attitudes and may delay seeking care due to fear of discrimination.2,13 One study reports that 71% of TGNB people experienced at least one instance of healthcare mistreatment, including insensitivity and awkward interactions, verbal abuse, substandard care, and refusal of care.14
Improving TGNB Oral Healthcare Through Cultural Competence
Traditionally, TGNB health issues have not been incorporated into dental school curricula, and it is likely that most dentists have very little education regarding the specific needs of this population.3 This creates a situation where TGNB patients are often required to teach their dentists about their health needs, leading to frustration and anxiety over their care.9 In order to increase access to oral healthcare and improve oral health outcomes for TGNB patients, dentists must become culturally competent in TGNB identity and health issues.8,15 Cultural competence can be defined as the integration of knowledge, skills, attitudes and behaviors that improve cross-cultural communication and interpersonal relationships. 11 Originally used in the context of race and ethnicity, the concept can be extended to sexual orientation and gender identity and is a process of continuous learning. Becoming culturally competent in treating transgender people is not as difficult as one may suspect, as the actual dental care remains the same. It is the chairside and front office interactions that can often be improved upon. Dentists must improve upon their knowledge of transgender identity and health issues to ensure an inclusive, understanding and welcoming environment.
Becoming Culturally Competent
Two general themes to consider on the pathway to becoming culturally competent include improving one’s knowledge regarding TGNB health and identity issues and improving one’s attitudes and behaviors toward TGNB people.8 By learning about transgender health and identity issues, dentists will relieve the burden on transgender patients, who often find themselves in the uncomfortable position of educating their healthcare provider. Dentists must also engage in self-reflection regarding our own attitudes and behaviors in order to ensure a welcoming environment for TGNB people. Understanding and accepting how patients self-identify will minimize the fear of discrimination TGNB people routinely experience in healthcare settings and is critical in reducing barriers to care while improving oral health outcomes.
Dentists have a duty to provide respectful care in a nonbiased manner to all patients. It is imperative that we recognize the need to become culturally competent in gender identity issues to ensure equitable oral healthcare for TGNB people. ♦
Strategies for Providing Culturally Competent Care
5,8,13
1. Engage in self-reflection of your values, attitudes and beliefs.
2. Educate yourself and your staff on TGNB health and identity issues. There are many good resources on the web, including hrc.org/resources/ transgender-and-non-binary-faq
3. Modify intake forms to include legal and preferred names, sex at birth, gender identity and preferred pronouns.
4. Ask TGNB people how they prefer to be addressed.
5. Ensure private spaces are available to discuss gender identity and health issues.
6. Avoid assumptions regarding gender identity and sexual orientation.
7. Identify your office as LGBTQ+ friendly with symbols of inclusion and by participating in the Gay and Lesbian Medical Association online directory (glma.org).
Drew Smith, DDS, MS, MA, is an orthodontist in London, Ontario, Canada, and serves as an adjunct clinical professor at the Schulich School of Medicine and Dentistry, Western University. He is a member of the American Society for Dental Ethics. To comment on this article, email impact@agd.org
References
1. Reeves, Karli, et al. “Provider Cultural Competence and Humility in Healthcare Interactions with Transgender and Nonbinary Young Adults.” Journal of Nursing Scholarship, vol. 56, no. 1, 2024, pp. 18-30.
2. Raisin, Joshua A., et al. “Barriers to Oral Health Care for Transgender and Gender Nonbinary Populations.” Journal of the American Dental Association, vol. 154, no. 5, 2023, pp. 384–392.
3. Tamrat, Jessica. “‘Trans-forming’ Dental Practice Norms: Exploring Transgender Identity and Oral Health Implications.” Canadian Journal of Dental Hygiene, vol. 56, no. 3, 2022, pp. 131–139.
4. Herman, Jody L., et al. How Many Adults and Youth Identify as Transgender in the United States? The Williams Institute, University of California, Los Angeles, School of Law, 2022.
5. Levesque, Pamela. “Culturally-Sensitive Care for the Transgender Patient.” OR Nurse, vol. 9, no. 3, 2015, pp. 19–25.
6. Macri DV, and K. Wolfe. “My Preferred Pronoun Is She: Understanding Transgender Identity and Oral Health Care Needs.” Canadian Journal of Dental Hygiene, vol. 53, no. 2, 2019, pp. 110–117.
7. Whyte, Stephen, et al. “Man, Woman, ‘Other’: Factors Associated with Nonbinary Gender Identification.” Archives of Sexual Behaviour, vol. 47, no. 8, 2018, pp. 2397-2406.
8. Vermeir, Ella, et al. “Improving Healthcare Providers’ Interactions with Trans Patients: Recommendations to Promote Cultural Competence.” Healthcare Policy, vol. 14, no. 1, 2018, pp. 11–18.
9. “Gender Identity.” Canadian Paediatric Society, June 2023, caringforkids.cps.ca/handouts/behavior-anddevelopment/gender-identity. Accessed 7 July 2024.
10. Bhardwaj, Amit, and Shalu Verma Bhardwaj. “Effects of Androgens, Estrogens and Progesterone on Periodontal Tissues.” Journal of Orofacial Research, vol. 2, no. 3, 2012, pp. 165–170.
11. Yu, Hyunmin, et al. “LGBTQ+ Cultural Competency Training for Health Professionals: A Systematic Review.” BMC Medical Education, vol. 23, no. 558, 2023, doi.org/10.1186/s12909-023-04373-3.
12. Sanchez, Nelson F., et al. “Healthcare Utilization, Barriers to Care, and Hormone Usage Among Male-toFemale Transgender Persons in New York City.” American Journal of Public Health, vol. 99, no. 4, 2009, pp. 713–719.
13. Hein, Laura C., and Nathan Levitt. “Caring for…Transgender Patients.” Nursing Made Incredibly Easy, vol. 12, no. 6, 2014, pp. 28–36.
14. Kosenko, Kami, et al. “Transgender Patient Perceptions of Stigma in Health Care Context.” Medical Care, vol. 51, no. 9, 2013, pp. 819–822.
15. Parish, Carrigan L., and Anthony J. Santella. “A Qualitative Study of Rapid HIV Testing and Lesbian, Gay, Bisexual, Transgender, and Queer Competency in the Oral Health Setting: Practices and Attitudes of New York State Dental Directors.” Oral Health & Preventive Dentistry, vol. 16, no. 4, 2018, pp. 333–338.
Life Insurance: Family Protection, an Investment Vehicle, or Both?
By Wesley W. Lyon II, CPA, CFP®
Over the last 18 months, my company has tracked the progress of over 200 dentists with whom we have consulted. We found, on average, dentists are overpaying for life and disability insurance by more than $4,600 annually. Assuming a 7% investment return and 30-year dental career, this is a $434,000 mistake! How can so many dentists overpay? The answer is simple — a lack of meaningful information combined with predatory sales techniques.
Most dentists require life insurance for most of their careers. High student loan debt, combined with practice acquisition debt and real estate debt, can place a heavy burden on a surviving spouse. At the onset of your dental career, the life insurance need can commonly reach $8 million or more. In order to calculate your need, you must first calculate the amount of money needed to retire, and then add on your total outstanding loans. This number is different for everyone, as your spending habits will dictate the amount needed to retire.
Once your need is calculated, the difficult decision of how to obtain this insurance comes next. Unfortunately for dentists, most insurance companies have placed a target on their backs. While some insurance companies truly look out for your best interests, most are seeking to maximize profits. We often see agents go as far as selling life insurance policies on your children, who are financially dependent on you. Mathematically, this makes zero sense. However, the fear of losing one’s child can spark many emotions.
Insurance as an Investment
At this point in the process, you have a few different options, including permanent policies, such as whole life, universal life, variable universal life, etc., as well as term life insurance. Often, permanent life insurance policies are sold with additional benefits, such as being investment vehicles, acting like second retirement plans and generating tax-free income. On the other hand, term life insurance is very simple. You pay a set premium over the term of the policy, and, in return, you are insured for a specific amount. The downside? The premiums go down the drain if you don’t die during the specified period. While some might say this is a bad thing, I beg to differ. Term life insurance is the most cost-effective solution to protect your family due to the low premium costs.
Avoid Insurance as an Investment
As mentioned before, permanent policies offer investment components as well as insurance components. I recommend avoiding these policies. They contain high fees, low returns and poor income tax treatment. Since these policies are deemed insurance products, rather than investment vehicles, standard disclosures and performance reports escape Securities and Exchange Commission regulation, oftentimes leading to misled consumers.
The latest reliable published data on permanent life insurance comes from a 1979 report from the Federal Trade Commission. This report found that permanent life insurance policies had
returns of -9% to -19% in the first five years, 1% after 10 years, and 2% to 4.5% after holding the policy for 20 years.¹ These returns were calculated after the cost of insurance was removed. I personally believe the return calculations were generous to the life insurance companies because they did not assume level insurance premiums, but the results are staggering nonetheless.
Fast forward to 2024, and the returns from these policies are largely hidden from public view. At McGill and Lyon Dental Advisors, we review about five policies per month. In our experience, almost all of these policies have negative rates of return on the investment portion.
Fees and Commissions
Having an investment account and insurance policy tied together doesn’t automatically make a poor product, but why would a company do this in the first place? The easiest answer is to make money. By combining the insurance and the investment product together, insurance companies make it very difficult to calculate exactly what the fees are. I recently reviewed a whole life insurance policy that had earned over $60,000 in interest for the year. However, the policy value did not increase year over year. This was because the administrative and insurance costs exceeded 4% of the policy value, leaving little room for investment returns. This left the doctor in a position where over $1 million was deposited into a whole life policy, and, 10 years later, they would receive less than $1 million if they withdrew their funds.
You might be wondering why someone would sell a product with such a poor return history. The answer lies with incentives. Insurance companies often pay over 50% of the initial premium to the agent in the form of a commission, a very lucrative business model for great salespeople. Due to high incomes, most insurance companies have these agents target doctors, dentists and lawyers first.
Lastly, insurance companies are allowed to present potential customers with “illustrations.” These illustrations show the hypothetical performance of a policy under a set of circumstances. Most agents will concentrate on the loftiest projections. However, the worst performing projections are closer to the truth. I recently had a client who was presented with an illustration of how a modest investment into a whole life policy could generate income for life. The presentation, however, ignored all other possible outcomes. What the agent didn’t concentrate on was, under the guaranteed assumptions, this policy would provide only five years of retirement income, leaving the client bankrupt in retirement.
Tax-Free Income or Tax Trap?
These policies are often sold as second retirement plans, mega Roth IRAs or tax-free income investments. While this may not be 100% false, it is misleading. Withdrawals from insurance products are taxed as ordinary income to the extent the value exceeds the tax basis. This means you will lose the tax-favored capital gains treatment that could be received by investing in low-cost, well-diversified index funds. What insurance agents should be explaining is that loans can be taken against the policy value tax-free, but you continue to pay the fees and expenses of the policy, which often reach over 4% of the policy value. Unfortunately, by the time many dentists
figure this out, they are trapped. They can either take the loan and continue to pay the fees or suffer a large tax bill to exit the policy.
Recommendation
Instead, simply purchase a level term insurance policy for the necessary period and invest the remaining monthly amount in low-cost investments for higher returns. This simple strategy will dramatically increase your wealth and allow you to retire years earlier. I recommend obtaining a policy with a level premium through age 60 to ensure financial security for your family. Some dentists will obtain two policies to reduce premiums, one with a shorter term such as 10 years to pay off practice loans, and one with a term of 20 or 30 years to ensure financial security for family members. Once you have achieved financial independence, drop your term insurance since it is no longer needed. As a bonus, you can call your insurance provider and lower your insured amount as your net worth increases and your insurance needs decrease, saving thousands more in annual premiums. ♦
Wesley W. Lyon II, CPA, CFP, is president and CEO of McGill and Lyon Dental Advisors. For more information on his firm’s comprehensive tax and business planning services for dentists and specialists, contact Janet Blair at 877.306.9780, or email consulting@mcgillhillgroup.com. To comment on this article, email impact@agd.org
Reference
1. “Life Insurance Cost Disclosure: A Report to the President and the Congress on Life Insurance Cost Comparison Indexes.” Federal Trade Commission, 1979.
Legal Matters
Successful DEA Inspections Require Knowing Your Compliance Obligations
By Jake Kathleen Marcus, JD, PGDip
Of concern to most dentists is the possibility of an inspection by the Drug Enforcement Administration (DEA). The DEA regulates the prescribing, distribution and administration of controlled substances, including those used in dental practices, and has the authority to conduct inspections of dental offices to ensure compliance with controlled substances regulations. Inspections may be routine or prompted by reports of irregularities, which may be made by any member of the public.
DEA Inspections
DEA inspections fall into two categories:
• Routine inspections: These are conducted periodically, often every few years, to ensure ongoing compliance.
• Triggered inspections: Inspections may be triggered by certain events, such as significant losses or thefts of controlled substances, complaints, irregularities in prescribing patterns, or other suspicious activities.
While there is no way to avoid an inspection entirely, compliance with DEA regulations is essential to avoid federal sanction in the form of penalties, which can include fines or suspension or revocation of your DEA registration, as well as action by your state dental board.
Areas of Focus During DEA Inspections
• Recordkeeping: Inspectors will review records related to the acquisition, dispensing and prescribing of controlled substances. This includes checking DEA Form 222 (used for ordering Schedule II substances) and inventory records.
• Inventory management: Inspectors will verify that initial and biennial (every two years) inventories are accurate and up to date and that they include all required information.
• Prescription practices: Inspectors will examine prescription records to ensure that they comply with DEA regulations. This includes verifying that all required information is present on prescriptions for controlled substances.
• Security measures: Inspectors will assess the physical security measures in place for storing controlled substances, ensuring they are securely locked and adequately protected against theft and diversion.
• Theft and loss reporting: Inspectors will check records to confirm that any thefts or significant losses of controlled substances have been promptly reported using DEA Form 106.
• Destruction of controlled substances: Inspectors will review records and procedures for the destruction of controlled substances to ensure they comply with DEA guidelines.
Preparation for a DEA Inspection
• Maintenance of accurate records: Ensure all records of controlled substances — including purchase orders, prescriptions and inventories — are complete, accurate and readily accessible.
• Secure storage: Verify that all controlled substances are stored in a secure, locked location that meets DEA standards.
• Regular audits: Conduct regular internal audits of controlled substances inventory and records to identify and correct any discrepancies.
• Training and education: Ensure that all staff members involved in handling controlled substances are properly trained in DEA regulations and the dental practice’s policies and procedures.
The following are the key points regarding compliance with DEA regulation of dentists.
DEA Registration
Dentists must obtain a DEA registration number to prescribe, dispense or administer controlled substances. This number is unique to the practitioner and must be renewed every three years. Dentists apply for DEA registration using DEA Form 224.1 The application can be completed online through the DEA Diversion Control Division’s website.1 It is critical to remember that DEA registration must be renewed, and, to the dismay of dentists who practice in multiple locations, each office in which controlled substances are used must have its own separate DEA registration.
In addition to the federal requirement, some states also require registration in order to prescribe controlled substances.2 State dental and pharmacy boards often provide additional guidelines and requirements.
Prescription Regulations
Controlled substances are classified into five schedules (I–V) based on their potential for abuse, medical use and safety. Dentists who sedate patients for procedures often employ Schedule II–V drugs, such as opioids (e.g., hydrocodone, oxycodone) and benzodiazepines (e.g., diazepam).
DEA regulations stipulate specific requirements for writing prescriptions for controlled substances. Prescriptions must include:
• the patient’s full name and address;
• the practitioner’s full name and address;
• the practitioner’s DEA registration number; and
• the drug name, strength, dosage form, quantity prescribed, directions for use and the number of refills (if any).
Dentists can — and in some states must — use electronic prescribing of controlled substances (EPCS) systems, which must meet DEA requirements to ensure security and authenticity.3
What dentists cannot do is prescribe drugs for use in a dental procedure. Prescriptions can only be written for medications for home use. Medications to be used in the dental office must be purchased directly from DEA-registered distributors. Of particular importance is that destruction of expired or damaged controlled substances must be done by a DEA-registered reverse distributor. 4
DEA Recordkeeping and Inventory
Dentists must maintain accurate records of all controlled substances they receive, dispense and prescribe.5 Records must be kept for at least two years and be readily available for inspection by the DEA. In addition, dentists must conduct an initial inventory of all controlled substances on hand when they first register with the DEA. They must also conduct a biennial inventory thereafter.
After a DEA Inspection
A DEA inspection may result in:
• Corrective actions: If any deficiencies are identified during the inspection, take immediate corrective actions to address them prior to any subsequent inspection or by a date specified by the inspector. This may include updating records, enhancing security measures or providing additional staff training.
• Follow-up: In some cases, the DEA may conduct followup inspections to ensure that corrective actions have been implemented.
Overview of the MATE Act
Effective June 27, 2023, the Medication Access and Training Expansion (MATE) Act mandates that all healthcare providers who are registered with the DEA to prescribe controlled substances must complete a one-time training related to opioid and other substance use disorders. Here are the key aspects of the mandatory training for DEA registration:
• Training: The MATE Act requires healthcare providers to complete at least eight hours of training. The training must cover topics such as:
o Safe prescribing practices: Education on the proper prescribing of opioids and other controlled substances to prevent misuse and abuse.
o Substance use disorders: Training on identifying and managing patients with substance use disorders.
o Pain management: Best practices for pain management that minimize the risk of addiction and abuse.
The training must be completed through an accredited provider. These programs are often available online or through professional organizations such as the American Dental Association. (Editor’s note: While AGD PACE–approved programs are not currently considered authorized providers of this training, AGD has compiled a list of CE providers that meet the statute requirement in order to ensure AGD members have access to required training and options: agd.org/education/learn/ medication-access-and-training-expansion-(mate). Additionally, AGD has been working diligently with legislators on a resolution to include AGD as an accredited provider, and movement is expected in 2025.)
• Submit documentation: Keep the certificate or proof of completion for your records. You may need to provide this documentation when applying for or renewing your DEA registration.
• State-specific regulations: Understand and comply with any state-specific requirements and guidelines for prescribing controlled substances.
The key to a successful DEA inspection — as well as a mandated state dental board inspection — is knowing and complying with the application regulation. Following the steps above can both reduce the anxiety associated with inspections and keep your dental office in line with best practices. A compliant dental office is also less likely to experience theft of controlled substances and is better able to detect employee misconduct. All of this results in better patient care and a more productive business. ♦
Jake Kathleen Marcus, JD, PGDip, has been a regulatory lawyer primarily in the healthcare space for over 35 years. They were recently awarded a postgraduate diploma in technology, media and telecommunications by Queen Mary University of London School of Law. To comment on this article, email impact@agd.org
References
1. “Registration.” Drug Enforcement Agency Diversion Control Division, U.S. Department of Justice, deadiversion.usdoj.gov/drugreg/registration.html. Accessed 11 July 2024.
2. “21 CFR Part 1301 - PART 1301—Registration of Manufacturers, Distributors, and Dispensers of Controlled Substances.” Cornell Law School Legal Information Institute, Cornell University, law.cornell.edu/cfr/text/21/ part-1301. Accessed 11 July 2024.
3. Drug Enforcement Administration, Department of Justice. “21 CFR Parts 1300, 1304, 1306, and 1311: Electronic Prescriptions for Controlled Substances.” Federal Register, vol. 75, no. 61, 31 March 2010, pp. 16236-16319, govinfo.gov/content/pkg/FR-2010-03-31/pdf/2010-6687.pdf.
4. “21 CFR 1317.55 Reverse Distributor and Distributor Acquisition of Controlled Substances from Collectors or Law Enforcement.” Code of Federal Regulations, National Archives, ecfr.gov/current/title-21/chapter-II/ part-1317/subpart-B/section-1317.55. Last amended 5 July 2024. Accessed 11 July 2024.
5. “21 CFR Part 1304 Records and Reports of Registrants.” Code of Federal Regulations, National Archives, ecfr.gov/current/title-21/chapter-II/part-1304. Last amended 5 July 2024. Accessed 11 July 2024.
MEDICAL-DENTAL SYSTEMS INTEROPERABILITY
THE NEXT CRITICAL STEP TO IMPROVING COLLABORATION AND UNDERSTANDING
By Mark W. Jurkovich, DDS, MBA, MHI, MAGD
Today, the amount of data being produced in healthcare has exploded as compared to just a decade ago. IQVIA and other large data analytics firms estimate that hospitals alone are producing over 50 petabytes of data a year. For context, 1 PB is equal to 1,000 terabytes or 1 million gigabytes, and 50 PB is more than twice as much data as is housed in the entire Library of Congress. This amount is growing at a rate of 36% annually, with as much as 97% of this data currently being unused.1 Adding hospital data to outpatient data, dental data and other sources expands the amount of health-related data dramatically.
Tools that help healthcare clinicians sort through information are valuable and perhaps essential from an efficiency standpoint. Currently, our physician colleagues have tools that use various types of artificial intelligence (AI) that assist electronic health record (EHR) systems in summarizing information, allowing physicians to have a more cohesive picture of the patient that may be based on the chief complaint or simply their medical history. Further, as the medical team adds more information on current findings and observations, lab results, etc., during the exam, the systems can actually provide decision-support assistance, such as determining whether more or other tests are warranted.
It is not uncommon for primary care physicians to be scheduled with three or even four patients per hour. Like most healthcare clinicians today, medical teams are pressed for time. To expect them to review written communications, change workflows or take other actions may be asking too much. Our historical methods of exchanging data simply are not working with our data explosion.
This is where information-exchange tools and interoperability make a difference. Without these tools, the opportunity to more clearly understand how medical and dental conditions impact each other and how care coordination might improve outcomes, lower costs and more may be out of reach.
What Is Interoperability?
Strictly speaking, true interoperability is a streamlined way of exchanging informa-
tion. In this article, the concept of health information exchange represents the basic exchange of healthcare information, which can include medical and dental history and treatment and administrative data and charts unique to the patient, still well beyond phone calls, faxes, etc. Interoperability will be represented as the most advanced form of information exchange, because EHR systems can be used more effectively to identify patients, identify key information being exchanged, and, with greater frequency, “consume” or populate the EHR with information received from another system with little or no human interaction or input beyond a simple approval. This is not common in the dental field at this time, but it is rapidly growing in medicine.
The Oral-Systemic Health Connection
For well over a decade now, research has been identifying numerous correlations between good dental health and improved overall health. Studies involving periodontitis have shown linkages to more problems with diabetic control, heart disease, strokes, arthritis and several other chronic medical conditions. Anecdotally, it remains uncommon for our physician colleagues to refer patients with these conditions for a dental examination (and likely few referrals from dentists to physicians are made to explore how improving inflammatory chronic medical conditions can help dental care). Improving communication and cross referrals has significant potential to help patients through increased related data and better knowledge about related health conditions. Further, without additional “proof” that there is an oral-systemic health connection that can be leveraged to improve outcomes or lower costs, healthcare systems may look to other areas of care first, where the digital “language” of their care systems more easily integrates with information in EHRs. A good example of this might be pharmaceuticals. Pharmaceuticals is a cost center more than twice as large as the dental industry.2,3 Its records and the language used already integrate with most (medical) EHRs, allowing for a much lower
upfront cost for care systems using AI to identify correlations and relationships that could produce better results and savings.
Dental systems often struggle to communicate effectively with medical EHRs. We in dentistry tend to use a different set of terms and codes, as well as limited amounts of structured and standardized data. Instead, dentistry tends to rely on patient self-reporting of medical conditions rather than obtaining this information directly from patients’ medical records.
How Can We Work to Develop
a Better Picture of the OralSystemic Connection?
Dentistry has led the charge of education to both the profession and the general public regarding the oral-systemic health connection. Further, dental benefit plans and Medicare periodically have expanded benefits for individuals with certain medical conditions, further enhancing public awareness and belief that there is a connection between oral and systemic health. Yet, a 2021 study of information exchange and dentistry looked at 97,460 dental visits and identified just 164 requests for medical information.4
Additionally, patients with certain problems may already be interacting with both a dentist and a physician to resolve their concern(s). The need for clear and timely communication to assist these patients in problem resolution may be critical.
Although the enabling act of Medicare has strict limitations on covering dental conditions, when a medical treatment protocol includes the need for some type of dental care (often an exam, prophylactic treatment or periodontal maintenance of some sort), the potential need to provide necessary information relative to the patient’s medical condition that qualifies the dental procedures for coverage may not be cost-effective using current methods of exchange. However, it may very well be expected — i.e., doing preventive services for someone needing surgery and then having to provide significant amounts of information in a timely manner to the physician, as well as the insurance company handling Medicare coverage for the patient.
Additionally, the information necessary to properly coordinate the clinical care is often not easily exchanged. It may require phone conversations, faxed information, and possibly some basic information exchange through a state-operated health information exchange or other tools that many dental clinicians are unfamiliar with. These exchanges generally require manual input into the records systems of all parties. Further, unless the information is exchanged in a timely fashion, it may not be available to the other clinician, potentially resulting in repeated tests, imaging or rescheduled appointments, all of which are frustrating to patients. True interoperability or even basic health information exchange can reduce or eliminate these issues.
Dentistry is seeing some development of integrated EHR systems or the ability to improve exchange of information. A few healthcare systems, such as HealthPartners in Minnesota, some care systems in the Northwest, some university health centers, and a growing number of federally qualified health centers are beginning to or have been using “integrated” medical/ dental records for some time. One example is Epic, the largest provider of EHRs in the United States, which offers a dental component called Epic Wisdom. Epic Wisdom provides instant access to medical and dental information and the opportunity to better understand the correlations between systemic and dental health, as well as decision tools to more effectively coordinate care. With the vast majority of dental practices still independent of larger healthcare systems, linkages that involve a totally integrated EHR system may still be well into the future. Thus, there is a growing imperative to exchange data between dental and medical EHRs for the foreseeable future.
How Might Interoperability Impact Dentistry (and Your Practice)?
One large dental support organization, PDS Health (formerly Pacific Dental Services), has gone well beyond simple experimentation and is taking some key steps to
enhance interoperability for its clinicians. PDS Health began transitioning to Epic Wisdom, which, in addition to being fully compatible with the Epic medical EHR system, is able to communicate through various well-established channels with most other EHR systems. This gives PDS Health dentists the capability of obtaining the most up-to-date medical information, laboratory results, medications, etc., in a growing number of instances as long as the patient consents to the release of this information. Potentially, this interoperability and exchange of information enables dentists to identify and further understand medical-dental relationships as well as provide information back to physicians and healthcare systems that may help improve patient outcomes and/or reduce costs. This may be of increasing importance in the marketplace if employers begin seeking more integrated care for their employees. We are also in an era of changing patient expectations. Today, it is not uncommon for patients to use “patient portals” for all things related to their healthcare and health insurance. Again, dentistry tends to lag behind the medical industry with regard to implementation of these tools. Patient portals allow for scheduling, filling out necessary pre-visit forms, paying for services, and obtaining information about their previous visits as well as educational materials patients can use to potentially improve their health and treatment outcomes.
Increasingly, it may be assumed that patients have expectations that comparable capabilities are available regardless of what kind of healthcare professional they are visiting. Historically, patients have had to fill out similar health information for every clinician they visit. This is now much less frequent among medical clinicians and care systems, which may also be improving accuracy5 and is better for patients, all due to interoperability. Again, dentistry is infrequently at this level, and patients can be frustrated by dental clinics’ inability to obtain information they may not fully understand but could be important to their dental care. A growing number of dental clinics are offering patients the ability to fill out certain paperwork in advance — which
still means filling out similar information yet another time — and this paperwork may lack some key components, such as recent H1Ac results and current medication dosages. While the ability to complete paperwork in advance is a good step forward, it may not meet patient expectations in the not-too-distant future.
If a patient does understand the possible oral-systemic health connection and they have a dental problem that may impact their overall health, they may expect the dentist to explain it to the appropriate physician(s) and get any key information placed into their medical records — a reasonable expectation, given that this is already happening regularly among many medical providers. However, one of the simple problems dentistry continues to deal with is the lack of effective and timely exchange between general dentists and dental specialists. This can result in tests or radiographic imaging being repeated and billed a second time to the patient because dental benefit plans will often only cover one such procedure in a select time period. Better information and image exchange within dentistry has the potential to limit patient out-of-pocket costs as well as reduce radiation exposure; better interoperability among dental and medical systems can take this efficiency even further.
The State of Dentistry and Information Exchange Today
Some dental colleagues (oral surgeons, those dealing frequently with sleep disorders and/or temporomandibular conditions, etc.) already exchange data with medical clinicians with greater frequency than many other dentists. This provides a basis for developing a platform to exchange, identifying where improvement might be possible, and evaluating how this can be done most efficiently from a workflow standpoint. These colleagues would be a good source of information, should you be interested in learning more.
It is equally important to recognize that exchange is not new to the profession. Things like using clearinghouses for insurance claims, sending digital scans to a laboratory, the example earlier about
“ONE OF THE SIMPLE PROBLEMS DENTISTRY CONTINUES TO DEAL WITH IS THE LACK OF EFFECTIVE AND TIMELY EXCHANGE BETWEEN GENERAL
DENTISTS
AND DENTAL SPECIALISTS.”
online form completion, and a few other administrative types of tasks are already being used in dentistry, and some represent true interoperability as defined above. Where dentistry is behind medicine is in the capability for and actual exchange of clinical information. Many of the administrative forms of interoperability have measurable financial value (time savings) to the clinician. The costs of exchanging clinical information are frequently borne by the dental practice, both in upgrading technology and in the charges for exchanging the information. These costs may create a financial limitation, but they may also be of significant value, much like electronic claims submission can be.
Clinical information exchange is also significantly more complex. It was noted above that dental and medical EHRs do not easily “talk” to each other. One of the reasons is that dentistry records different information and even the same information in a different way. Where a physician might document a certain type of problem such as diabetes in a separate data field in their database, some and perhaps many dental EHRs do not. Even if they do, they might use a different term or metadata that requires further work before it can be transferred.
Another key aspect is making sure the correct patient is identified. This sounds like it should be straightforward, but it is and remains a very complex task. AHIMA,
one of the larger training organizations for administrative and clinical staff, has been advocating for unique patient identifiers for healthcare, not unlike what the government currently does with Social Security. The primary reason for this advocacy is that a small percentage of patients are very difficult to properly identify due to similarity of names and ages, or frequent address changes, thus eliminating the capability of exchange and creating barriers to true data “consumption” into an EHR system. Another check is needed by clinical staff before the data can be integrated, which means more staff time spent.
How Can Dentistry Move Toward Improved Clinical Information Exchange?
Some of the basic elements involve standards, security tools, improved systems and affordable ways to participate in health information exchanges. About a decade ago, the American Dental Association (ADA) endorsed a firm that could provide secure email to allow for more rapid, HIPAA-compliant and legally acceptable ways to provide information to another clinician. Some dental specialists went further by providing a secure portal, allowing referring dentists to input information that became instantly available to the specialist. Today, one of the absolute costs of doing business for anyone with computerized
records and a connection to the internet is having a computer operating system that is regularly updated to address any newly identified security vulnerabilities.
Standards are another area that is key to information exchange, and they are changing rapidly. Exchange formats used by our medical colleagues can include continuity of care documents (CCDs) and can consist of a download of medical information that could be very extensive, making them less useful because of the time it takes to review the information. Over the past few years, the United States and most of the world has been moving toward a standard that can streamline these documents to more specific needs and be transferable in real time. This standard is called HL7 FHIR, where HL7 stands for Health Level Seven International, the standards organization that develops exchange tools and protocols, and FHIR stands for Fast Healthcare Interoperability Resources. U.S. government agencies, such as the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, have been encouraging and working to make FHIR the primary exchange format. FHIR tools allow for much more focused, and thereby limited, information exchange. A specific American National Standards Institute (ANSI)– and ADA-approved dental standard, No. 1084, Core Reference Data Set, serves as the basis for development of some of the FHIR exchange sets used in dentistry. We are gradually seeing the adoption of FHIR capabilities by some dental EHR systems due to demand by users. The Veterans Health Administration and some federally qualified health centers have been some of the leaders in pushing the dental EHRs they use into having this capability. Yet, CCDs remain far and away the most common form of document exchanged.
Recently, the ADA Standards Committee on Dental Informatics completed a new ANSI-approved standard, the Oral Dataset Interoperability Standard (ODIN). ODIN provides for the permissioning, data bundling, authentication and necessity validation for structured electronic data elements to support key information exchange among and between
dental and other healthcare settings. This includes the bidirectional electronic sharing of essential patient demographic, dental and medical encounter data, as well as patient clinical data in a structured, computable format between dental or other healthcare venues.
Another major effort by the federal government is creating “exchanges” where patient information can be readily identified and moved to another entity with patient permission. Referred to as QHINs (qualified health information networks), they must pass rigorous criteria and use common methods to exchange information. This may be the path parts of dentistry will need to use, simply to contain costs. The most likely path will be for the dental EHR vendors to develop a pathway with a QHIN. If a dentist is then seeking information on a specific patient, that information request would be “packaged” by the dental EHR, then the information packet would be forwarded to the QHIN (hopefully with directional information on where to find the patient information). The original QHIN then works with all other QHINs in the exchange, and each QHIN or QHINs that contain information for the patient accesses it from an EHR system and forwards it back to the original/requestor QHIN and subsequently to the dental EHR or another tool that allows viewing of the information requested (if available). All of this takes place in real time, measured in seconds (minutes at most). Depending on the capabilities of the dental EHR, the information could immediately populate a patient’s record (likely after a single approval click from a staff member), update information when it is “new,” reduce patient time and make the information much easier for the clinician to locate. This is an example of true interoperability, and improved patient satisfaction, patient care and patient safety would be the result. Many states have developed health information exchanges (HIEs) during the last decade or so. Some of these may require all healthcare professionals, including dentists, to participate. The healthcare professionals contract with a firm (much like the QHIN described
above) to provide exchange services. A “roster” of all patients that the healthcare professional has records on is uploaded (and regularly updated) to this firm so that information requests can locate where the patient may have records and provide for rapid information exchange.
A Possible Path
Today, there are numerous resources available; however, many require a level of baseline knowledge to be useful to the average person. Depending on whether you are a solo practitioner, a small group or part of a larger group such as a DSO, the path forward could be very different.
If exchanging information beyond phone calls, texts and emails is new to you, you may want to use a basic approach to familiarize yourself with the processes. It may also result in better security and meeting state or federal privacy and security requirements.
A great source for learning more about information exchange in general is healthit.gov/topic/health-itand-health-information-exchange-basics/ health-it-and-health-information-exchange
Some Initial Steps
1. Make sure your operating system is up to date and you either regularly check for updates or have automatic updates turned on. Many dentists already use a technology company to take care of their computer systems; if so, the technology company should be doing this regularly.
2. Talk with colleagues who refer to you or whom you refer to. Find out if they are using portals, what information you should exchange with them, etc.
3. Explore with your patients what medical care systems they are members of, and find out if they use their medical care system’s patient portal. Often, they will also know the name of the EHR system their medical care system uses (patients frequently refer to “MyChart” or similar, and those names are usually proprietary to the EHR vendor).
4. Find out from your patients if they would use online forms, online scheduling, online payments, etc. While there are costs involved in these services, they
do have the potential to save time and improve patient satisfaction.
5. Consider signing up for secure messaging capability as a possible starting point. There remain several vendors in the field. Secure messaging allows for information exchange securely with both other clinicians and your patients. You can find additional information from one of the largest exchange platforms here: directtrust.org/what-we-do/ direct-secure-messaging.
6. Monitor frequency of use, how you might alter workflows or how this might allow you to improve workflows. An example might be that you have obtained the necessary information that allows you to properly counsel the patient on their medications before an extraction so you don’t “waste” an appointment because they need to take or stop taking some medication prior to treatment.
7. As you get more comfortable with exchange, research options such as state HIEs and who the vendors are. Discuss with your dental EHR vendor their capabilities to participate in an exchange, and encourage them to add or adapt their data structures to meet your needs for information available for the patient.
8. Consider participation with the ADA Dental Experience and Research Exchange (DERE) registry project. As it expands and grows, you will have greater capability to compare your practice to other similarly sized practices as well as improve the information available to help the profession better understand the oral-systemic health connection. ♦
Mark W. Jurkovich, DDS, MBA, MHI, MAGD, is director of data infrastructure at Health Care Systems Research Network. He currently serves on the Minnesota Health Information
Exchange Advisory Council, is a member of the ADA Standards Oversight Committee and is chair of the SNOMED International Dentistry Clinical Reference Group. He practiced general dentistry for almost 40 years. To comment on this article, email impact@agd.org.
References
1. Greene, Linnie. “How Healthcare Data Technology Is Leveraged by Leaders.” Arcadia, 6 Sept. 2023, arcadia.io/resources/healthcaredata-technology.
2. “Trends in Prescription Drug Spending 2016-2021.” Office of Science and Data Policy, U.S. Department of Health and Human Services.
3. “National Dental Expenditures 2022.” Health Policy Institute, American Dental Association.
4. Taylor, Heather L., et al. “Health Information Exchange Use During Dental Visits.” AMIA Annual Symposium Proceedings Archive, 2020, pp. 1210-1219.
5. Patel, Jay, et al. “Assessing Information Congruence of Documented Cardiovascular Disease Between Electronic Dental and Medical Records.” AMIA Annual Symposium Proceedings Archive, 2018, pp. 1442-1450.
Self-Instruction
Practice Management and Human Relations
(Subject Code: 556)
The 10 questions for this exercise are based on information presented in the article, “Medical-Dental Systems Interoperability: The Next Critical Step to Improving Collaboration and Understanding” by Mark W. Jurkovich, DDS, MBA, MHI, MAGD, on pages 12–17. This exercise was developed by members of the AGD editorial team. Exercise No. IM156, 1 CE
1. IQVIA and other large data analytics firms estimate that hospitals alone are producing over _____ petabytes of data a year. This amount is growing at a rate of 36% annually, with as much as _____% of this data currently being unused.
A. 125; 94
B. 100; 95
C. 75; 96
D. 50; 97
2. One petabyte is equal to _____ terabytes.
A. 10
B. 100
C. 1,000
D. 10,000
3. The acronym EHR stands for _____.
A. elective health record
B. electronic health record
C. elective health resource
D. electronic health resource
4. A 2021 study of information exchange and dentistry looked at 97,460 dental visits and identified just _____ requests for medical information.
A. 164
B. 264
C. 364
D. 464
Reading the article and successfully completing the exercise will enable you to:
• understand the current state of medical-dental systems interoperability;
• identify ways to increase interoperability and the effects this would have on healthcare professionals and patient care; and
• recognize how increased interoperability could lead to more collaboration among dental and medical healthcare professionals.
This exercise can be purchased and answers submitted online at agd.org/self-instruction.
Answers for this exercise must be received by Aug. 31, 2025.
5. The acronym CCD stands for _____ care documents.
A. core
B. critical
C. comprehensive
D. continuity of
6. In the HL7 FHIR standard, HL7 stands for Health Level Seven International, the standards organization that develops exchange tools and protocol, and FHIR stands for _____ Resources.
A. Fast Healthcare Interoperability
B. Functional Hierarchy of Interfacing
C. Framework for Harnessing Information
D. Facilitation of High-Speed Interconnected
7. Recently, the ADA Standards Committee on Dental Informatics completed a new American National Standards Institute–approved standard, the Oral _____ Standard (ODIN).
A. Dental Informatics Network
B. Dataset Interoperability
C. Demographics Information Network
D. Diagnostics Integration
8. ODIN provides for the permissioning, data bundling, authentication and necessity validation for structured electronic data elements to support key information exchange among and between dental and other healthcare settings. This does not include the bidirectional electronic sharing of essential patient clinical data; only anonymized patient demographic data.
A. Both statements are true.
B. The first statement is true; the second is false.
C. The first statement is false; the second is true.
D. Both statements are false.
9. The acronym QHIN stands for qualified _____ network.
A. healthcare identifier
B. health integration
C. healthcare interoperability
D. health information
10. A(n) _____ is a state-maintained network that may or may not require all healthcare professionals within the state to participate in it.
A. QHIN
B. EHR
C. HIE
D. FHIR
2024 FALL FELLOWSHIP REVIEW COURSE AND EXAM
Fellowship Review Course
The Fellowship Review Course was designed to provide a refresher in 17 dental disciplines, as well as to assist members in preparing for the Fellowship Exam.
Dates: Oct. 4–5, 2024
Time: 7:30 a.m. to 5 p.m.
Location: Academy of General Dentistry, 560 W. Lake St., Chicago, IL
Note: Premium Plus Members receive a 20% registration discount.
Fellowship Exam
The Fellowship Exam is a four-hour 252-question multiple-choice test emphasizing clinical applications of accepted dental knowledge, techniques, and procedures in general dentistry. The Fellowship Exam fee is a separate fee from the course registration fee.
Date: Oct. 6, 2024
Times: 7:30 a.m. to 1 p.m.
Location: Academy of General Dentistry, 560 W. Lake St., Chicago, IL
Search for “Fellowship Review Course” on agd.org
HOW WILL THE GREAT TAX BATTLE OF 2025 IMPACT YOU?
By Wesley W. Lyon II, CPA, CFP®
Tax legislation promises to be a major focus next year because many individual tax provisions from the Tax Cuts and Jobs Act (TCJA) are set to expire Dec. 31, 2025, automatically raising income taxes for most taxpayers. There has not been major legislation since the TCJA was passed in 2017 because neither party can seem to agree on changes. However, the expiration of the TCJA will force both sides to negotiate or face backlash from the general public, as neither side plans to increase taxes on the middle class.
Expiring Provisions: What Will Change?
The TCJA reduced individual income tax rates across the board, leading to lower taxes for most Americans. The law almost doubled the standard deduction, eliminating the need for many taxpayers to fill out an itemized deductions worksheet. At the
“The expiration of the Tax Cuts and Jobs Act will force both sides to negotiate or face backlash from the general public, as neither side plans to increase taxes on the middle class.”
same time, the law capped the deduction of state and local taxes to no more than $10,000 per taxpayer, leading to even fewer taxpayers itemizing their deductions. Another provision, the 20% qualified business income deduction, was also introduced, adding a 20% deduction for many business owners, but only if certain requirements were met. The additional deductions were welcomed by many small business owners, but ultimately complicated their tax planning. Many of these individual tax provisions will expire, reverting back to pre-TCJA legislation, which means many individual income tax brackets will increase.
Mandatory Negotiations Ahead
With the current law set to expire Dec. 31, 2025, I expect Congress to negotiate new legislation in 2025. Both parties tentatively agree that raising taxes on those making more than $400,000 would be bad for Congress. If the current law is allowed to expire, income taxes on those making $400,000 will increase by up to $20,000 annually. Congress will also be tasked with handling the debt ceiling, which was suspended until 2025 by the Fiscal Responsibility Act of 2023.¹ A temporary suspension is likely again, with both parties using the debt ceiling as leverage.
Potential Changes
The Republicans are likely to push for a full extension of the TCJA, while the Democrats will push for higher taxes on the wealthy. Each spring, the U.S. Department of the Treasury releases its “General Explanations of the Administration’s Revenue Proposals,” or “Greenbook,” which outlines tax proposals for the party of the current president. Based on the most recent Greenbook, here are the top changes impacting dentists that are expected to be argued in Congress — as well as potential solutions.²
Increase Income Tax Rates on Those Making $450,000 or More
Increase top marginal income tax bracket to 39.6%.
The TCJA cut tax rates for all income tax brackets. The Greenbook proposal would increase the top marginal rate back to 39.6%, from a current top marginal rate of 37%, for those with taxable incomes above $450,000. Based on the proposal, it appears that both parties aim to keep the current tax brackets in place for those making under $450,000.
Apply the net investment income tax (NIIT) to all income sources
The NIIT is a 3.8% surtax on all unearned investment income, including rent, dividends, interest, capital gains, etc. However, active trade or business income is excluded, including privately owned dental practices and their related real estate. Furthermore, the rate is proposed to increase from 3.8% to 5.0% for taxpayers earning more than $450,000 (married filing jointly returns). This would increase the top federal marginal tax rate to 44.6%.
Solution: Be sure to maximize all deductions, especially retirement plan contributions, in order to avoid maximum combined federal income and NIIT rates of 44.6%.
Increase Capital Gains Rates
Long-term capital gains currently receive favorable treatment under the law, with maximum tax rates of 20%, plus the 3.8% NIIT if applicable. The Greenbook proposal would increase the rates to match ordinary income rates for taxpayers with over $1 million of income, potentially more than doubling taxes on large practice sales.
Solution: Utilize an installment sale in order to receive a portion of the purchase price each year, only paying taxes up to the extent you receive funds. This will allow you to keep your income below $1 million each year, saving 19.6% of any proceeds above $1 million.
Increase IRS Enforcement
In a move likely to gain bipartisan support, Internal Revenue Service (IRS) enforcement will be further increased. The IRS has been busy upgrading its systems to identify problematic returns. Likely targets include fraudulent Employee Retention Tax Credit claims, abusive research and development tax credits, and a continued crackdown on syndicated conservation easements.
Solution: Push the limits within the bounds of the law! Always consult a trusted adviser prior to making any drastic decisions. Remember, if it sounds too good to be true, it likely is.
Decrease Estate Tax Exemption Limit
The basic exclusion amount (BEA), more commonly known as the lifetime exclusion amount, is the amount of assets you can transfer to your children without paying estate (death) taxes. The TCJA doubled the BEA, currently sitting at $13,610,000 per spouse. This provision will expire Dec. 31, 2025, setting up a debate between both parties. If no new legislation is enacted, the limits will be cut in half to the pre-TCJA
“Don’t let alarmists lead to bad decision-making. Tune out the pundits, seek wise counsel, and think twice before making any rash decisions.”
limits, adjusted for inflation. There is currently a lack of information available on both parties’ wishes, but this is an issue likely to hit the pockets of major donors on both sides of the aisle. Don’t be surprised if a compromise comes quickly regarding a new estate tax limit.
Solution: Consider spending more, gifting assets now to remove future appreciation from your estate, or increasing charitable gifting.
Remember, these are just proposals, and laws will need to be negotiated. The president only has so much power, as tax legislation must be passed by Congress and signed by the president. This usually leads to radical proposals from both sides being left on the sideline. Don’t let alarmists lead to bad decision-making. Tune out the pundits, seek wise counsel, and think twice before making any rash decisions. ♦
Wesley W. Lyon II, CPA, CFP, is president and CEO of McGill and Lyon Dental Advisors. For more information on his firm’s comprehensive tax and business planning services for dentists and specialists, contact Janet Blair at 877.306.9780, or email consulting@ mcgillhillgroup.com. To comment on this article, email impact@agd.org
References
1. U.S. Congress. Fiscal Responsibility Act of 2023. Congress.gov, Library of Congress, 118th Congress (2023-2024), House Report 3746, 3 June 2023, congress.gov/bill/118th-congress/housebill/3746/text.
2. General Explanations of the Administration’s Fiscal Year 2025 Revenue Proposals. U.S. Department of the Treasury, 11 March 2024, home.treasury.gov/policy-issues/tax-policy/revenue-proposals.
By Ross Isbell, DMD, MBA
Mints That Will Literally Make Your Mouth Water
Flintts Mints
Flintts flintts.com
Dry mouth products in the pharmacy dental aisle have been the same for decades, and they have been lacking energy and excitement just as long. Flintts
Mints are an interesting addition, and they should be part of your recommended salivary induction therapies. They are shaped like circular flowers and come in slim, brightly colored metal boxes that easily fit in a pocket or clutch. Of the sampler pack I tried, my flavor ranking is: strawberry, cherry, grape, lemon then mint. Overall, I significantly preferred the fruity flavors over the mint. There is some sweetness to the mints due to isomalt and sucralose, which are nonfermentable artificial sugar substitutes that oral bacteria aren’t able to easily metabolize, which should help reduce plaque formation compared with regular mints that contain sugar. Magnesium stearate is the binding agent that combines the powder of various plant extracts, the most important of which is spilanthes. Spilanthes is supposedly able to numb, reduce inflammation and help heal ulcers. The mints produce a tingling sensation at varying intensities in the area you place them depending on the product. Though I could not find an absolute measurement system, the company uses a relative labeling system that lists these as different “F strengths,” ranging from 100 to 300. I tried placing the mints in multiple locations around the buccal vestibule and sublingual to see if there was a difference. I found that placing one on the cheek near the parotid papilla is most effective. Repeated placement under the tongue caused roughness and ulceration, whereas placing them in the buccal corridor didn’t cause a physical change in my tissue. Only one mint is needed to produce increased salivation, especially with the higher strengths, but, for maximum stimulation, a mint could be placed bilaterally and sublingually in areas near each major gland group location. Using the mints as lozenges will result in about 30 minutes of effectiveness, while chewing makes the effect more intense, but only lasts about five minutes. This is an interesting adjunctive product for dry mouth patients to feel some relief with a nice variety of flavorings.
Picking Up Good Vibrations
Dental Pod Zima Dental zimadental.co
Ultrasonic cleaning methods have been used in dentistry for a long time as part of instrument sterilization processes for debris removal, but the units are large and quite noisy. In my practice, we were searching for a way to make an ultrasonic bath part of our zirconia bonding process, so we started to look for smaller bath sizes and found the Dental Pod from Zima Dental. The Dental Pod has been a helpful and easily moveable tool, cleaning devices in individual operatories. It typically uses 42,000-hertz ultrasonic waves to vibrate whatever solution is placed in the container, producing nanobubbles in the Pod. This vibration, or cavitation, and bubble formation does not cause physical damage to objects, but it is effective at separating objects or devices from debris and plaque. A standard cleaning entails approximately 4,000 vibrations per second through a five-minute cycle. Depending on the amount of water and weight in the Pod, it will adjust the frequency to optimize the cleaning effect. At just over four inches in diameter, it can contain a single arch of most appliance types, such as clear aligners, mouth guards and dentures. The volume of fluid contained is 150 milliliters (about five fluid ounces). It is also effective at cleaning jewelry, handpiece burs or crowns. The sanitary tablets sold with the product contain sodium bicarbonate as well as sodium carbonate peroxide, citric acid and flavorings to create a clean taste and smell while not being corrosive to metal. Since I use this in my practice, I take measures to maintain a more sanitary environment, such as wiping the interior after use and using a plastic bag as a liner. The Dental Pod is sold for $99.99, so it is not as big an investment as a sterilization unit. For zirconia bonding, I place crown or bridge units prior to sandblasting in an alcohol solution after try-in and treatment with Zirclean or Ivoclean. The Dental Pod is a small and easy upgrade for a hygiene or prosthetic operatory — or for your personal bathroom.
Ross Isbell, DMD, MBA, currently practices in Gadsden, Alabama, with his father, Gordon Isbell, DMD, MAGD. He attended the University of Alabama at Birmingham (UAB) School of Dentistry and completed a general practice residency at UAB Hospital. Isbell has confirmed to AGD that he has not received any remuneration from the manufacturers of the products reviewed or their affiliates for the past three years. All reviews are the opinions of the author and are not shared or endorsed by AGD Impact or AGD. To comment on this article, email impact@agd.org
Be Particular About Your Particles
Ivoclean
Ivoclar
ivoclar.com
A crucial step in achieving a high bond strength is effective cleaning of the intaglio surface of zirconia and lithium disilicate restorations. One of the market leaders in that category is Ivoclean from Ivoclar. This pinky purplish suspension of water and zirconium oxide particles is highly effective at removing phosphate groups leftover from salivary phospholipid contamination. This works due to a chemical equilibrium reaction when a concentration gradient of more abundantly available zirconium particles is reached in an alkaline pH of about 13 to facilitate detachment from the restoration surface and attachment to the free-floating particles of the solution. Sodium hypochlorite is also effective at cleaning surfaces, but it doesn’t actively remove phosphate groups. Phosphate group aggregation only increases with exposure to phosphoric acid from a traditional etch, and etching with hydrofluoric acid on an already etched restoration could result in a weakened structure. So, using an atraumatic cleaning solution like Ivoclean is critical to a strong and strongly bonded prosthetic. After removing the adjusted restoration from the oral cavity, simply paint or coat the intaglio surface for 20 seconds with Ivoclean using a clean microbrush to agitate while treating. Then rinse with water for 20 seconds over a 2.25-inch Coghlan’s filter funnel attached to the highvolume suction. Air-dry for 20 seconds. After the surface is cleaned, I sandblast and then treat the surface with a methacryloxydecyl dihydrogen phosphate (MDP) primer like Monobond Plus prior to delivering with a bonding agent and an adhesive resin cement. The Ivoclean bottle contains five grams, which is typically enough doses for about 50 restorations, so it effectively costs about $1 or less per use. Since this is a solution, make sure to shake it if you aren’t using it often, but I typically see very little separation in the appearance of the liquid. Remember, if you try the restoration into the mouth again after Ivoclean treatment, you must redo the treatment since the phosphate groups have reattached. While it is understandably annoying to add steps to your process, including a surface treatment by Ivoclean will enhance your bond strength and the lifetime of your restorations.
Here is the Isbell Dental zirconia bonding process:
1. Try in and adjust until the fit is good and confirmed with radiograph.
2. Rinse with water to remove blood or other debris.
3. Apply cleaning agent, such as Zirclean or Ivoclean.
4. Perform alcohol bath in ultrasonic cleaning device.
5. Sandblast with alumina oxide.
6. Apply MDP primer, such as Z-plus or Monobond Plus, to intaglio surface.
7. Treat prep with universal bonding agent.
8. Fill intaglio with resin cement and deliver.
Upcoming
Look for this article and more in the September/October 2024 issue of General Dentistry:
Severe radiographic artifact created by a large fenestration of the skin and labial mucosa following placement of a plate piercing
The presence of facial jewelry and medical devices within a radiographic field of view may promote the formation of artifacts that challenge diagnostic interpretation. The objective of this article is to describe a previously unreported radiographic anomaly produced by an oral piercing site below the lower lip.
This unusual artifact masqueraded as a severe resorptive defect, dental caries, or cervical abfraction and occurred following removal of an extremely large labret below the lower lip and subsequent acquisition of a radiographic image. Clinicians should seek correlation of atypical radiographic presentations with soft tissue defects secondary to injury or intentional oral piercing.
In the October 2024 issue of AGD Impact
• The Role of Compassion in Healthcare • Frenectomies in the General Dental Practice
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