AGD Impact December 2024

AGD Impact News for the General Dentist

TECH TOOL

Artificial Intelligence Chatbots Play Increasing Role in Dentistry

Meet AGD’s New President Ethical Considerations for AI

December 2024, Vol. 52, No. 12

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Contents

TECH TOOL

Artificial Intelligence Chatbots Play Increasing Role in Dentistry

By William S. Bike AI chatbots, the most prominent of which is currently ChatGPT, have begun to play a huge role in numerous sectors of society, including healthcare and dentistry. In dentistry, AI and ChatGPT are becoming integrated in three key areas: education, practice management and diagnosis.

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2 Editor’s Note The Importance of a Well-Rested Lifestyle

3 AGD News 6 Legal Matters Legal Liability Arising from the Use of AI

by Dentists: What Jane Austen Has to Do with It

8 Financial Management 3 Proven Strategies to Solve the Hygienist Crisis

10 Ethics Balancing Intuition and Technology: Ethical Considerations for AI in Dental Practice

Dr. Chetty, a SecondGeneration AGD Dentist, Takes Up Presidency

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By Caitlin Davis On Nov. 24, 2024, Chethan Chetty, DDS, MAGD, was inducted as AGD president during the House of Delegates’ annual meeting in Chicago. This coming year, he plans to help guide the organization into the future by taking steps to increase grassroots engagement and promote membership while remaining open to organizational changes that could help modernize and improve operations.

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12 Communications How to Make Time for Everything

23 Testing the Tools

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Editor’s Note

The Importance of a Well-Rested Lifestyle S leep allows the body to restore healthier brain function and elevates physical health and well-being. However, as adults, we never seem to have enough time to accomplish our daily goals. Rushing around from morning to night is not a healthy lifestyle, but it seems to be the norm in our fast-paced world.

We rush to get out of the house, sacrificing a decent meal to start the day. As dentists, we often exert much mental energy treating complicated cases that appear in our dental chairs. We must focus intensely for short periods of time. We deal with many stresses throughout the day — running a business, creating a professional and proper medical experience, and handling myriad personal issues in our lives and in the lives of those around us. Stress becomes innate and must be dealt with before serious acute health issues arise. These stressful days can affect our sleep patterns. Constant lack of proper, deep sleep may raise the risk of chronic issues such as hypertension, diabetes and stroke.

“A positive quality of life means creating balance, maintaining health, and developing relationships filled with respect and love.”

Relieving stress can begin with calming oneself in preparation for a restful night. Moving the body can help reduce stress levels and improve temperament. Research indicates that aerobic exercise a couple times a week may significantly reduce stress levels and improve depressive tendencies. Pilates is a critical part of my lifestyle.

It is challenging and uncomfortable, but so rewarding. I truly wish I had started 25 years ago.

Depletion of essential nutrients and vitamins can also affect sleep patterns and increase anxiety.

Eating better meals, eating them in moderation

and consciously reducing processed foods helps. Again, in our fast-paced world, it is easier to grab that hamburger or sub sandwich. Because I lecture around the country, grabbing junk food is easy, but I’ve worked hard to train myself not to act on these urges. Planning time and exchanging empty calories with better energy sources not only reduces weight gain but also makes one feel more vitalized.

Our cell phones seem to be attached to our hands and ears. While each of us needs human contact, we must learn to communicate in a balanced way to ensure a balanced lifestyle. I have mentioned it is imperative that, as professionals, we meet and exchange ideas in person. While virtual learning is convenient, nothing beats sharing knowledge and experiences in person. Learning this way only elevates our clinical skills and reduces stress by making us more assured practitioners.

A positive quality of life means creating balance, maintaining health, and developing relationships filled with respect and love.

Self-help requires a conscious desire to realize deficiencies and build a means to address them.

Each day requires an effort to achieve our goals.

Procrastination is not an option. This only leads to a heavy mind and an overwhelming lack of productivity. Once we start running late, we have to catch up, and we may give up or, worse, make serious mistakes in judgment. An effective coping mechanism to help reduce daily anxiousness and create better sleep patterns is to address issues head-on, communicate with those around us, eat better and take care of our bodies. There are many issues in life that cannot be controlled, but pausing and noticing our personal stressors may raise our quality of life to incredible heights.

Timothy F. Kosinski, DDS, MAGD Editor

Editorial Staff 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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How to Reach Us Academy of General Dentistry 560 W. Lake St., Sixth Floor Chicago, IL 60661-6600 agd.org impact@agd.org 888.243.3368 312.335.3427 (fax) DISCLAIMER: The Academy of General Dentistry does not necessarily endorse opinions or statements contained in essays or editorials published in AGD Impact. The publication of advertisements in AGD Impact does not indicate endorsement for products and services. AGD approval for continuing education courses or course sponsors will be clearly stated. AGD Impact (ISSN 0194-729X) is published monthly by the Academy of General Dentistry, 560 W. Lake St., Sixth Floor, Chicago, IL 60661-6600. Canadian Mailing Information: IPM Agreement number 40047941.

Change of address or undeliverable copies should be sent to: Station A, P.O. Box 54, Windsor, Ontario, N9A 6J5, Canada. Email: impact@agd.org. Periodical postage paid at Chicago, IL and additional mailing office. *AGD members receive AGD Impact as part of membership; annual subscription rates for nonmembers are $70 to individuals/$90 to institutions (orders to Canada, add $15). Online-only subscriptions available outside U.S./Canada are $75 to individuals/$115 to organizations. Single copy rates are $17.50 to individuals/$20 to institutions (orders to Canada, add $2.50). All orders must be prepaid in U.S. dollars.

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The appropriate remittance of $3 per article/10¢ per page is paid directly to the CCC, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. The copyright owner’s consent does not extend to copying for general distribution, for promotion, for creating new works, or for re-sale. Specific written permission must be obtained from the publisher for such copying. The Item-Fee Code for this publication is 0194-729X. Printed in U.S.A. © Copyright 2024, Academy of General Dentistry, Chicago, IL.

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AGD News Awards

Be a Part of Convocation at AGD2025 Apply to receive your Fellowship, Mastership, or Lifelong Learning and Service Recognition at AGD2025 in historic Montréal, Quebec!

Complete all requirements and submit applications by Dec. 31, 2024.

Show your dedication to enhancing your clinical knowledge, and apply today! Learn more at agd.org/education/awards-recognition/ other-awards/. If you need help acquiring the required CE search the AGD CE Directory or browse the Online Learning Center.

Oregon Dentist Dr. Julie A. Spaniel Awarded Prestigious Humanitarian Service Award AGD recently recognized Julie A. Spaniel, DDS, a general dentist from Portland, Oregon, with the prestigious 2024 AGD Humanitarian Award. The award was presented during AGD’s Annual Meeting in Chicago, Nov. 22, 2024. Spaniel, a member of AGD for more than 35 years, was recognized for her selfless international mission work and commitment to mentoring young, up-and-coming dentists. This award is given each year to a dentist who contributes volunteer service in conjunction with a consistent commitment to enhancing the image of general dentistry through the continuous delivery of quality dental care.

“Dr. Spaniel has made service a way of life,” said Bill Jordan, DMD, MAGD, Oregon AGD past president. “Her work with underserved populations can only enhance the opinion of those she serves that the dental profession as a whole cares and sacrifices to meet their needs.”

Spaniel began her dentistry career after receiving her DDS from the University of North Carolina at Chapel Hill School of Dentistry. As a dental student, Spaniel was offered the opportunity to provide dental services to underserved communities of North Carolina. In 2010, an experience in Ghana led her to participate in missions providing oral healthcare to underserved populations in Ghana, Honduras, the Maasai Mara region of Kenya, and Uganda.

In 2018, with the relationships and connections she made in Uganda and Kenya, Spaniel founded the nonprofit organization One World Brigades. The organization’s mission is to bring student

volunteers to rural communities in Honduras, Ghana and Kenya to provide medical and dental health services. In 2020, the organization assisted in building a school in Kenya’s Maasai Mara region. In addition, the organization has assisted with clean water projects, sanitary restroom facilities and teachers’ living quarters, and is launching a solar project this year.

“Over the years, I have found equal joy in providing care and watching [the student volunteers] grow and change before my eyes,” said Spaniel. “The people, both the students and adults, who have joined us on our trips are never the same after they return home.”

Spaniel is currently in private practice. She is actively involved in the Oregon Dental Association and the American Dental Association (ADA), chairing the Dental Wellness Committee for the state of Oregon. She is on the Dental Wellness Advisory Committee for the ADA and was recently asked to serve on the first cohort of 10 wellness ambassadors to the ADA. She is the annual meeting coordinator and president of the National Academy for Private Dental Practice. She is on the board of the Oregon AGD, serves as past president on the executive board of the Washington County Dental Society, and is actively involved in the American Academy of Oral Systemic Health.

Nominate Colleagues for the 2025 Albert L. Borish, Distinguished Service and Humanitarian Awards AGD is seeking nominations for the 2025 Albert L. Borish, Distinguished Service and Humanitarian awards, all of which recognize exceptional achievements and contributions to the dental profession. Access the nomination forms by visiting agd.org/ continuing-education-events/get-recognized/awards. All nominations and supporting documentation must be submitted by March 14, 2025, to the AGD Awards Committee, Office of the Executive Director, 560 W. Lake St., Sixth Floor, Chicago, IL 60661-6600.

For more information, email executiveoffice@agd.org or call 888.243.3368, ext. 4330. Award recipients will be honored during the 2025 House of Delegates annual meeting.

AGD Fact Sheets

Talking to Patients About Flossing AGD fact sheets provide your patients with all of the information they need to maintain their oral health. Fact sheets on more than 25 oral health topics are available for downloading online and can be customized to include your name and practice information. Download the fact sheet “Floss to Prevent Gum Disease” at agd.org/factsheets.

Is Your Practice Seeking Dental Staff?

AGD’s Marketplace & Career Center allows you to search for candidates and post open positions.

FIND THE PERFECT FIT FOR YOUR OFFICE TODAY

marketplace.agd.org/employers

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AGD News Advocacy

In Memoriam

2024 Virtual Advocacy Conference

Richard W. Dycus, DDS (1961–2024)

The 2024 Virtual Advocacy Conference will take place Dec. 20, noon to 4 p.m., and Dec. 21, 9 a.m. to 1 p.m. CST. AGD works every day to ensure that general dentists like you are heard when and where it matters most. Join this free virtual event to gain insights into the current legislative and regulatory landscape and how it affects your practice.

Hear from members of AGD’s two advocacy councils — the Legislative & Governmental Affairs Council and the Dental Practice Council — on issues they are tracking, and learn how you can make a difference at the state and federal levels.

Richard W. Dycus, DDS, a past president of the Tennessee AGD as well as a dedicated and respected husband, father, brother, church member and dentist, died Sunday, Oct. 6, at Cookeville Regional Medical Center following a brief illness.

He was born in May 1961 in Davidson County, Tennessee.

He earned a BS in chemistry from Tennessee Tech University in 1983 and went on to graduate from the University of Tennessee College of Dentistry in 1987, where he laid the foundation for a distinguished career in dentistry.

From 1989 until his retirement in 2023, Dycus operated a dental practice in Cookeville, Tennessee, earning a distinguished reputation among his peers and the community. His contributions to the field of dentistry included serving as the past president of both the Tennessee Dental Association (TDA) and the Tennessee AGD, as well as trustee to the TDA and on several councils and committees at the local, state and national levels, marking him as a leader and an advocate for dental health in the state and nation.

Dycus is survived by his beloved wife of 40-plus years, Patricia (Patty) M. Dycus; a daughter, Megan E. Dycus; a son, William W.W. Dycus; and brothers: Mark E. Dycus and his wife, Alicia, of Murfreesboro, Tennessee, and David K. Dycus and his wife, Amanda, of Huntsville, Alabama; aunt, Louise W. Kemp, of Greensboro, North Carolina; and many nieces and nephews, who will cherish his memory. He was preceded in death by his parents, Foy W. Dycus and Peggy K. Dycus.

Learning Objectives: • Gain insights and perspectives on various state and federal oral health issues.

• Develop an awareness of how intradentistry collaborations can impact advocacy efforts.

• Discover how you can influence legislative and regulatory conversations.

• Discuss the advocacy efforts AGD is undertaking on behalf of our members.

Agenda Topics: • Advocacy Within Organized Dentistry.

• How Federal Regulatory Reform Impacts Your Practice.

• The CDT Code.

• Dental Artificial Intelligence.

• Dental Benefits Plan Frustrations.

• Future of Federal Dental Benefits.

• Perspectives from a State Legislator.

• Dental Loss Ratio Reforms.

Topics subject to change.

This event is free for AGD members ($525 for nonmembers) and worth 6.75 continuing education credits under the AGD 770 Self-Improvement subject code. Learn more and register online at agd.org/advocacy/ agd-priorities/advocacy-center/2024/12/20/default-calendar/ virtual-advocacy-conference.

Get Social and Connect with AGD See Pictures & Updates

Instagram: @academyofgeneraldentistry Facebook: Academy of General Dentistry X (Formerly Twitter): @AGDdentist

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Legal Matters

Legal Liability Arising from the Use of AI by Dentists: What Jane Austen Has to Do with It

By Jake Kathleen Marcus, JD, PGDip

T

he use of artificial intelligence (AI) in dentistry, as in many other healthcare fields, raises questions about liability for harm or errors that may result from its use. These liability concerns typically center around who is responsible if AI systems provide incorrect or misleading information or if errors result in patient harm. It is critical that dentists understand the potential liability they face when using AI or tools that use AI and what dentists can and should do to protect themselves and their patients.

Several years ago, as part of the work for my graduate diploma in the law of technology, I took a course at Queen Mary University of London on AI. It was a deep dive into the science (which I generally understand) and the math (which I rarely understand) of algorithms, large language models and generative AI. It also covered the myriad legal issues requiring regulation, such as the use of AI in policy profiling (deeply flawed and resulting in civil rights violations the world over), and how use of the enormous amounts of data required raises copyright claims (even if the “garbage that comes out” means what went in was garbage, someone wrote that garbage, and the writer wants to be paid).

Around the same time, the lead of IT at a major tech company told me why generative AI — the AI that purports to create new ideas — simply didn’t work. Her one-word answer: “hallucinations.”1 When AI doesn’t know the answer to a question, it simply makes one up, generating a response it thinks you want to hear.

Her example: When asked about something Elizabeth Bennett did in “Sense and Sensibility,” some generative AI systems will have an answer. The problem, as any Jane Austen fan can tell you, is that Elizabeth Bennett is a character in “Pride and Prejudice,” not “Sense and Sensibility.” While this particular “hallucination” doesn’t happen anymore, there remains significant concern regarding the risk of AI hallucination in healthcare.2 I include this hallucination story here because, if AI can tell you what it thinks you want to hear about Jane Austen, it can also “hallucinate” diagnoses and treatment plans. Both the lawyer and the Jane Austen fan in me conclude that someone is going to get sued.

Professional Liability, or ‘Will AI Get Me Sued?’

Dentists have a duty of care to their patients, and if they choose to use AI in their diagnoses or treatment-planning, they remain

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responsible for the final decisions made. Dentists cannot solely rely on AI-generated data to absolve themselves of liability. If a dentist uses an AI tool that provides incorrect information, but the dentist fails to notice and/or act and a patient is harmed, the dentist could still be held liable for malpractice. Both law and ethics require that dentists exercise their own professional judgment in all cases.

A crucial element in a dental malpractice action is whether the dentist deviates from the “standard of care.” As healthcare providers and lawyers know (or should know), the applicable standard of care can be a moving target based on medical research, education and even the geography of the patient. With the many unresolved questions regarding AI, there is not yet an accepted standard of care for the use of AI in dentistry, thus creating greater vulnerability for dentists. Courts will have to consider whether using AI meets or exceeds the standard of care expected from a competent dentist, but, presently, no clear definitions exist.

Shared Liability?

In some cases, liability might be shared between the AI developers, manufacturers and dentists. If, for example, an AI tool misdiagnoses a condition due to flaws in its algorithm, both the creators of the AI system and the dental professional using it could face liability.

However, the dentist’s failure to critically assess the AI’s output before applying it in treatment is legally the fault of the dentist. Where there is damage to the patient and fault on the part of the dentist, the dentist is likely to be found liable for all or part of whatever damage occurs.

Medical Device Regulation

Insurance Implications

AI tools used in dentistry may be classified as “medical devices” depending on their function. The Food and Drug Administration (FDA) regulates medical devices, including some AI-powered technologies. Therefore, if AI software is classified as a medical device, the manufacturer is required to ensure its safety, effectiveness and accuracy. If the tool malfunctions or provides misleading information, the manufacturer may be liable for product defects or negligence.

But dentists cannot rely on FDA regulation to avoid liability in the event of a bad patient outcome. Dentists still have an obligation to fully inform themselves regarding the medical devices they use. FDA regulation may require the device to carry warnings or use instructions, which shift liability to the dentist if the dentist does not read and follow the warnings or varies in any way from the device instructions. If a medical device causes harm because of a defect in manufacture, some liability might be shifted to the manufacturer. However, if a device is harmful because it is not used in accordance with its instructions, the liability lies with the dentist and not the manufacturer. The involvement of AI in the design, manufacture or operation of the device does not change this most basic fact of a dentist’s liability for harm.

Professional malpractice insurance for dentists might also need to evolve to address the risks of AI usage. Some insurance policies may not currently cover harm resulting from AI tools, which could expose dentists to greater personal financial risk. This is a problem with a simple solution — ask your carrier. If you use AI, be insured for its use.

Informed Consent Dentists should inform patients when AI is being used in their care. This transparency ensures that patients are aware of the nature of the technology used, allowing them to consent to or opt out of such treatments. If patients are not informed and something goes wrong, it could lead to legal challenges based on the failure to obtain informed consent.

However, the nature of AI and its inherent unknowns means the dentist may not understand either how the AI works or what mistakes it can make. If the dentist does not understand, the dentist cannot explain to the patient. If the dentist cannot explain to the patient, the patient cannot give informed consent. This cycle seems unbreakable. However, in the informed consent process, a dentist can reveal the limitations of what they know. Informing patients that there are unknowns is something dentists do every day and should not fear.

Data and Privacy Concerns AI in dentistry often relies on patient data, including scans, radiographs and other health information. Misuse of this data or breaches in patient privacy, especially with AI systems that involve cloud storage, could lead to liability under privacy laws, such as the Health Insurance Portability and Accountability Act (HIPAA).

For dentists using AI, it is critical that HIPAA and the Health Information Technology for Economic and Clinical Health Act (HITECH) are strictly followed. For example, any system that uses or stores patient information, regardless of whether AI is used, must be HIPAA-compliant. For any transmission or storage of patient data that will involve a third-party company, the dentist must have a business associate agreement with that entity. For all of its potential benefits, AI is yet another risk to the dentist for sanction by the U.S. Department of Health and Human Services Office for Civil Rights for violation of HIPAA and/or HITECH.

Conclusion and Best Practices Liability for the use of AI in dentistry is complex and evolving. It typically involves the interplay between the dentist’s professional duty, the manufacturers’ responsibility for the AI tools and evolving legal standards around AI in healthcare. It is essential that dental professionals understand that they bear the ultimate legal responsibility for harm that results from damage to their patients arising from the use of AI in treatment and in treatment plan decisionmaking. Dentists must be sure they are fully aware of the scope of malpractice coverage in the event of an AI-involved outcome. While informed consent from patients can mitigate some potential liability, patients cannot give truly informed consent to treatment choices they do not fully understand — particularly if, given the nature of AI, the dentist themself does not fully understand how the AI functions.

Best practices to limit potential liability arising from the use of AI in the dental office are (and note these are best practices in dental offices even if “use of AI” is removed as a variable): • Redraft all HIPAA/HITECH/data privacy documents to address the use of AI in your practice.

• Redraft informed consent documents to include what you do and what you do not know about the AI you are using, regardless of whether the AI is classified as a software or medical device.

• Stay informed and keep your staff informed. There is no shortage of continuing education on the use of AI in dentistry. Be sure you and your team are attending.

• Ask your professional liability carrier about your coverage for damage that might be caused by the use of AI or tools that use AI. • Read the warnings and instructions on all equipment and software that uses AI, and follow them.

Thus far, litigation resulting from the use of AI in healthcare has concerned copyright and antitrust — business concerns that do not put healthcare providers themselves at greater risk of liability. Also — and critically — the use of AI may very well result in fewer clinical mistakes. Fewer clinical mistakes should result in fewer malpractice claims. It is too early to know if this is true, and too few medical liability claims have been filed to see a pattern, but dentists can best protect themselves and their patients by staying informed. ♦ 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. Shen, Yiqiu, et al. “ChatGPT and Other Large Language Models Are Double-edged Swords.” Radiology, 2023, vol. 307, no. 2, doi: 10.1148/radiol.230163.

2. Moulaei, K., et al. “Generative Artificial Intelligence in Healthcare: A Scoping Review on Benefits, Challenges and Applications.” International Journal of Medical Informatics, vol. 188, August 2024, p. 105474, doi: 10.1016/j.ijmedinf.2024.105474.

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Financial Management

3 Proven Strategies to Solve the Hygienist Crisis or the past few years, an overwhelming complaint across the entire dental industry has been that owners can’t find hygienists. According to the American Dental Association Health Policy Institute, the industry lost almost 10,000 hygienists between 2020 and 2023, or almost 5% of the workforce.1 Meanwhile, according to the U.S. Bureau of Labor Statistics, the employment of dental hygienists is projected to increase by 9% over the next decade.2 Since this shortage is unlikely to solve itself overnight, make sure to implement these three strategies to attract and maintain top talent.

Once you have all A and B employees, be sure to reward them not only with money, but also with random acts of kindness. For example, I work with a dentist who will sporadically send his staff to happy hour. Rather than forcing his employees to hang out with him, this dentist discovered it was best to call the bar and pay the tab, allowing the employees to enjoy time with each other. These acts of kindness should always be random, as once something becomes a regular occurrence, the staff will view it as an entitlement program.

Lastly, empower your employees! Many leave due to a lack of job satisfaction. For hygienists, do you have protocols for how to handle obvious treatment needs? While the hygienist certainly shouldn’t be responsible for recommending treatment, being on the same page can both empower your hygienists and increase your conversion rate. For example, if there is a crack in the tooth, does the hygienist point it out? Do they explain the next steps and provide some comfort? Having standard procedures and a gameplan for the hygienist to help educate your patients will make them feel more valuable while also ensuring the patient understands the need for treatment.

Cultivate a Strong Company Culture

Offer Competitive Compensation and Benefits

Put simply, your employees must enjoy coming to work. To accomplish this, you must get rid of the bad employees and reward the good ones. I generally group employees into three categories — A, B and C employees. A-level employees are all-stars that can’t be persuaded to misbehave or slack off. They are hardworking and loyal by nature. C-level employees are the opposite, constantly trying to pull one over on you and hoping to bring everyone else down with them. B employees are in the middle and will follow the strongest lead. In order to mitigate having a disastrous culture, eliminate all C employees quickly, because they are the main source of disruption in your office.

Many dentists are shocked and caught off guard by employees receiving offers to work elsewhere for substantially more money.

With a lack of hygienists and increased demand, this should come as no shock. The problem many dentists don’t see coming is that by having one employee successfully negotiate a higher wage, the remainder threaten to leave one by one until wages are increased. It’s best to get competitive from the start. The Bureau of Labor Statistics website (bls.gov) is a great place to find wage ranges by area.

The option of corporate dentistry has also provided hygienists with an array of benefits should they switch jobs. Private practice

By Wesley W. Lyon II, CPA, CFP®

F

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owners must compete here as well. Offering a retirement plan is great, but the real key is health insurance, followed by paid time off. Be sure to communicate these benefits each year by providing an annual pay statement, showing their effective hourly wage including benefits.

Implement a Production-Based Bonus System Lastly, we need to encourage hygienists to produce more in order to cover these additional expenses. Based on consulting with hundreds of dentists over the past few years, I have found most hygienists are hesitant to return to pre-COVID protocols of 50-minute appointment intervals for routine cleanings, instead choosing to enjoy more free time on the clock. In order to turn profits around, hygiene appointment times need to return to pre-pandemic lengths, and the urgency to fill cancellations needs to increase. Rather than threatening hygienists, try a productionbased bonus system instead.

This bonus system will pay the hygienists a percentage of any production over their daily baseline. For example, if a hygienist’s baseline production is $1,100 per day, but he or she produces $1,300 per day, the bonus would be based on the $200 increase.

Often, dentists will pay 30% of this increase as a bonus.

The key is to ensure the baseline is set correctly. If one of your hygienists is currently producing only $600 per day, you cannot simply create a bonus of 30% of anything above $600. Instead, you need to calculate the baseline based on three times daily wages, since the industry standard for hygiene pay is one-third of net production. For example, if a hygienist is paid $46 per hour, the baseline production figure would be $46 multiplied by 8 hours, multiplied by three to ensure that wages are equal to one-third of net production. In our example, this would set the baseline at $1,104 per day.

To pay the bonus, I recommend calculating the differences quarterly, rather than daily. Let’s assume this hygienist worked 40 days in a quarter. He or she would have a total baseline production of $1,104 × 40, or $44,240. If the hygienist’s true net production was $52,500, then the bonus would be equal to 30% of the difference ($52,500 - $44,240 = $10,260), or $3,078. This is the equivalent of an additional $9.62 per hour.

The hygiene shortage is unlikely to solve itself anytime soon.

While implementing these strategies is always easier said than done, dentists who take these to heart will have an easier time maintaining staff, recruiting replacements, and increasing production and collections. With the current shortages in the market, I recommend dentists be proactive rather than reactive, at least until we see some staffing relief. ♦ 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 Danielle Fitzgerald at 877.306.9780, or email consulting@mcgillhillgroup.com. To comment on this article, email impact@agd.org.

References 1. “Wage and Job Count Dashboard.” American Dental Association Health Policy Institute, ada.org/resources/ research/health-policy-institute/wage-and-job-count-dashboard. Accessed 7 Oct. 2024.

2. “Dental Hygienists: Occupational Outlook Handbook.” U.S. Bureau of Labor Statistics, 29 Aug. 2024, bls.gov/ooh/healthcare/dental-hygienists.htm. Accessed 7 Oct. 2024.

Dental Seminars & Symposia, LLC Nationally Approved PACE Program Provider for FAGD/MAGD credit.

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Ethics

Balancing Intuition and Technology: Ethical Considerations for AI in Dental Practice

By Robert D. Stevenson Sr., DDS, FAGD, FACD, FICD, FPFA, FAAHD

This column is a collaboration between AGD and the American College of Dentists.

A

s artificial intelligence (AI) technology becomes increasingly integrated into dental practices, dentists like Amanda Jones, DMD, find themselves navigating new ethical and professional challenges. Jones sits at her office computer, her brow furrowed in concentration. An emergency patient waits in the next room, and the diagnostic software on her screen recommends extraction of a grossly carious, painful tooth. Despite the software’s recommendation, Jones, a recent graduate, believes the tooth is restorable. She faces a dilemma: Should she trust her intuition or the judgment of the computer program?

Our society has become captivated with the possibilities of AI. Generative AI has shown its value in creating documents, images and video. The technology is also making inroads into the practice of dentistry, with the promise of improved diagnostic accuracy, streamlined operations and enhanced administrative management. Studies show that AI’s accuracy in identifying caries, periapical radiolucencies and bone loss may equal or exceed that of the average dentist.1,2 Generative AI can be valuable administratively as a tool for claims submission, marketing and treatment planning. It can also aid in evaluating contracts. Generative AI will also provide an executive summary of articles in dental journals that busy dentists can’t seem to get to otherwise. Predictive AI is a new application of AI to healthcare. Predictive AI can evaluate patterns and predict possible outcomes based on the patterns it discerns. Besides obvious business and investment applications, it has the potential to predict possible outcomes, particularly in disease progression such as precancerous lesions. It may also help in establishing prognoses for treatment of intraoral diseases, implant placement and other processes.

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While AI offers many benefits, it also raises important ethical questions that must be addressed. Data privacy and security are high on the list for dentists. The current models of AI are trained to recognize patterns in words or images. As a platform is exposed to more samples, its accuracy increases. Bear in mind that the dentist has the ultimate responsibility for securing protected health information when using AI; this responsibility must not be entrusted to the software alone.

An AI system is no better than the data it has reviewed.

Methods must be developed to ensure AI is exposed to diverse patient groups to minimize biases that could lead to inaccurate diagnoses. A prudent dentist should be prepared to critically evaluate output from the tools he or she uses; there is no substitute for critical thinking in dental care. As dentists use these tools, they must be aware of the limitations of computer learning and be prepared to evaluate the responses they receive from their software.

Eric S. Swirksy, in the Journal of the American College of Dentists, notes that “the words ‘bias,’ ‘disparities’ and ‘algorithm’ do not appear in American Dental Association (ADA) Principles of Ethics & Code of Conduct, but they do not need to.”3 The American College of Dentists’ (ACD) “Ethics Handbook for Dentistry” also applies but does not specifically address AI. Each of the five principles in the ADA Code has application to AI. Even if one is not an ADA member, the legal system expects that each dentist should abide by these principles. The principle of stewardship, as described by the ACD, describes the responsibility as a member of the dental profession to safeguard the standards and reputation of the dental profession, including one’s colleagues.4 The principle of autonomy applies to the choices the dentist makes as well as to empowering the patient to participate in treatment decisions. Data privacy is an essential element of autonomy, and respect for the patient’s preferences about diagnostic processes and treatment are crucial. For instance, if an AI system recommends a treatment that conflicts with a patient’s preferences, how should a dentist navigate this situation while respecting the patient’s autonomy?

Nonmaleficence is honored as the practitioner critically assesses the options provided by his or her electronic consultant. If critical thinking and professional clinical judgment are discarded, the inherent risk of unwanted outcomes leading to harm increases. Protocols should be developed to ensure that the dentist’s professional judgment is respected and takes precedence over artificial opinions.

Beneficence is at the heart of all dental treatment. Competence is a key part of providing appropriate care; it develops through experience, focused continuing education and training in new methods of technology. The dental team, under guidance of the dentist, should be well informed.

The principle of justice focuses on minimizing biases and promoting fairness in clinical decisions. Bailey states that “AI-driven interventions should improve equity and not worsen existing disparities.”5 Justice, in tandem with veracity, suggests that the provider be transparent and honest about the tools used in diagnosis and treatment-planning if the patient expresses an interest. Justice also demands the use of critical thinking in clinical decisions.

Veracity calls for the clinician to be honest with patients and honest with themself. The limitations of artificial decision-making

must be honestly accounted for when considering what and how to treat any condition within the scope of the dentist’s practice.

The dentist should also consider the principle of reflection, as addressed by the ACD. Being reflective assists the dentist in developing clinical judgment and is a valuable tool in improving the delivery of dental care.

Finally, the ACD discusses accountability. Each dentist is accountable for his or her own actions and decisions. The dentist must be willing to bear responsibility for their own treatment decisions and for treatments rendered. The increasing integration of AI in dental practices complicates the attribution of responsibility for errors or incorrect diagnoses. When an AI-recommended treatment leads to poor patient outcomes, it’s unclear who bears liability — the dentist relying on the AI, the AI’s developers or the AI system itself.

To ensure responsible AI use in clinical settings, it is crucial to develop explicit guidelines and legal frameworks. Both AGD and the ADA are already taking steps to address these issues.

Understanding these ethical principles is crucial as dentists navigate the practical implications of AI in their daily practices. AI is likely to become more consistent and objective than any single human clinician. Human practitioners rely on their limited personal experience and gut feelings, while AI relies on patterns drawn from the broad experiences of many. It may offer a second opinion based on its compilation of numerous successful outcomes. AI can augment what we see, influence how we see it, and enhance the management of our treatments and our decisions.

In conclusion, while AI has the potential to revolutionize dental practice, it is crucial for dentists to critically evaluate AI recommendations and uphold ethical standards. Jones’ dilemma at the beginning of this column highlights the importance of balancing technological advancements with professional judgment and patient-centered care. Dentists can ensure that AI serves as a valuable tool rather than a replacement for human judgment. What should Jones do? What would you do if you were in her position?

My late colleague, Ronald Antimarino, DMD, often said, “You’re the doctor. Make the right decision.” Take responsibility and choose a course of action. ♦

Disclosure: The author was assisted by Microsoft Copilot AI in creating the clinical scenario and editing this paper.

Recommended Reading “Principles of Ethics and Code of Professional Conduct: With Official Advisory Opinions Revised to March 2023.”

American Dental Association, ada.org/-/media/project/adaorganization/ada/ada-org/files/about/ada_code_of_ethics.pdf.

Kluck-Nygren, Cindy. “Dental Practice Advocacy Survey Results: AGD Members’ Use of Artificial Intelligence (AI)/Augmented Intelligence (AuI) in the Dental Practice.” Academy of General Dentistry, 2024, agd.org/docs/default-source/default-document-library/ agd-member-survey-re-ai-aui_2024-june30_cd.pdf.

“Dentistry—Overview of Artificial and Augmented Intelligence Uses in Dentistry.” American Dental Association, 2022, ada.org/-/media/project/ada-organization/ada/ada-org/ files/resources/practice/dental-standards/ada_1106_2022.pdf.

Robert D. Stevenson Sr., DDS, FAGD, FACD, FICD, FPFA, FAAHD, is associate professor and preclinical curriculum coordinator at Western University College of Dental Medicine. To comment on this article, email impact@agd.org.

References 1. Perhani, F. “Promises and Perils of Artificial Intelligence in Dentistry.” Australian Dental Journal, vol. 66, no. 2, June 2021, pp. 124-135.

2. Alowais, S., et al. “Revolutionizing Healthcare: The Role of Artificial Intelligence in Clinical Practice.” BMC Medical Education, September 2023, vol. 23, no. 689.

3. Swirsky, E. “Plausible Deniability and Algorithmic Bias in Automated Decision-Making.” Journal of the American College of Dentists, vol. 90, no. 3, Fall/Winter 2023, pp. 25-31.

4. Ethics Handbook for Dentistry. American College of Dentists, 2024, acd.org/communications/ethics-handbook/.

5. Bailey, Meredith A. “Ethical Considerations for the Integration of Artificial and Augmented Intelligence in Dentistry.” The Journal of the American Dental Association, vol. 155, no. 8, 2024, pp. 721-722.

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Communications

How to Make Time for Everything

By Gerard Scannell, DDS

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n our fast-paced world of dentistry, achieving a good work-life balance is an essential but often elusive goal. Many dental professionals strive to excel in their careers while simultaneously managing family life, personal health and continual professional development. For those with young families, especially new parents like myself, this balancing act can be even more challenging. When you consider the desire for mini vacations, time for self-care and the pursuit of professional growth, it becomes clear that finding harmony in these different aspects of life is crucial for long-term success and well-being.

As I’m writing this, my four-week-old newborn is lying by my side. And, although she is top of mind for me, I know it’s important to balance other aspects of my life. From my perspective, that starts with planning and flexibility. Parenthood is a full-time job, and combining it with a dental career requires strategic time management and strong support systems. Here is some wisdom that family and friends have bestowed upon my wife and I as we begin this journey: Set realistic expectations. It’s essential to acknowledge that you won’t be able to do everything perfectly all the time.

Accepting this can alleviate a lot of pressure. Prioritize what’s most important each day and allow yourself to let go of perfectionism.

Create a good support system. Surround yourself with a supportive network of family, friends and colleagues who understand the demands of your profession. A well-connected support system will provide both emotional and practical assistance when you need it.

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Incorporate flexible scheduling. One of the advantages of being a dentist is that, in some cases, you can have control over your schedule. Consider adjusting your clinic hours to fit the needs of your family, whether that means working fewer days or arranging your schedule around school drop-offs and pickups. My wife owns her own practice and will be slowly transitioning back to work after maternity leave. I know this is not a luxury everyone has, but there are surely some ways to incorporate flexibility into your schedule.

One of the most profound suggestions someone gave us is to remember that we aren’t superheroes and don’t have to be. Many of us have type-A personalities and strive to do everything perfectly, but that is often counterproductive when we are trying to achieve a good work-life balance.

Taking Breaks As we manage the demands of work and family, we can benefit significantly from taking short, regular breaks in the form of mini vacations. These quick getaways can recharge your energy, enhance your creativity and improve overall well-being. It’s easy to let months slip by without taking time off, but scheduling mini vacations ahead of time ensures you commit to the break. Plan short trips over long weekends, or take advantage of holidays. Even a few days away can make a difference. Make a conscious effort to disconnect from work when you’re on vacation, as well. Turn off your phone’s email notifications, and resist the urge to check patient records. Instead, focus on enjoying time with your family or simply relaxing. This gives you time to truly reset mentally.

Even if you can’t take a trip far from home, spending a day or two away from the office, reading or engaging in hobbies, can provide a mental refresh. You may think this will set you back professionally, but I would argue that it does the opposite.

When you return to work, you’re likely to feel more focused and energized, and this renewed energy can help you be more present in both your professional and personal lives.

Another important aspect of achieving success in our personal and professional lives is our overall health. Dentistry can be physically demanding. We spend long hours sitting, standing, bending and working in all sorts of awkward positions. Taking care of your physical health is essential, not only for your wellbeing but also for your ability to provide quality care for your patients. Physical activity is vital for keeping your body strong and resilient. Whether it’s yoga to improve flexibility, strength training to build endurance or simply going for a walk, make time for exercise. Even a 20-minute daily routine can have significant benefits. Pay attention to ergonomics in your practice. Use ergonomic dental chairs and equipment designed to minimize strain on your body. Practicing good posture and taking regular breaks to stretch can help prevent chronic issues like back pain and neck strain. A healthy body needs adequate rest and proper nutrition.

Make sure to get enough sleep to recover from the day’s work, and fuel your body with balanced, nutritious meals that provide the energy needed for demanding workdays. Dental professionals are susceptible to burnout due to the high-stress nature of our work. Mindfulness practices such as meditation, deep breathing or even regular counseling can help manage stress and maintain a healthy work-life balance.

Continuing Education Balancing professional development with your personal life is another challenge that dental professionals face. In the everevolving field of dentistry, it’s important to stay updated on the latest techniques and technologies. However, continual learning doesn’t have to come at the expense of personal well-being.

Remember to set realistic goals for your professional development.

Rather than overloading yourself with courses and certifications, choose a few key areas of growth and focus on them. Prioritize quality over quantity when it comes to continuing education.

Virtual conferences, webinars and online courses have become more accessible than ever. These can be great tools for keeping up with advancements in dentistry without leaving home for extended periods. Block out specific times in your schedule dedicated to learning and skill development. By setting aside time for professional growth, you ensure it remains a priority without conflicting with family or personal time.

Establish both short-term and long-term career goals. Whether it’s opening your own practice, specializing in a particular area of dentistry or improving patient care, having a clear roadmap for your career can help you maintain motivation and focus on meaningful progress.

Achieving work-life balance as a dental professional may not be easy, but it’s possible with intention and thoughtful planning.

Raising a family, caring for your health and advancing your career in dentistry are all important, and they can coexist with the right approach. By prioritizing time for yourself, your family and your professional growth, you can create a fulfilling, well-rounded life both inside and outside the clinic. ♦ Gerard Scannell, DDS, is a general dentist practicing in his hometown of St. Petersburg, Florida. To comment on this article, email impact@agd.org.

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TECH TOOL Artificial Intelligence Chatbots Play Increasing Role in Dentistry

By William S. Bike

I

n general, the concept of artificial intelligence (AI) is using software to execute tasks formerly performed exclusively by humans.1 AI chatbots, the most prominent of which at this time is ChatGPT (which stands for “Chat Generative Pre-Trained Transformer”), use AI software to train on large language models — vast amounts of textual data from various diverse sources — in an attempt to both understand conversational questions and generate humanlike responses.2 AI chatbots have begun to play a huge role in numerous sectors of society, including healthcare and dentistry. In dentistry, AI and ChatGPT are becoming integrated in three key areas: education, practice management and diagnosis. While the technology’s advantages are promising, dentists and legislators alike are cautious that standards need to be put in place before even more widespread adoption.

EDUCATION “Educators are incorporating generative AI technology in dental schools,” explained Kyle Stanley, DDS, co-founder of Pearl, a company that uses AI to enhance patient care in dentistry. “AI can simulate complex dental procedures, provide virtual patient interactions, and offer personalized learning modules that adapt to each student’s pace and understanding.”

Cortino Sukotjo, DDS, PhD, MMSc, MHPE, chair of the department of prosthodontics at the University of Pittsburgh School of Dental Medicine, said, “Generative AI technology, like ChatGPT, is being utilized in dental education to create more interactive and personalized learning experiences.”

ChatGPT is an advanced conversational AI model developed by OpenAI.2 It is available through a web interface available to both the public and professionals, and it’s described as easy to use.3 Sukotjo was one of the authors of a study published recently in The Journal of Prosthetic Dentistry in which dental school faculty deployed an experimental chatbot.4 “It was designed to respond to clinical procedure questions frequently asked by students,” he said.

“The chatbot reduces the need for faculty intervention, thereby

decreasing delays and bottlenecks in the clinic. Students found the chatbot to improve their clinical experience while reducing anxiety.”

A chatbot can answer student questions such as what instruments they will need for a procedure or which code is appropriate for logging information in the electronic patient record.5 Unlike faculty, the chatbot is available 24 hours per day, seven days per week.

“Future usage will include computer vision helping students identify carious lesions and periodontal disease utilizing 2D radiographs,” said Callan D. White, DDS, FAGD, of Asheville, North Carolina, who has researched dental AI for AGD’s Dental Practice Council as chair of its Subcommittee on AI and Augmented Intelligence.

AI chatbots are being used not only for student education, but also for patient education. “There are really two scenarios,” explained Kaveh Nedamat, DDS, MBA, founder and CEO of Toothly AI in Toronto, Ontario. Toothly is a platform that supports dentists in providing faster and more accurate diagnoses.

“The first scenario is where a dentist uses ChatGPT within the appointment to provide support in their communication with patients,” Nedamat said. The second is in patients’ search for information via search engines outside of the appointment. “There is often misinformation with this type of search,” he added, noting that patients “lack context and often process information in a way that is not helpful.”

Often patients don’t have the time, ability, knowledge, etc., to understand what is and isn’t rooted in science,” he added. “I would say there is also a predatory element out there trying to spread misinformation in order to sell prospective patients products that make great claims. Examples would be misinformation surrounding fluoride, amalgams, root canals, etc.”

Toothly, Nedamat noted, is working to develop a solution that bridges this knowledge gap.

“ChatGPT is being used to provide patients with easily understandable information about dental procedures, oral hygiene and agd.org/impact

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preventive care,” Stanley said. “Informed patients are more likely to accept recommended treatment plans.”

“ChatGPT and similar AI tools are revolutionizing patient education by providing easily accessible, understandable information about dental health,” said Qiao Fang, DDS, MSD, visiting clinical assistant professor in the department of restorative dentistry at the University of Illinois Chicago College of Dentistry, and another author of The Journal of Prosthetic Dentistry study.

White agreed. “Patients are educating themselves with the use of large language models (LLM) like ChatGPT,” he said. LLMs understand, process and generate human language and information based on large amounts of data.

Dental researchers are harnessing ChatGPT to analyze data and dental literature, identify patterns and generate insights.2 “Dental researchers today have an amazing opportunity to utilize LLMs like ChatGPT to scan thousands of studies and papers,” White said.

“ChatGPT can quickly sift through electronic health records, research papers and clinical trial data to identify patterns and correlations that might be missed by human researchers,” Fang said.

White explained that ChatGPT’s “prompts are crucial in selecting the correct information needed and can save researchers a tremendous amount of time.”

“Dental researchers are leveraging ChatGPT to sift through large datasets and extract valuable insights and patterns,” Stanley said. “This helps in identifying trends, understanding patient outcomes, and conducting epidemiological studies with greater efficiency and accuracy.”

“ChatGPT has demonstrated its effectiveness in helping scholars with the authoring of scientific research and dental studies,” Anushree Tiwari et al. stated in Cureus, because researchers “have been able to summarise, interpret and rephrase scientific data by using ChatGPT.”6

PRACTICE MANAGEMENT Concerning practice management, “with AI providing the capacity for supreme efficiency in dentistry,” Nedamat said, “it can be applied to dental practices, especially in settings where resources are limited and need to be optimized. I view computer vision-assisted diagnostic support as part of the solution to health deserts.”

“AI chatbots are being integrated into office management software to handle appointment scheduling, patient inquiries and reminders,” Stanley said, “which reduces the administrative burden on dental staff, improves patient communication and enhances overall office efficiency.”

Edward J. Zuckerberg, DDS, FAGD, works with several companies involved in AI and explained that AI can be used “to automate the creation of SOAP [subjective, objective, assessment and plan] notes from verbal conversations between dentists and patients and to incorporate these into the practice management software.”

“AI chatbots help reduce the administrative burden on staff, allowing them to focus more on patient care,” Sukotjo said.

Fang believes AI “has significantly boosted the popularity of teledentistry,” he said. “AI-powered tools enable more effective

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remote consultations by assisting dentists in diagnosing conditions based on patient-provided data and images. These tools can also triage cases to determine which ones require in-person visits, thus optimizing the use of clinical resources.”

Stanley noted that “AI-driven tools can assess patient photos and radiographs submitted online, allowing dentists to provide preliminary diagnoses and treatment recommendations without an in-person visit.” “[AI] can mean a dentist in a central location can manage multiple hygienist-driven practices at once,” Nedamat explained. “This is done via video chat and can be made more efficient with the assistance of AI-driven diagnostic support. The dentist and hygienist can effectively perform a clinical exam, communicate the results in a visually appealing way to the patient and triage the patient to the appropriate dental specialist. Those patients residing in oral health deserts can still receive excellent care and only travel when necessary.”

Scott Froum et al., in Dental Economics, noted that ChatGPT can be used by the practice for website and search engine optimization (SEO) and development.3 ChatGPT can also be used to reply to patient emails; create and send surveys; and write blogs, social media posts and newsletters.7 Revenue cycle management may also be improved, Stanley said.

“AI helps streamline revenue cycle management by automating billing processes, predicting payment delays and identifying errors in claims submissions,” he said. “This ensures faster and more accurate reimbursements, reducing the time and effort required for manual processing.”

“This is an area of AI development that will be extremely beneficial for everyone involved in the dental care setting and is developing very quickly,” White added. “Not only will it help patients understand and better utilize their insurance benefits, but it will also help dental teams be more efficient in insurance administration. The goal is seamless communication between the patient, provider and insurance company where verification, adjudication and payment can happen in real time.”

“AI systems can quickly identify discrepancies or errors in billing and claims, reducing the time and effort required to resolve these issues,” Fang said.

DIAGNOSIS Concerning diagnosis, “AI deep learning algorithms can detect anomalies like caries, periodontal disease and other oral pathologies with high accuracy,” Fang said. “These tools provide a differential diagnosis, thereby enhancing the dentist’s diagnostic capabilities, ensuring nothing is overlooked and streamlining the screening process.”

Zuckerberg is chief dental officer for Viome, a Seattle-area company that has “the first noninvasive oral and throat cancer screening from saliva samples, which by itself is pretty amazing.

But they also deliver six detailed oral health scores: gingival health, caries susceptibility, breath odor, pathobiont activity, fungal activity and genotoxic activity,” he explained. “They literally have to sift through trillions of nucleotide data points and weed out unwanted

AI will not replace dentists, but a dentist with AI will replace a dentist without.

Don’t be replaced.

— Kaveh Nedamat, DDS, MBA

The most crucial element of AGD’s policy is the position that AI should never supersede or replace the dental practitioner in clinical decisions or in any way erode the patient/ practitioner relationship.

— Callan D. White, DDS, FAGD

ChatGPT can quickly sift through electronic health records, research papers and clinical trial data to identify patterns and correlations that might be missed by human researchers.

— Qiao Fang, DDS, MSD

data to come up with the relevant scores. This task would be impossible without AI.” In the office, Zuckerberg said, “For speed of analysis and thoroughness as it relates to some obscure information on the image that dentists might overlook — be it a small radiolucency or calcification that might be dismissed as insignificant — the AI will document these every time and measure changes over time in a manner that human eyes cannot.”

Zuckerberg is passionate about oral cancer detection/prevention and offered an example where AI can be helpful: “A lesion is nonmalignant with some dysplastic changes or conditions that fall under oral pre-malignant disease, like leukoplakia and others.

The surgeon is put in a difficult position of either telling the patient they don’t have cancer but urging the importance of future monitoring with re-biopsy periodically, or the aggressive approach of total excision.”

Zuckerberg noted that Proteocyte AI in Toronto, for which he is a senior adviser, now has an AI tool that can calculate “a score, expressed as a percentage likelihood that a particular lesion will undergo a malignant transformation over the next five years,” giving “both the surgeon and the patient a realistic basis for a treatment choice.”

“Computer vision is a facet of AI that can aid dentists in the examination of radiographs,” White said. “These AI algorithms have learned to detect variations of contrast within radiographs to help dentists detect carious lesions. The AI can measure the size and depths of the lesions. There are also AI algorithms that can detect bone loss around teeth and subgingival calculus, helping providers diagnose periodontal disease.”

AI analysis of radiographs can identify caries and other abnormalities “with high accuracy,” Stanley noted. “Beyond radiographs, AI tools are also being used to analyze intraoral scans and patient records to assist in diagnosing conditions and planning treatments.”

Among diagnostic uses, Zuckerberg explained, are “AI utilization merging diagnostic information from cone beam computed tomography images to better enable endodontists to locate second mesiobuccal and accessory canal locations as well as blockages and extreme curvatures that could not be seen easily.” AI can also be used to “design prostheses, determine ideal types — removable versus fixed — and select components and materials.”

“AI is also used in orthodontics software to help visualize malocclusions and predict optimal treatment results for patients,” White added. agd.org/impact

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ChatGPT and similar AI tools are revolutionizing patient education by providing easily accessible, understandable information about dental health.

— Qiao Fang, DDS, MSD

But AI isn’t just helping dentists streamline their processes.

Dental insurers are also engaging the technology.

“Insurance companies are using AI to review and verify dentists’ diagnoses and treatment plans to ensure they align with coverage policies,” Stanley explained.

This has some dentists concerned.

Stanley noted insurance companies’ use of AI may “lead to disputes if AI assessments differ from those of the treating dentist, potentially affecting reimbursements.”

“The same algorithms that are used by dentists to improve their diagnostic ability and patient communication are also being used by insurance companies to deny claims,” Nedamat said.

Therefore, Fang said, “it is crucial for dental professionals to maintain detailed and accurate records to support their diagnoses and treatment plans.”

“The good news is that, in most states, you cannot deny a claim without a human, so insurance companies are using this technology to approve your claims so they don’t have to go to the expensive human consultants,” Stanley said, noting that if AI designates a procedure as nonapproved, “it gets flagged and routed to a human.” White agreed. “As far as I know, and what we are allowed to know, a human still has to review a nonapproved claim prior to the denial,” he said.

White also offered a positive, saying, “Insurance companies are using AI abilities to help eliminate fraud, waste and abuse by auditing the data collected from submitted insurance claims.” However, he noted that “it should be of the highest importance for organized

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The same algorithms that are used by dentists to improve their diagnostic ability and patient communication are also being used by insurance companies to deny claims.

— Kaveh Nedamat, DDS, MBA

dentistry, like AGD, to ensure that any claim denials are reviewed by a dental consultant. AI should only be used as an audit for the insurance company.”

There is also some concern among dentists that AI is aiding insurance companies in “takeback” claims, where insurance companies request refunds for previously paid claims.

Stanley offers a positive, saying, “AI can audit past claims more efficiently, potentially identifying errors or discrepancies that lead to such refund requests.”

“The clinical exam is imperative, and AI can be used as an adjunct to assist in diagnosis and not the other way around,” Nedamat said. “This almost feels like it should be mutually exclusive, meaning companies providing support to dentists to increase case acceptance of the right treatment shouldn’t be then providing the same algorithms to insurance companies to deny claims or even takeback payouts, namely because there is a lack of context.”

DEVELOPING STANDARDS Organized dentistry — along with organized medicine and federal and state governments — are working to implement standards and oversight on AI. An American Dental Association (ADA) standards workgroup created a white paper that provides an overview of how AI is currently being used in dentistry and how it might be used in the future. The ADA is developing standards to guide dentistry’s adoption of AI. White has been involved in those efforts as a representative of AGD.

AGD also created an AI policy. In AGD’s policy statement, White states: “The most crucial element of AGD’s policy is the position that AI should never supersede or replace the dental practitioner in clinical decisions or in any way erode the patient/practitioner relationship.”8 AGD’s policy promotes transparency in the development and use of AI systems and states that, when third-party payers utilize AI, the technology “should not unduly track and/or attempt to influence recommended treatment and [should] ensure equal reimbursement for providers without regard to the use of AI within the practice.”8 Federal lawmakers are also leery of healthcare decisions made solely by AI. Earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that Medicare Advantage plans cannot make medical necessity determinations using an algorithm or software that does not take into account individual circumstances. Reps. Jerrold Nadler (N.Y.) and Judy Chu (Calif.) and Sen. Elizabeth Warren (Mass.) went a step further and, in June, sent a letter to CMS urging it to increase oversight of AI and develop guardrails on the use of AI and algorithms to determine Medicare Advantage coverage for seniors. The letter points out that “several [Medicare Advantage] insurers are using unregulated algorithms and AI tools to determine when to cut off payment for patient treatments.”9 State lawmakers are also turning their attention to AI in healthcare, attempting to create guardrails that promote privacy, data integrity and transparency. In 2023, 11 states introduced legislation related to AI use in healthcare, up from three in 2022.10 These laws echo the themes of the majority of the nascent standards — that AI cannot replace humans when it comes to decision-making and that patients must be informed when it is being used.

Some of these laws are already being tested. In July 2023, a group of patients sued Cigna Healthcare, alleging that the company’s doctors circumvented the legally required physician review process by using an AI algorithm to automatically deny thousands of claims.11 The case is still early, but it demonstrates that AI’s role in healthcare is far from agreed upon.

AI’S FUTURE IN DENTISTRY “AI is here to stay and will be extremely useful in many facets of dentistry,” White said.

Fang offered a caveat, however: “We need to be aware that AI tools do not replace dentists’ expertise. AI diagnostic results still require supervision by human professionals.”

White offered his own caveat: “My concern is how this information will be stored, used and protected. There should be more transparency in the usage of patient information by AI companies and insurance providers.” He also called for “AI standardization to prevent biases,” and further stated that “AI should only be used as a tool and should never come between the patient and provider. AI software should ensure that patient information is stored correctly, used only for the purpose intended, and protected from breaches and nefarious purposes.”

Nonetheless, “AI usage in dentistry is growing quickly,” White said. “It will be extremely important to have testing and validation standards to prevent unwanted biases and optimize specificity and sensitivity outcomes.”

Both Fang and Sukotjo see AI involvement in predictive analytics for preventive care as well as the integration of AI with other emerging technologies such as augmented and virtual reality and robotics.

Froum et al. noted in Dental Economics that by utilizing the AI powering ChatGPT, researchers can create protein-language models to study biological data and optimize established molecules to improve the efficacy of and to repurpose drugs.3 Fang and Sukotjo also see an increasing need for attention to ethical considerations to ensure that AI technologies are used responsibly and effectively.

De Souza et al. in General Dentistry also cited ethical concerns, noting that “integrating ChatGPT in dentistry can be highly beneficial, but it is crucial to address ethical considerations, accuracy and privacy concerns.”2 Nedamat offered a final warning: “Democratization of health information is inevitable, and we as a profession will either adapt or die,” he concluded. “AI will not replace dentists, but a dentist with AI will replace a dentist without. Don’t be replaced.” ♦ William S. Bike is a freelance writer and editor based in Chicago. He is a former director of advancement communications for the University of Illinois Chicago College of Dentistry. To comment on this article, email impact@agd.org.

References

1. Dysart, Joe. “Artificial Intelligence and Dentistry: Mostly Blue Skies Ahead.” AGD Impact, vol. 50, no. 4, April 2022, pp. 12-17.

2. De Souza, Lucas, et al. “ChatGPT and Dentistry: A Step Toward the Future.” General Dentistry, vol. 72, no. 4, July/August 2024, pp. 72-77.

3. Froum, Scott, et al. “ChatGPT: Will It Revolutionize the Dental Industry?” Dental Economics, 13 April 2023, dentaleconomics.com/science-tech/article/14290255/chatgpt-will-it-revolutionize-the-dental-industry.

4. Fang, Qiao, et al. “Artificial Intelligence (AI)-Driven Dental Education: Exploring the Role of Chatbots in a Clinical Learning Environment.” The Journal of Prosthetic Dentistry, 21 April 2024, doi: 10.1016/ j.prosdent.2024.03.038.

5. Mitchum, Rob. “Can a Chatbot Help Educate Dentistry Students?” UIC Today, 15 May 2024, today.uic.edu/ can-a-chatbot-help-educate-dentistry-students.

6. Tiwari, Anushree, et al. “Implications of ChatGPT in Public Health Dentistry: A Systematic Review.” Cureus, 2023 Jun; 15(6) e40367.

7. Wilson, Matt. “Meet Your New Dental Communications Assistant: ChatGPT.” Dentistry IQ, 13 July 2023, dentistryiq.com/front-office/article/14296324/chatgpt-a-game-changer-in-dental-patient-communicationand-content-creation.

8. Kluck-Nygren, Cindy. “Dental Practice Advocacy Survey Results: AGD Members’ Use of Artificial Intelligence (AI)/Augmented Intelligence (AuI) in the Dental Practice.” Academy of General Dentistry, agd.org/docs/ default-source/default-document-library/agd-member-survey-re-ai-aui_2024-june30_ cd.pdf?sfvrsn=b519d4ed_2. Accessed 10 Oct. 2024.

9. “Reps. Nadler, Chu & Sen. Warren Lead Bicameral Letter to CMS Urging Oversight of Artificial Intelligence and Algorithms Used in Medicare Advantage Coverage Decisions.” Congressman Jerry Nadler, 25 June 2024, nadler.house.gov/news/documentsingle.aspx?DocumentID=396200 10. “Artificial Intelligence and Health Care: A Primer.” National Conference of State Legislatures, 20 Aug. 2024, ncsl.org/health/artificial-intelligence-health-care-a-primer?utm_source=national+conference+of+state +legislatures&utm_term=0_-2a71222d97-%5blist_email_id%5d&utm_campaign=2a71222d97-thisweek-aug-4&utm_medium=email.

11. Greenberg, David S. “Health Insurers Sued Over Use of Artificial Intelligence to Deny Medical Claims.”

ArentFox Schiff LLP, 22 Dec. 2023, afslaw.com/perspectives/health-care-counsel-blog/health-insurers-suedover-use-artificial-intelligence-deny.

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Dr. Chetty,

a Second-Generation AGD Dentist, Takes Up Presidency 20

AGD IMPACT

DECEMBER 2024

By Caitlin Davis

O

n Nov. 24, 2024, Chethan Chetty, have the opportunity to build relationDDS, MAGD, was inducted as AGD ships with your patients. Now, 24 years president during the House of Delegates’ into practicing, it’s amazing for me to see annual meeting in Chicago. This coming how those relationships have developed. I year, he plans to help guide the organization have patients who were also just starting into the future by taking steps to increase their careers when I was starting mine, grassroots engagement and promote and we’ve kind of grown up together. Now membership while remaining open to our kids are the same ages, and that’s a fun organizational changes that could help dynamic. Those are special relationships modernize and improve operations. and memories that not many people have.”

Dentistry and AGD are traditions for the Chetty family. His father, R.K. Chetty, is also a general dentist and AGD member and past leader, and his wife, Avani, is an AGD component executive. His youngest son, Rushil, is currently applying to dental schools for Fall 2025 entrance.

“My dad never really pressured me to become a dentist, so I originally wanted to go into medicine,” Chetty said. “I got all the way into my junior year of college and had already taken the MCAT. Then one night I was hanging out with my friends, and we were talking about why we wanted to be doctors, and I had this moment of questioning whether it was really Dr. Chetty with his father, Dr. R.K. Chetty. what I wanted to do. That started me down a different path of thinking about what it is that really drives me and A History with AGD makes me passionate about what I want to An AGD leader himself, Chetty’s father do. I rethought dentistry as a career and inspired him to be a part of his community realized that it actually did have everything I and to serve the profession. Chetty joined the wanted: being my own boss, working directly Southern California AGD board in 2003 and with patients, working with my hands, and continues to be an active leader. In that time, having more manageable hours and more he has served as president of the Southern time with my family than I would as a doctor.” California AGD twice and as California After Chetty graduated from the University AGD president in 2016. He also served as of Southern California Ostrow School of California AGD MasterTrack assistant direcDentistry in 2000, he joined his father’s tor from 2015 to 2019. He helped transform practice and worked together with him for the California MasterTrack program into the next 20 years, then took over the practice one of the most comprehensive MasterTrack after his father's retirement. During that time, programs in AGD. And, as president of his while maintaining the practice philosophy constituent, he was instrumental in establishand culture, he grew the business to include ing its Pathway to Fellowship program to help multiple associates, hygienists and specialists. encourage new dentists to attain their AGD “I think general dentistry was the place Fellowship and eventually Mastership. Chetty I always wanted to be,” said Chetty on continued to serve as an active board member not pursuing a specialty. “I wanted to be of his constituent until he took office as AGD a family dentist. As a general dentist, you vice president in 2022.

“I owe everything about my practice and the success of my dental career to AGD,” Chetty said. “I would never have done the things I have done or achieved what I have achieved if I didn’t have that AGD education and philosophy throughout my career. AGD has given me the opportunity to be around some of the most amazing dentists I have ever known, and they encouraged and inspired me to do more with my career. You have to surround yourself with greatness to become great; those professional associations will force you to level up again and again.”

In 2011, Chetty was invited to serve on the AGD Communications Council. In his seven years as a member, he was involved in many significant projects, such as social media, digital publications and streamlining communications. In 2017, Chetty joined the Membership Council, of which he would eventually become chair. During this time, he worked closely with leaders at all levels to implement new initiatives that established a cohesive membership strategy. Having worked on two national councils so deeply entwined with directly serving AGD’s membership, Chetty is used to crafting new products and benefits to increase the value of AGD to general dentists. When asked what is AGD’s greatest member benefit, his answer was unequivocal: continuing education (CE).

“CE is the most special thing about AGD,” he said. “The focus of AGD CE is always to be able to learn something over the weekend and apply it immediately in your practice on Monday. We’ve all been to CE courses that are not AGD courses — some of them are pretty good, but a lot of times, you feel like you just got sold something. AGD CE focuses on practicality.”

“However,” he continued, “the secret sauce of AGD is the community. Having peers and friends who believe in the same kind of dentistry as you — who believe in providing excellent care — is a great thing. I found a great group of friends when I participated in the California AGD MasterTrack program. We finished our agd.org/impact

21

Dr. Chetty with his family.

program in 2016, but, to this day, we still talk every single day. If you have a patient in the chair and something is not going the way you need it to, you can just message the text group chat, and someone will respond and tell you exactly what to do. We have a lot of relatable experiences, and we continue to push each other. CE is No. 1, but along with that comes engaging with the community of dentists within AGD who really believe in each other.

AGD helps you find your people.”

But Chetty is also passionate about the benefits of AGD that members may not engage with directly.

“I would be remiss if I didn’t mention the impact that AGD’s advocacy efforts have on our members,” he said. “That is kind of a secret, in a way, because the average dentist may not know all of the things we are doing for dentistry. I am very cognizant of the fact that a lot of the things I get to do today in my general practice are a result of battles that have been waged over the past several decades about dentistry and how we relate to specialists and even the medical profession. For example, in my practice, I do a lot of orthodontics and implants; I am very aware that I would not have that opportunity if AGD wasn’t there fighting in the legislative arena to protect our scope of practice. It’s enlightening to be on this side of leadership and see how the whole process works in terms of the efforts that we make as an organization and the passion from the people who

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AGD IMPACT

DECEMBER 2024

Dr. Chetty at AGD2023 in Las Vegas with Drs. Eric Wong, Michael Lew, Mike Bromberg and Howard Chi.

are on the front lines of our initiatives.

Our advocacy efforts benefit all general dentists, not just those who are AGD members, so it’s a huge impact.”

“I would never have done the things I have done or achieved what I have achieved if I didn’t have that AGD education and philosophy throughout my career.”

Challenges Ahead When asked about the biggest challenges AGD is facing as an organization and how he plans to address them during his presidency, Chetty said: “That’s the million-dollar question, but it’s also something we’ve been talking about within leadership for years. The Baby Boomer generation of dentists is starting to retire.

As that happens, it’s changing the numbers and demographics of our membership. It’s also changing the needs of our membership, as many more of our members now work for corporate or large group practices. The landscape of dentistry is changing, and it’s important that we continue to evolve and

ensure we are responsive to the needs of our members today. We need to continue to stay relevant, and one of the ways we can do that is elevate and support our constituents, which are able to better engage and support the different needs of dentists in individual areas and communities. Our strength as a national organization comes from our constituents and their grassroots-level understanding of what dentists need. We are also in the process of renewing our strategic plan, and I am really excited and passionate about the process of evaluating what works and what can be added or improved upon to make our organization better than ever. As long as we make decisions as an organization that are informed by the voices of our members and our leaders, that’s perfect.”

Chetty’s time as president will last until the end of the House of Delegates’ 2025 Annual Meeting, Nov. 14–16, 2025.

“I’m so excited to have the opportunity to give back to an organization that has given me so much,” he said. “I also want to acknowledge and thank my wife because she’s the one who really encouraged me to do this. She has been by my side every step of the way and has been so supportive in allowing me to fulfill this dream. None of this is about me; it’s about what I can do for this organization, and I’m ecstatic to have that opportunity.” ♦ Caitlin Davis is associate editor of AGD Impact. To comment on this article, email impact@agd.org.

Testing the Tools

By Ross Isbell, DMD, MBA

A Cord-Cutter’s Dream

A Strong Bond to Restorations

DentaLaze Shofu shofu.com

Z-Prime™ Plus Bisco bisco.com

In my office, we often need hemostasis around our restorative work, and, if pressure and time won’t solve it quickly enough, we jump to using a diode laser. We have a corded laser unit ready to go in our primary crown prep operatory, but it requires some effort to move. In contrast, the DentaLaze by Shofu is much easier to transport. It is a small handheld cordless option for gingivectomies, hemostasis or any other diode application. The DentaLaze is shaped like a pen, is easy to grip, is lightweight at 100 grams and measures 163 millimeters — about the size of a large handled elevator. As my pinch-hitter laser, I keep it plugged in and charged at all times. While it will allegedly run for 45 minutes before needing charging, I’ve never used it for that long. If you use it intermittently, it will automatically go into standby mode after three minutes and sleep mode after an additional two minutes. It operates at an 808-nanometer wavelength with a 3- and 5-watt pulsed wave or at 1W, 2W or 3W continuous waves. I typically keep it on 2W continuous because I’m working at preparation margins and not using it for more extensive work, though it is more than capable. The guiding beam is an interesting green color instead of the average red, so it is easy to see where your active work site is. In general, if you can’t see your guide beam spot, you should evaluate whether or not the filament structure is compromised and needs to be adjusted or repaired. The tips are single-patient use, so, if the filament is compromised, such as if I have bent it too extremely, I typically just swap to a new one for better performance. If it is covered in too much debris, try wiping it with a water-wetted gauze or use a fiber cutter prior to replacing the tip. A disposable plastic sheath is used to cover the whole device to make sterilization simple and cross-contamination unlikely. With only two buttons for swapping modes and turning it on and off, there is little to confuse. The intro kit with the laser and all appropriate charging equipment and disposables is $3,500. Due to this pen housing the entire laser apparatus, it is not the smallest handpiece available among diode lasers, but it is a worthy tradeoff to be able to work without a foot pedal or a cord of any sort.

While the company still recommends that you and your assistant wear protective eyewear, there is also an adjustable viewing lens attachment, so, if your posture and view are appropriate, you can utilize only the pen without swapping out your loupes. If you are looking for a little more freedom and a little less clutter on your countertop, check out DentaLaze.

When I was in dental school, a hot debate was whether bonding to zirconia was possible. As it turns out, it was more of a “not yet” situation.

With advanced chemistry and primers like Z-Prime™ Plus from Bisco, it is now possible to bond and achieve great results with zirconia and no longer require the same aggressive preparation styles of the past. Z-Prime Plus is a single homogenous material primer that uses a mixture of a methacryloyloxydecyl dihydrogen phosphate (MDP) monomer and biphenyl dimethacrylate (BPDM), which is a patented hydrophilic carboxylate monomer that Bisco has been using for many years with its All-Bond line of products. Assuming that the intaglio surface has been sandblasted and cleared of phosphate groups with an aggressive alkaline cleaning agent such as Zirclean® or Ivoclean®, this MDP monomer works to prepare the intaglio surface for high bond strength by bonding with phosphate groups directly to the zirconia and methacrylate groups to the resin cement. The BPDM monomer works synergistically with the MDP monomer by utilizing moisture from the dentinal tubules to bond to the dentinal substrate. The combination of these two monomers makes it ideal for boosting the strength of zirconia bonding, but also makes it not as effective at glass ceramic bonding, such as porcelain, except for encouraging the laminar effect by wetting the substrate. For bonding glass ceramics, a silane primer should be used instead. Z-Prime Plus is compatible with any resin luting cement, though I almost always use it with a dual-cured cement, and it will increase bond strength to almost any zirconia or metal substrate. It is temperature-stable for multiple years, so it can be stored in your cabinet instead of the refrigerator. Z-Prime Plus has a film thickness of only 2 micrometers, so it won’t affect the marginal fit of your crown. It does not need to be light cured, but it is light sensitive, so you should only apply it when you intend to proceed directly into your delivery process. Z-Prime Plus is a simple addition to your bonding protocol and should allow you to make more conservative preparation designs with the same long-term success. This product begins to level the playing field between bonding strengths of lithium disilicate and zirconia while still allowing for the greater biocompatibility and flexural strength of zirconia.

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.

agd.org/impact

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Upcoming Look for these articles and more in the November/ December 2024 issue of General Dentistry:

Stop the Bleed ActCel® Hemostatic Gauze ActCel® actcelgauze.com When planning oral surgery, I always discuss bleeding risks with my patients. I am especially concerned about these risks with patients who are on blood thinners. While some of these patients may be able to take a holiday from their medication and help achieve a quicker union from clotting, not all patients are allowed to discontinue their medication, even temporarily.

In situations where the patient will still be requiring oral surgery but cannot stop their medication, I need to plan for prolonged bleeding times. The first attempt to control bleeding in an open extraction site is to pack it, either with bone grafting material and collagen membranes, bone wax, or a hemosponge/collagen plug. This helps to remove the bony socket from the equation, but not the soft tissue. Especially when suturing a site together, it also helps to have a topical agent other than pressure. ActCel® topical hemostatic gauze is among my favorite for dressing such a wound. This material is created from a regenerated cellulose that will easily dissolve when wetted, such as with blood, and turns into a gel. It rapidly absorbs blood and actively recruits platelets and clotting agents to fill open vessels at the site of the wound. If I am having any trouble slowing down bleeding with standard gauze, I swap to ActCel, which I cut in strips to lay across the incision line or area of nonclosure. I then continue monitoring until hemostasis is achieved and sometimes will send some home with the patient. Hopefully, uncontrolled bleeding isn’t a regular occurrence in your office and you don’t need ActCel often, but its three-year shelf life will make it unlikely that your supply will go bad. After bleeding has slowed, you can choose to rinse away the gel, but I typically just leave it in place since it doesn’t really have a flavor and just feels smooth. You also can layer cotton gauze on top of it to keep it in place for longer. Whenever the patient decides to stop utilizing the gauze, the ActCel gel will either peel away with the gauze or eventually be washed away with water or saline rinses. I do not recommend hydrogen peroxide because that can dissolve the clot and reinitiate bleeding. Since the ActCel gel is made of cellulose, it breaks down into saline and glucose, so there is no danger if it remains in the mouth or is ingested.

The best part about ActCel as an aid is that it causes no tissue damage, unlike some other hemostatic chemicals. This material deserves a home at least in your emergency kit, if not your standard surgical site management kit.

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AGD IMPACT

DECEMBER 2024

• Dentistry’s ethical responsibility to patients’ overall health through sustainable practices and climate change awareness • The confusing regulatory landscape of enteral sedation in the United States • Clear aligner therapy and symptoms of temporomandibular disorders: a case report

In the January 2025 issue of AGD Impact: • 10 Dentists to Watch • Dentistry on the Inside: Exploring the Prison Dental System

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