CDA Journal - October 2021: Pediatric Patients, Parenting and the Pandemic

Journa C A L I F O R N I A

D E N TA L

October 2021 Behavior Guidance Patient-Centered Care Teledentistry Impact of COVID-19

A S S O C I AT I O N

Pediatric Patients, Parenting and the Pandemic: Caring for Children in Modern Times Sharine V. Thenard, DDS, MS

n

O C T O B E R 2021

Vol 49 Nº 10

CYBER SUITE LIABILIT Y

Protect records and reputation.

Get cyber protection that goes beyond data breach.

The rise of cybercrime compromises the security and productivity of practices of every size. Benefit from comprehensive coverage to respond to and recover from today’s emerging risks.

See how TDIC’s Cyber Suite Liability policy keeps you covered: • • • •

Coverage for data compromise response expenses .

Recovery from computer attack and cyber extortion Data compromise liability and legal proceedings Network security and electronic media liability

Talk to an agent or apply today at tdicinsurance.com/cyber.

Protecting dentists. It’s all we do.

®

800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 @TDICinsurance

Oct. 2021

C D A J O U R N A L , V O L 4 9 , Nº 1 0

d e pa r t m e n t s

605 The Editor/Generous Colleagues 607

Impressions

655 RM Matters/Ransomware on the Rise: Steps To Protect Your Practice and Systems From Cyber Disruption

657 Regulatory Compliance/Compliance With HIPAA Rules Supports Cybersecurity

660 Tech Trends f e at u r e s

611 Pediatric Patients, Parenting and the Pandemic: Caring for Children in Modern Times An introduction to the issue.

607

Sharine V. Thenard, DDS, MS

615 The Millennial Family: Adapting Behavior Guidance to Contemporary Parenting C.E. Credit The purpose of this paper is to review generational differences, the impact of parenting on child development and changes in approval of behavior guidance techniques to propose new approaches to child behavior.

Adi A. Genish, DDS, and Clarice Law, DMD, MS

631 Pediatric Patient-Centered Care in General Dentistry: We’re Closer Than You Might Think This paper gives an overview of PCC in general health care, explains PCC aspects already in play in the prevention and treatment children receive from pediatric dentists and serves as a primer for general dental practitioners to incorporate PCC principles into their care of children.

Kimberly J. Hammersmith, DDS, MPH, MS; Susan A. Fisher-Owens, MD, MPH; and Paul S. Casamassimo, DDS, MS

641 Teledentistry: Opportunities and Recent Developments in Pediatric Dentistry This article describes the uses of teledentistry, motivation for its use and UCSF Pediatric Dentistry’s current and future plans to implement teledentistry in clinics and the community.

Jean Marie Calvo, DDS, MPH; Paul Glassman, DDS, MA, MBA; Lisa Berens, DDS, MPH; Enihomo Obadan-Udoh, DDS, MPH, DrMedSc; and Ray E. Stewart, DMD, MS

649

Impact of COVID-19 on the Pediatric Population This study explores the physical, emotional, psychological and developmental impacts of the COVID-19 pandemic on children, including how it has affected access to dental care.

Jessica Y. Lee DDS, MPH, PhD; Janice A. Townsend, DDS, MS; and Eva C. Ihle, MD, PhD

O C TOBER 2 0 2 1

603

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

CDA Officers Judee Tippett-Whyte, DDS President president@cda.org Ariane R. Terlet, DDS President-Elect presidentelect@cda.org John L. Blake, DDS Vice President vicepresident@cda.org Carliza Marcos, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Richard J. Nagy, DDS Immediate Past President pastpresident@cda.org

D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Alicia Malaby Communications Director

Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor Sharine V. Thenard, DDS, MS Guest Editor

Volume 49 Number 10 October 2021

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus

Permission and Reprints

Journal of the California Dental Association Editorial Board

Robert E. Horseman, DDS Humorist Emeritus

Andrea LaMattina, CDE Publications Manager Andrea.LaMattina@cda.org 916.554.5950

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

Production Shelly Peppel Senior Visual Designer

Manuscript Submissions

Upcoming Topics

www.editorialmanager. com/jcaldentassoc

November/ Stem Cell Research December/ Health Literacy II January/ Dental Student Research

Letters to the Editor www.editorialmanager. com/jcaldentassoc

Advertising Sue Gardner Advertising Sales Sue.Gardner@cda.org 916.554.4952

Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif.

Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Copyright 2021 by the California Dental Association. All rights reserved.

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

Connect to the CDA community by following and sharing on social channels

@cdadentists

604 OC TOBER

2021

Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Editorial

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Generous Colleagues Kerry K. Carney, DDS, CDE

W

e do not learn best from the content forced upon us. We learn from doing and through experiences and lessons from mistakes.” This quote was sent to me by a colleague from Michigan recently. It makes clear the importance of learning from our mistakes.

Scholarly publications like the Journal of the California Dental Association provide information for the benefit of the profession of dentistry. The Journal has three main target groups for the information we provide: dentists, scholars/researchers and policymakers.

The Journal emphasizes translating research data into practical information that can be incorporated into everyday clinical practice. In addition to helping dental practitioners improve their skills, both therapeutic and diagnostic, the Journal helps scholars/researchers perfect the communication of their findings. The information presented in the Journal has been the evidenced-based underpinning for much state and national policy.

The Journal provides a classic avenue of scientific education. However, the opening quote points out that learning is not restricted to the classic didactic medium. Learning also springs from trial and error. An instructor in dental school told us that if we are perfect in everything we try in dental school, then we have wasted the opportunity to learn from our failures in a safe and supportive environment.

Ours is a profession of perfectionism.

That sounds like an admirable goal – everyone striving to be perfect. However, perfectionists tend to concentrate on the goal and not the measures necessary

The definition of generous is showing a readiness to give more of something than is strictly necessary or expected or showing kindness toward others.

to get there. What makes extreme perfectionism so toxic is that those in its grip desire only success. They are focused on avoiding failure, resulting in a negative orientation. They believe that the esteem and approval of others is always and only dependent on a flawless performance.

Like in gymnastics, every deviation from perfection results in a reduced score. In the case of dentistry, a reduced score results in a diminution of self-esteem.

Our dental education was based on achieving the perfect tooth preparation, the perfect crown retention, the perfect endodontic cleaning and fill. The goal was to recreate a perfect bench procedure inside the mouths of our patients. And therein lies the problem. Our perfected bench skills are heavily impacted by the live, conscious patient variable.

The typodont or manikin is cooperative, dry, easy to visualize and infinitely patient. The manikin never sighs, looks at her watch or asks repeatedly “how much longer?” The human part of dentistry is very difficult for perfectionists.

Another dental editor once told me he wished that there existed a Journal of Bad Outcomes. He reminded me that research that fails to support the research hypothesis is seldom considered important enough to publish. If there were a Journal of Bad Outcomes (JBO), it could be a great help to the practitioner. The JBO

could save us time, embarrassment and wasted money (consider all the money we spend on gadgets or materials that sound wonderful and turn out to be worthless). The JBO could also spare us the emotional pain that goes with recognizing that we are not perfect.

I would want a lifetime subscription.

Until there is a JBO, another avenue of trial-and-error learning exists: our generous colleagues. Dentistry can be a lonely practice. A sole practitioner may have little opportunity to establish a community of peers, colleagues who are generous and secure enough in their own abilities to share their less than perfect results, their trials and errors, their bad outcomes. These generous colleagues are not to be confused with practitioners who really are unable to produce good reliable outcomes with good prognoses for acceptable longevity.

The former encourage us to learn and progress. The latter need to remediate and improve their proficiency.

Generous colleagues are not interested in propping up their own self-esteem by diminishing others. They understand what every dentist goes through and offer advice from their own laundry list of “bad days” or bad outcomes. They remind us that we are not the only one who has our night’s sleep ruined when we see the name of a certain patient on the next day’s O C TOBER 2 0 2 1

605

C D A J O U R N A L , V O L 4 9 , Nº 1 0

schedule. Generous colleagues know what it is like to have a busy day with difficult procedures only to have some essential piece of equipment fail. They also have had a great appointment with a young, insecure child turn sideways when the parent leans around the door to ask in a plaintive tone, “Are you OK, Punkin?”

They know what others have to deal with every day because they have been there. The generous colleague recognizes when things have not gone the way planned. (For example, they know it has been a bad day when they see you remaking a five-unit temporary bridge on what was supposed to be cementation day.) After the patient is dismissed, the generous colleague will tell you they have experienced much worse and give encouragement and reassurance.

It is an honor and pleasure to know a community of generous colleagues.

However, Empathy Avenue is not a oneway street. Generosity is not as easy as one might think. It requires a measure of selfconfidence, an acknowledgment that we

ourselves are not perfect, and a measure of trust. The generous colleague must trust that the revelations of bad outcomes or bad-day experiences will not be taken as signs of incompetence or lack of skill.

The definition of generous is showing a readiness to give more of something than is strictly necessary or expected or showing kindness toward others.

A generous colleague is something we should all strive to be. When a colleague has a less than perfect outcome, it behooves us to generously remind them that they are good and skilled clinicians and that as a result of their experience, they have learned something that will make the rest of their clinical lives better.

Generous colleagues remind us that no one bats 1,000, but we all step up to the plate to give our best every day. n

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

E-VAC INC.© Made in USA

PREVENT PAINFUL TISSUE PLUGS PROTECT YOUR EQUIPMENT FROM COSTLY REPAIRS

The Original E-VAC Tip

EMAIL: kenevac@hotmail.com CALL: (509) 448-2602

FDA Registered

Package of 100 Contact Your Local Dental Supply Company 606 OC TOBER

2021

• Disposable • Inexpensive • Non-Toxic

Impressions

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Moderate Alcohol Use Linked With Higher Cancer Risk A new study from the World Health Organization’s (WHO) International Agency for Research on Cancer (IARC) has found an association between alcohol and a substantially higher risk of several forms of cancer, including breast, colon and oral cancers.

Increased risk was evident even among light to moderate drinkers (up to two drinks a day) who represented 1 in 7 of all new cancers in 2020 and more than 100,000 cases worldwide, according to the study published in the journal Lancet Oncology.

In Canada, alcohol use was linked to 7,000 new cases of cancer in 2020, including 24% of breast cancer cases, 20% of colon cancers, 15% of rectal cancers and 13% of oral and liver cancers.

“All drinking involves risk,” said study co-author Jürgen Rehm, PhD, senior scientist at the Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute at the Centre for Addiction and Mental Health (CAMH). “And with alcohol-related cancers, all levels of consumption are associated with some risk. For example, each standard-sized glass of wine per day is associated with a six times higher risk for developing female breast cancer.”

The impact on cancers is often unknown or overlooked, highlighting the need for implementation of effective policy and interventions to increase public awareness of the link between alcohol use and cancer risk and decrease overall alcohol consumption to prevent the burden of alcohol-attributable cancers, researchers said.

The modeling study was based on data on alcohol exposure from almost all countries of the world, both surveys and sales figures, which were combined with the latest relative risk estimates for cancer based on level of consumption.

The main mechanism of how alcohol causes cancer is through impairing DNA repair, according to the study. Additional pathways include chronic alcohol consumption resulting in liver cirrhosis and alcohol leading to a dysregulation of sex hormones, leading to breast cancer. Alcohol also increases the risk of head and neck cancer for smokers, as it increases the absorption of carcinogens from tobacco.

Research into the link between light to moderate drinking and cancer is relatively new and public policy does not yet reflect the degree of cancer risk, according to the study.

“As an epidemiologist, I would recommend higher taxes to fully reflect the burden of disease from alcohol,” Dr. Rehm said. “Along with limiting the physical availability and marketing of alcohol, price controls are recognized as high-impact, cost-effective measures to reduce alcoholrelated harm.”

Read more of this study in Lancet Oncology (2021); doi: 10.1016/S1470-2045(21)00279-5. n O C TOBER 2 0 2 1

607

OCTOBER 2021

IMPRESSIONS C D A J O U R N A L , V O L 4 9 , Nº 1 0

Mice were anesthetized and injected with the inflammation detection probe and live fluorescence imaging was performed. (Credit: Kahn I, et al. Licensed under Creative Commons CC BY-NC 4.0.)

Light Therapy Helps Burn Injuries Heal Faster Light therapy may accelerate the healing of burns, according to a University at Buffalo-led study.

The research, published in Scientific Reports, found that photobiomodulation therapy — a form of low-dose light therapy capable of relieving pain and promoting healing and tissue regeneration — accelerated recovery from burns and reduced inflammation in mice by activating endogenous TGF-beta 1, a protein that controls cell growth and division.

The findings may impact therapeutic treatments for burn injuries, which affect more than 6 million people worldwide each year, said lead investigator Praveen Arany, DDS, PhD, assistant professor of oral biology at the UB School of Dental Medicine.

“Photobiomodulation therapy has been effectively used in supportive cancer care, age-related macular degeneration and Alzheimer’s disease,” said Dr. Arany. “A common feature among these ailments is the central role of inflammation. This work provides evidence for the ability of photobiomodulation-activated TGF-beta 1 in mitigating the inflammation while promoting tissue regeneration utilizing an elegant, transgenic burn wound model.”

The study measured the effect of photobiomodulation on the closure of third-degree burns over a period of nine days. The treatment triggered TGF-β1, which stimulated various cell types involved in healing, including fibroblasts and macrophages (immune cells that lower inflammation, clean cell debris and fight infection).

608 OC TOBER

2021

Younger Adults Taking Meds That Could Affect Oral Health A new study in the journal Technology and Health Care demonstrates that many younger adult dental patients are taking medications and highlights the importance of dental providers reviewing medication histories regardless of the age of the patient.

The study from Regenstrief Institute and the Indiana University School of Dentistry looked at dental records from 11,220 dental patients over the age of 18.

The results showed: • 53% of all patients reported taking at least one medication.

• 12% of those aged 18–24 were taking at least one medication.

• 20% of those aged 25–34 were taking at least one medication.

“The number of younger adults on medication really surprised us,” said senior author Thankam Thyvalikakath, DMD, PhD, director of the Regenstrief and the IU School of Dentistry dental informatics program. “Often dentists will assume individuals this age aren’t on medications, but these results underscore the importance of paying attention to medical histories of all patients, because medications can play a significant role in oral health.”

Younger adults were most likely to be taking antidepressants, which can cause dry mouth, and opioids, which carry the risk of addiction.

“We need to be aware of these possibilities, because dry mouth increases risk for tooth decay and tooth loss, and dental professionals should be proactive with preventive measures,” said Dr. Thyvalikakath. “In the same way, if someone is taking an opioid, we as dentists need to make sure we are not overprescribing these medications to that patient and possibly contributing to dependence or substance use disorder.”

The study showed that older patients were more likely to be taking medications to treat chronic conditions like high cholesterol, hypertension and diabetes.

Across all ages, white patients were more likely to be on a medication.

Learn more about this study in Technology and Health Care (2021); doi:10.3233/THC-202171.

The researchers also developed a precise burn healing protocol for photobiomodulation treatments to ensure additional thermal injuries are not inadvertently generated by laser use.

The effectiveness of photobiomodulation in treating pain and stimulating healing has been documented in hundreds of clinical trials and thousands of academic papers.

The therapy was recently recommended as a standard treatment for pain relief from cancer-associated oral mucositis (inflammation and lesions in the mouth) by the Multinational Association for Supportive Care in Cancer.

Read more about this study in Scientific Reports (2021); doi.org/10.1038/s41598021-92650-w.

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Study Finds Anti-Inflammatory Immune Activity That Favors Oral Cancer Research led by Estefania NovaLamperti, PhD, from the Universidad de Concepción (Chile) found that chemical mediators, which induce an anti-inflammatory regulatory response that favors tumor development through the vitamin D signaling pathway, are to blame for preventing an effective antitumor immune response in oral cancer.

A key question in oral cancer has been how an anti-inflammatory

microenvironment is induced, boosting the growth of tumors. The main biological agents of the immune system are T cells, which have different phenotypes. In cancer, the presence of regulatory T cells (Tregs) and helper T cells type 2 (Th2) are associated with a worse prognosis, while the responses of helper T cells type 1 (Th1) within tumors, in general, show a better prognosis.

Study Examines Oral Health Outcomes in Children Researchers from the University of Illinois Chicago have received funding from the National Institute of Dental and Craniofacial Research for a five-year study to understand the oral health of children in low-income communities.

The new study, backed by $1.2 million in the first year, plans to look at predictors of oral health behaviors and caries risk in low-income, urban young children over time, said Molly Martin, MD, associate professor of pediatrics at the UIC College of Medicine and the principal investigator for the COordinated Oral Health Promotion (CO-OP) Chicago Cohort Study.

The CO-OP Chicago project was previously funded to reduce oral health disparities in children. For that study, researchers developed an objective assessment for toothbrushing behaviors in the homes of high-risk children under age 3. The study then tested an oral health community health worker intervention.

The new study builds off the previous one, this time with the goal to determine multilevel predictors of oral health behaviors and caries. Researchers will collect caregiver-reported and observed child oral health behaviors, dental plaque scores, diet, parenting styles, dental provider access and social risk factors every six months for an additional four years. Children will be evaluated for caries at ages 5 and 7.

Researchers hope to gain insight on factors that impact oral health including access to nutritious foods, access to dental services and psychological stress.

Community-level factors, community-level violence and area deprivation and economic indicators will also be studied.

Learn more about the study on the CO-OP Chicago website.

T-cell attacks cancer cell.

Using flow cytometry techniques, the research team was able to feature the T-cell phenotypes predominant in biopsies of 15 patients with oral cancer and compared them with the T-cell populations found in biopsies of 16 disease-free controls.

Thus, they identified a predominant distribution of T cells expressing CCR8+ receptors, Th2-like regulatory T cells and a small population of Th1 cells.

The researchers then hypothesized that the tumor microenvironment obtained from biopsy cultures of oral cancer patients had the ability to induce an anti-inflammatory phenotype itself.

To test this assumption, the research team challenged immune T cells subpopulations with the cancer secretome, and using genomics and proteomics techniques, determined how the mRNA transcripts and proteins expressed by these cells are modified. Notably, transcriptomics showed that oral cancer secretome induced the expression of a group of genes that control the vitamin D (VitD) signaling pathway in T cells. Moreover, the proteomics study revealed the presence of several proteins associated with the production of prostaglandin E2 (PGE2) linked to VitD rapid signaling in cell membranes. In addition, the researchers found a reduction in the proteins that carry VitD into the cell.

As a result, the team suggested that the decrease in the mobility of VitD promotes an increase in its concentration in the tumor microenvironment, inducing an anti-inflammatory phenotype favorable to the tumor.

Learn more about this study in Frontiers in Immunology (2021); doi.org/10.3389/fimmu.2021.643298.

O C TOBER 2 0 2 1

609

introduction C D A J O U R N A L , V O L 4 9 , Nº 1 0

Pediatric Patients, Parenting and the Pandemic: Caring for Children in Modern Times Sharine V. Thenard, DDS, MS

GUEST EDITOR Sharine V. Thenard, DDS, MS, is a practicing pediatric dentist in the Bay Area.

She earned her DDS from the University of California, San Francisco, and completed her MS degree and certificate in pediatric dentistry at The Ohio State University and Columbus Children’s Hospital (now Nationwide Children’s Hospital). Dr. Thenard has served as past president of the California Society of Pediatric Dentistry and the

Alameda County Dental Society and as trustee of the California Dental Association and currently serves on the TDIC/TDICIS board. She is a diplomate of the American Board of Pediatric Dentistry and a fellow of the American Academy of Pediatric Dentistry and American College of Dentists.

Conflict of Interest Disclosure: None reported.

W

hen I entered my residency in the early 2000s, there was already talk among pediatric specialists about how prevalent parenting styles were changing from previous generations.

More than 15 years later, the consensus is it is still happening.

Being a pediatric dentist is challenging.

Children are unique. They are not “little adults,” and their teeth are not just smaller versions of permanent teeth. I would say, however, that the greatest challenge in treating children is not the clinical aspect, but the behavioral and psychological aspects. Children are attached to adults, and the accompanying adult also has plenty of emotional needs that the dentist must assess and decide how to address. Parental guilt, defensiveness or denial are all emotions that any dental professional needs to deal with, along with sometimes unrealistic expectations or very prescriptive guidelines from parents.

I remember one mother telling me before

an operative appointment with an anxious boy: “Don’t tell him about his cavities, don’t tell him why he’s here today, don’t let him see any dental tools, don’t use nitrous … and don’t let him cry!”

In addition to being a pediatric dentist, I am also a parent of three children. If there is one thing that makes a decent human being feel insecure, frustrated and at times helpless, it is being a parent.

Parenting is incredibly complex, challenging and emotionally charged.

I often find myself getting very frustrated with my children, while being patient with other people’s children in the office is a given. I can confidently say that many of us who are currently raising children have decided which elements of parenting we would like to replicate from our own upbringing and which we adamantly refuse to use on our own children. Many parents today take guidance from books or other parents and do their best. Parenting is happening in the context of today’s society, not in isolation and not in the society of days past.

O C TOBER 2 0 2 1

611

introduction C D A J O U R N A L , V O L 4 9 , Nº 1 0

In addition to the psychological dynamic between parent or caregiver and the child, the changing nature of family structure and family dynamics also impacts parent behavior and child behavior. Dr. Clarice Law and colleague’s article sheds light on understanding the parent-child dynamic to deliver person-centered dental care to children. While the nature of parenting is changing, the understanding of child development continues to deepen.

I think you will find the update on childhood brain development, along with emotional and cognitive development, fascinating. In addition, the article reviews generational differences, impact on child development and new approaches to managing child behavior.

Just as understanding the parentchild dynamic is vital in the delivery of person-centered dental care to the child, so too is the understanding of that family’s environment and beliefs.

Because parents are the gatekeepers to their children’s food, activities and hygiene, they also control their health.

In their article, Dr. Paul Casamassimo and colleagues give an overview of person-centered care, also known as patient-centered care (PCC), and tailoring prevention and treatment to the child and family. They explain how PCC has been used in pediatric dentistry and how it can expand the general dentist’s awareness of the greater influences of societal and environmental factors of oral health.

PCC acknowledges the individual and interacting contributions of the patient, family, community and environment in disease and health maintenance.

While being a dentist who provides care for children in the best of times has its share of difficulties, being a dentist who cares for kids in COVID-19 times is even more stressful. Like you, I have had to navigate how to safely deliver care during 612 OC TOBER

2021

the pandemic. How do we care for patients in ways that keep everyone safe, without worsening our patients’ dental conditions, and within the confines of what is behaviorally and emotionally acceptable for children and their caregivers? Dr. Ray Stewart and co-authors describe how pediatric dentistry has experienced an increase in telehealth technology to serve children’s dental needs. Because of the pandemic, the UCSF Department of Pediatric Dentistry and many other dental practices in California now use teledentistry in their care models.

While the nature of parenting is changing, the understanding of child development continues to deepen.

Professionals who care for kids must be aware that the underlying circumstances and stressors that manifest as behaviors for both patient and parent often carry over into the interactions parents have with their child’s health care provider. Not surprisingly, the COVID-19 pandemic has further complicated this. I have had families come into the office over the past year and tell me that this was the first outing for their children in months.

I know many parents whose children have shown behavioral changes, children who were perfectly welladjusted before who now suffer from anxiety or depression and are in therapy.

The pandemic and the resulting isolation have negatively harmed many children in ways that are being

noticed now and likely in ways that will leave a lasting impact on this generation. In their article, Dr. Jessica Lee and colleagues describe the effects on child development, psychological consequences of the pandemic and the impact on dentistry for children.

Whether you are currently treating children in the dental office or trying to raise your own while keeping your mental health intact, I hope you will appreciate this issue of the Journal. It highlights how extraordinary childhood is with the complexities of cognitive, emotional and social development, all layered with parental and environmental influences and topped with an unexpected pandemic. I thank the authors who have shared their time and knowledge on these relevant topics.

It is truly a privilege to treat children.

It’s difficult and at times delicate, but also delightful and so much fun.

Children see the world through fresh eyes, speak the truth and find wonder in the everyday. Whether treating them in the dental chair or raising them at home, we should remember that children are indeed a gift. They deserve our attention and kindness and for us to keep trying our very best. n

®

Your dental community is in your corner.

TOGETHER WE ARE LIMITLESS

CDA’s mission is to fiercely protect, educate and advocate for you and your profession.

One of the many ways we’ve kept dentists covered and confident was by building and growing The Dentists Insurance Company. As a CDA member, you can tap into exceptional protection at a fair rate, plus tools and expertise to manage your risks.

Share in the benefits of insurance built by dentists, to protect only dentists, at cda.org/tdic.

Cynthia Brattesani, DDS CDA member since 1989 TDIC policyholder since 1993

IT’S A VERB.

Create smiles.

Change lives.

CDA Foundation volunteers and donors truly change the lives of others. Through your generosity, Californians in underserved communities gain access to dental treatment that relieves pain, restores dignity, creates smiles and opens more opportunities.

See ways to give at cdafoundation.org.

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

C.E. Credit

The Millennial Family: Adapting Behavior Guidance to Contemporary Parenting Adi A. Genish, DDS, and Clarice Law, DMD, MS

abstract Understanding the parent/child dynamic is important in the delivery of person-centered dental care to the child. However, the nature of parenting has changed and understanding of child development has continued to develop, affecting the ability of dentists to influence child behavior. The purpose of this paper is to review generational differences, the impact of parenting on child development and changes in approval of behavior guidance techniques to propose new approaches to child behavior.

Keywords: Generational differences, behavior guidance, behavior guidance techniques, parenting, interpersonal neurobiology, affective neuroscience

AUTHORS Adi A. Genish, DDS, is a health sciences assistant clinical professor in the section of pediatric dentistry at the University of California, Los Angeles, School of Dentistry. She is actively involved in the predoctoral pediatric dentistry program at UCLA and is board certified by the American Board of Pediatric Dentistry.

Conflict of Interest Disclosure: None reported.

Clarice Law, DMD, MS, is a health sciences clinical professor in the sections of pediatric dentistry and orthodontics at the University of California, Los Angeles, School of Dentistry.

She is the acting chair of the section of orthodontics and is actively involved in graduate education in pediatric dentistry and orthodontics. She is board certified by the American Board of Pediatric Dentistry and the American Board of Orthodontics.

Conflict of Interest Disclosure: None reported.

T

he millennial generation is defined by the Pew Research Center as the cohort of individuals who are now between the ages of 25 and 40.1 It is possibly the most studied generation and has been mostly maligned in popular media, with attention drawn by book titles such as “Not Everyone Gets a Trophy” and “Generation Me” and with memes and videos focusing on perceived shortcomings. The millennial generation has now reached the life stage where parenting and family life become important and is now poised to become the dominant proportion of caregivers for children in the dental setting. Studies indicate that family life is different within the millennial generation in terms of marriage status, living arrangements and a host of other factors.1

Understanding this changing dynamic is essential to success in the emerging person-centered model of dental care.

The American Academy of Pediatric Dentistry discusses the importance of parental influence: “Positive attitudes toward oral health care may lead to the early establishment of a dental home.

Early preventive care leads to less dental disease, decreased treatment needs and fewer opportunities for negative experiences.”2 The American Academy of Pediatrics emphasizes how patientand family-centered care can improve outcomes by improving the patient’s and family’s experience and increasing satisfaction. Notable side benefits are an increase in professional satisfaction and more effective use of health care resources.3 The American Dental O C TOBER 2 0 2 1

615

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

Education Association has also advocated for a person-centered approach that promotes disease management in the context of social interrelationships.4 While there may be regional, genderbased, cultural and socioeconomic factors that influence parenting and child behavior, creating a robust dentistparent-child triad with an eye toward science-based interactions with children and their parents must be a focus when shifting from a surgically oriented, patient-centered model of dental care to a wellness-oriented, person-centered model. Thus, the purpose of this paper is fourfold: 1) to review some of the social shifts that mark the current living generations; 2) to review the influence of parenting on child development; 3) to summarize changes in behavior guidance over the past 20 years; and 4) to propose some new approaches to child behavior as a new generation of parents and children emerge in the dental practice.

yet always hovering over their children and making noise.”5,6 These baby boomer parents most likely acquired this reputation of “hovering” over children because of the societal influences at work throughout their own upbringing during the post-World War II time of peace, prosperity and family growth.7–11 The baby boomers, who are now 57–77 years old, are described as one the wealthiest and best-educated generations of parents in history, obtaining access to financial resources that helped them raise their children.12 While some boomers may have

Each new cohort has a perspective on parenting that may change based on societal influence, economics and technology.

Contemporary Generations

While various social factors have always played a role in shaping the parent-child-provider relationship, evolving generational differences can drive how these factors alter the dynamics of this triad. Each new cohort has a perspective on parenting that may change based on societal influence, economics and technology. Understanding varying generational traits in the U.S. allows for a better understanding of contemporary parenting styles and how this may impact child behavior and thus strategies for dentists to treat children.

One of the earliest labels of a parenting style emerged in the early 1990s. Foster Cline and Jim Fay are credited with coining the phrase “helicopter parent” and assigning it to the baby boomer “parents of millennials who sometimes [were] helpful, sometimes annoying, 616 OC TOBER

2021

experienced some economic volatility, the unemployment rate during this time was generally low, allowing for a family structure with two working parents.12 The ability to shelter their millennial children and overindulge through their parenting was facilitated by increased income as well as small family sizes due to the advent of oral contraceptives and abortion rights.12,13 These generational experiences promoted a family environment that was often child-centric.

Generation X, now between the ages of 42–56, makes up the majority of the parent population in current practice.

Gen Xers were raised in a very different economic time than the baby boomers, experiencing economic recession, a divorce boom and an overall increase in crime and incarceration across the U.S.10

These “latchkey” kids had a reputation for being resourceful due to being frequently left home alone by a single working parent or two working parents, a characteristic evident in their parenting approach.10 As a result of growing up during a more tumultuous time in the U.S., individuals of Generation X are thought to be more skeptical of institutions, organizations, government or tradition.10 As parents, they have earned a new title, the “stealthfighter parent,” coined by public policy consultant Neil Howe.7,8 While less likely to hover closely, “stealth-fighter parents will choose when and where they attack and strike rapidly, in force with no warning.” The Gen X “security moms” and “committed dads” have also been known to have the ability to be “even more attached, protective and interventionist than boomers ever were.”7,8 As a whole, Gen Xers are thought to have taken an even more guarded and engaged approach to parenting their children with a targeted focus on preparing them for their future.10,13 While positive and nurturing in many ways, the baby boomer “helicopter parents” and Gen X “stealth fighter parents” are thought to have fostered a modern generation of young adults and adolescents who have exhibited a pattern of dependence, needing assistance in decision-making, expecting immediate feedback and holding a sense of entitlement and unrealistic expectations, whether in their own lives or their children’s.14 The current generation of children, most of whom are children of Gen X, are between the ages of 6 and 26 and have been labeled Generation Z or iGen. They are still being characterized by social psychologists and sociologists, as are the children of the yet-to-be-defined generation “alpha” that will follow them.

Anecdotally, the dominant characteristics of Gen Z/iGen have resulted in a strong

C D A J O U R N A L , V O L 4 9 , Nº 1 0

reaction within the social media communities of individuals who work with children, including educators, physicians and dentists. Thus, it is important for the dental provider to understand the social, societal and parental contexts that influence their development and behavior to ultimately provide a more personcentered approach to care.

Contemporary Childhood

One of the most revealing works on the current status of Generation Z/iGen is “Coddling of the American Mind” by Greg Lukianoff and Jonathan Haidt.15 Originally published as an article in The Atlantic in 2015,16 the authors expanded their content and included scholarly references in the hardcover title they released in 2018. Lukianoff, an attorney and free-speech advocate, and Haidt, a social psychologist and professor of ethical leadership at New York University, had noticed an alarming increase in anxiety, depression and suicide rates among the college students entering college around 2013–14. Determined to identify some of the societal trends precipitating these troubling outcomes in young adults, Lukianoff and Haidt presented six possible causes, three of which relate to the generational differences exhibited by contemporary parents. Paranoid parenting, the decline of play, anxiety and depression were hypothesized to have led to this unfortunate trend, particularly among Generation Z/iGen. Within the same time frame as Lukianoff and Haidt’s developments, the fields of affective neuroscience and interpersonal neurobiology were similarly providing a foundation to understand how these three concepts affect contemporary childhood.

Neuroscientists propose that during the early stages of a child’s life, the lower “reptilian” part of the brain dominates function while higher brain functions

develop later in childhood.17 The lower brain structures, namely the limbic system, orchestrate emotions as hormones regulate the seven primary lower brain systems: the “alarm systems” of RAGE, FEAR, PANIC/ GRIEF and the “calm systems” of CARE (attachment), SEEKING and PLAY.17 The seventh system of LUST generally doesn’t enter into discussions about the effect of parenting on brain development.

The more a lower brain system is activated throughout development, the more interwoven it becomes with personality — “emotional states becoming

The more a lower brain system is activated throughout development, the more interwoven it becomes with personality ...

personality traits.”17 Under the umbrella of these systems, parenting and society influence child personality and behavior.

Lukianoff and Haidt’s key findings build on this neurological foundation.

Lukianoff and Haidt’s work highlights the relevance of these neurodevelopmental findings, as they identified a shift in parenting approach near the beginning of the transition into the millennial generation. They suggested that an era of “paranoid parenting” began in the U.S. with a pair of highly publicized child disappearances in 1979 and 1981, triggering the National Child Safety Council’s advocacy for photos of missing children to appear on milk cartons and the initiation of the longstanding “America’s Most Wanted” television series. Meant to draw public awareness and to elicit support

in the search for missing children, the attention made parents more concerned about child safety. The culture of paranoid parenting was the subject of a series of scholarly publications by Furedi18 who noted: “This is a culture that continually incites the public to worry about every dimension of children’s lives. It is a culture that dramatizes every issue facing mothers and fathers and turns everyday problems into scare stories. It is also a culture that denigrates parental competence and insists that mothers and fathers cannot cope without the help of experts. These cultural messages are zealously promoted by a formidable network of professional experts, child rearing gurus, child protection advocates, fear entrepreneurs and politicians.” Many contemporary children are raised in an overprotected environment, with parents preventing them from experiencing both physical danger and “stranger danger.” From a brain development perspective, when young children are taught to perceive the world to be a dangerous place, lower brain structures like the hippocampus and the amygdala trigger the release of stress hormones. This lower brain FEAR system can impair higher brain development, impair emotional regulation and promote negative implicit memory associations with challenging life events.17,19 Paranoid parenting can extend to the dental setting, with some parents expressing concerns about not wanting their children to have bad experiences or failing to trust their dental providers. This is particularly challenging with the increase in parental presence in the operatory that has occurred over the past two decades.

Another of Lukianoff and Haidt’s reasons for the alarming outcomes for the oldest individuals identified as Generation Z/iGen is the decline of play. Contemporary children appear to be lacking in the kind of free play more commonly associated O C TOBER 2 0 2 1

617

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

with the latchkey children of Gen X. Free play is specifically defined as physical activity initiated by and directed by the participants. This is distinct from organized play where an adult supervises the activities. The lower brain PLAY system has an important role in brain development and activates neurotransmitters that promote higher brain development, activate antistress mechanisms, decrease impulsivity and overactivity and develop emotional regulation when a child is engaged in physical play.17 The contemporary child is thought to be less physically and socially competent, less risk tolerant and more anxious. Under these conditions, the dental setting may seem like a particularly threatening environment.

Paired with a caregiver who exercises paranoid parenting, a child with an underactive PLAY system may find routine dental procedures to be difficult because of their invasive or novel nature. This type of child may prove to be a challenge even for providers with high proficiency with basic behavior guidance techniques.

The final of Lukianoff and Haidt’s reasons for the decline in mental health for college-age students is an increase in anxiety and depression. The use of handheld electronic devices and social media are cited as possible reasons.20,21 Although these studies focus on the high school and college-age population, younger children are also increasing their use of electronic devices. The lower brain SEEKING system provides motivation to explore.17 When activated, the SEEKING system triggers the release of dopamine, which stimulates cognitive development in the frontal lobe, and opioids, which have antianxiety effects. SEEKING is optimally activated in the context of interpersonal relationships and is thought 618 OC TOBER

2021

to be underactivate in the context of excess screen time. Lack of one-on-one connection or parental attunement can also result in an underactive SEEKING system, which could also be related to the increased use of handheld electronic devices by parents. A “connected” child or a child with a “connected” parent might be lacking in the skills to connect with a dentist in a manner that supports basic behavior guidance or they may lack the drive and motivation to successfully fulfill the expectations required for successful completion of a given dental procedure.

Both parents and children have influenced the parameters under which the doctor can interact with the child patient.

As societal changes have shaped parenting, parenting has likewise influenced the nature of interactions professionals have with the individuals of Generation Z/iGen. Both parents and children have influenced the parameters under which the doctor can interact with the child patient. As such, acceptance and use of various behavior guidance techniques have also changed with the generational shifts.

Behavior Management of the Past

The last major wave of publications in the pediatric dentistry literature regarding changes in parenting styles appears to have started in 2002, with the publication of a study that was first presented to the College of Diplomates of the American Board of Pediatric

Dentistry annual session in May 2001.

The study, by Casamassimo et al.,22 consisted of a questionnaire mailed to 1,129 ABPD diplomates. The key conclusion was that “diplomates report that parenting changes have occurred and they believe these are negative (bad) and have adversely influenced behavior and caused changes in pediatric dentists’ behavior management.”

In November 2003, the second Behavior Management Consensus Conference was held. The proceedings were summarized in the May/April 2004 issue of Pediatric Dentistry. Three of the presentations focused on child behavior and the influence of parenting.

Presenters acknowledged that children and families “live and grow in a different social context than 15 years ago”23 with trends for families “to live increasingly isolated and disconnected lives in our society … with parenting in today’s society … occurring in an increasingly stressful context.”24 Presenters suggested that changes in family had influenced child behavior. “Behavior of pediatric patients reflects fewer boundaries, less discipline and self-control and lowered behavioral expectations by parents and contemporary culture.”25 Other studies focused on behavior management.

One study presented at the conference specifically asked participants to report if they used each of the 13 behavior guidance techniques with children.

Despite the reports of changes in parenting styles and child behavior, the study revealed little actual change over the previous five years of practice.26 And more significantly, respondents reported no plans to change their use of behavior management techniques going forward.

During the conference, some very specific recommendations were made regarding behavior management techniques, including:

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Reevaluate the definitions of child behavior in the dental setting, including definitions of appropriate behavior.

■ Develop training in effective communication with parents for pediatric dentists and their staffs.

■ Seek further information on the impact that changing parental attitudes toward behavior management techniques may have on the quality and accessibility of treatment.

■ Conduct research in specific areas of behavior management, particularly in communicative techniques.”26 There were also some very thoughtful conclusions about the changing nature of family dynamics and the subsequent effect on child behavior. Presenters advocated for a holistic approach. “Diagnosing the child and family within the immediate local context is central to developing and accomplishing an effective dental treatment plan.”23 Overall, an empathetic approach was suggested. “It is easy to be critical of parents and their parenting efforts; however, there is much more involved than simply parents who do not care or who are knowingly doing the ‘wrong thing.’ Parenting is difficult under the best of circumstances. For a growing number of parents, the stressors in our society are making it increasingly difficult to parent effectively. It is important to remember that parenting occurs within the context of a society, not in isolation, and parenting problems often reflect society’s problems.”24 These conclusions continue to be relevant in the current shift toward person-centered care.

In the years following the 2003 Behavior Management Consensus Conference, there was an increase in interest in the association between parenting practices and problem behaviors in general. PubMed summaries of articles ■

addressing “parenting AND problem behavior” numbered less than 100 per year until 2001, after which numbers dramatically increased to a peak of 547 articles in 2018. Specific to dentistry, a number of articles attempted to identify relationships between parenting style and behavior guidance, with a summary of the Baumrind typology described in this journal in 2007.27 Diana Baumrind’s first description of her eponymous parenting typology was first published in 196628 and has been cited 4,495 times.

Baumrind measured parenting according

It is important to remember that parenting occurs within the context of a society, not in isolation, and parenting problems often reflect society’s problems. to two dimensions — warmth, which “implies being involved and interested in the child’s activities, listening to the child and being supportive,” and demandingness, which refers to “the amount of control a parent imposes on a child (e.g., expectations for behavior), the implementation of standards and rules and the degree to which a parent enforces the standards and rules.”29 The typology was modified in 1983 to include four parenting styles: authoritarian (low warmth, high demandingness), authoritative (high warmth, high demandingness), permissive or indulgent (high warmth, low demandingness) and the additional category of neglectful or uninvolved (low warmth, low demandingness).30 Studies that focused on the influence of parenting style on approval of behavior

guidance techniques suggest that parents characterized by the authoritative typology are likely to partner well with their child’s provider in use of communicative basic behavior guidance techniques, with the majority of parents in one behavioral coding study choosing not to intervene during local anesthesia administration on their children.31 Subjects scoring high in the permissive category tended to initiate physical contact with the patient by taking the patient’s hand (74%), stopping the treatment (70%) and questioning the pediatric dentist regarding the effectiveness of the anesthesia (50%).31 An unpublished study of approval ratings of behavior guidance techniques suggested that permissive parents approve of pharmacologic techniques (oral conscious sedation, intravenous general anesthesia and general anesthesia in the operating room setting) more highly than do authoritative or authoritarian parents.32 Authoritarian parents reacted to local anesthesia administration with use of physical control, firmness and displeasure.31 Similarly, ratings of authoritarian parents indicate approval of voice control and use of protective stabilization.32 A number of other studies focused on the influence of parenting on child fear in the dental setting. The number of articles fulfilling the criteria of “parenting AND dental anxiety” has doubled since 2009, indicating a high degree of interest in the subject. A systematic review relating parenting to dental anxiety and misbehavior summarized the findings of eight articles mostly published between 2008–2015 that met inclusion criteria.

“Parenting style was shown to affect dental anxiety in a study of children who visited the dentist for the first time, whereas no effects were seen in children with previous dental experience.”33 More recent publications demonstrate mixed O C TOBER 2 0 2 1

619

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

results, with one failing to find associations between parenting style and child behavior in the dental setting34 and others suggesting more positive outcomes with authoritative parenting styles in children with no previous dental experience.35,36 An additional study demonstrated no association between parenting style and dental fear and anxiety.37 Studies on the influence of parenting and oral health have also increased, with the search term “parenting AND dental caries” returning three times the number of results in the past decade and “parenting AND oral hygiene” also rising steadily in numbers. Associations are demonstrated between the more desirable authoritative parenting style and oral health. Quek et al. wrote in the conclusions to their study, “Authoritative parenting was associated with positive attitudes regarding both preventive dietary and oral hygiene practices. Actual oral hygiene practices were more optimal in children with authoritative parents, but parenting styles had no impact on actual dietary habits.”38 Viswanath et al. wrote in their conclusions, “Children of both authoritative and authoritarian parents showed lower caries risk status while the permissive parenting group demonstrated a threefold increase in caries status compared to authoritative parenting.”39 In sum, although conclusions presented at the 2003 Behavior Management Consensus Conference suggest that changes in parenting have affected child behavior in the dental setting, subsequent studies on the influence of parenting styles have only been able to demonstrate that positive parenting practices are associated with better oral health, lower caries risk and positive behavior in the dental setting.

Studies have not clearly identified the outcomes for the authoritarian, 620 OC TOBER

2021

permissive/indulgent or uninvolved/ negligent parenting typology. Whether parenting style turns out to have positive or negative effects on pediatric oral health, the American Academy of Pediatrics policy statement indicates that family should be the child’s primary source of strength and support.3 In a person-centered care approach, parental approval of care techniques is an essential component of high-quality clinical decision-making. Interestingly, approval of behavior guidance techniques by parents has changed

In a person-centered care approach, parental approval of care techniques is an essential component of high-quality clinical decision-making. over time, as have changes in use of techniques by providers. Understanding these changes will be important in adapting to the emergence of the millennial parent and their approval of behavioral guidance techniques.

Communicative techniques make up the majority of the techniques used by providers and approved by parents.

Adair’s 2004 study of members of the American Academy of Pediatric Dentistry could be considered a baseline study for the 21st century, with a 66% response rate among the 4,180 members who had been sent the research instrument.26 Results suggested that more than 90% of providers used tell-showdo, nonverbal communication, positive reinforcement and distraction. Tell-showdo has clearly been demonstrated to

show extremely high parental approval, with the other techniques likely to have remained high in approval. The same study population expected increases in use of all of these techniques in the years to come. Considering the highly expressive nature of contemporary parents, skills in communicative behavior guidance techniques will continue to be important.

The aversive techniques, however, are more controversial. By 2004, the least frequently used technique was hand-over-mouth exercise (HOME) with 21% of providers reporting use.

However, 50% of respondents indicated that they had already decreased use of HOME and another 24% indicated that they expected to decrease use.26 This controversial aversive technique has since been removed as an approved behavior guidance technique from the American Academy of Pediatric Dentistry’s Reference Manual. Voice control, or use of a firm tone, was being used by 92% of respondents in 200426 with approximately double the percentage of respondents anticipating decrease in the years to come based on changes in parenting. Indeed, parents are not as approving of voice control as they may have been in the past, with its use ranking below general anesthesia and oral conscious sedation.40 Current data suggest that parents are only mildly approving of the use of voice control.41 And providers with more than 30 years of experience report higher utilization in the past than currently.42 Passive immobilization (sometimes referred to as a “papoose board”) is worth discussing in the context of contemporary parenting because of its decline in acceptability. Based on the 2004 dataset, 66% to 74% of pediatric dentists used passive immobilization with nonsedated children and either

C D A J O U R N A L , V O L 4 9 , Nº 1 0

28% or 11% to 17% indicated that they expected to use it less frequently.26,43 Parental approval was low,40 with acceptability lower only for the handover-mouth exercise. The American Academy for Pediatric Dentistry began discussing recommendations for use, and by the time the 2013 AAPD Reference Manual was released, the guidelines had changed. The technique is now called protective stabilization and includes both active restraint (physical limitation by an individual) and passive restraint (physical limitation by restrictive equipment such as the papoose board).44 The guidelines emphasize use of protective stabilization only in specific situations, such as urgent care, limited treatment in a child where sedation or general anesthesia is not an option, children with movement disorders and with the sedated patient.

Contraindications include use in a cooperative nonsedated patient or those with nonemergent needs.

Use of protective stabilization is not considered appropriate if used for the practitioner’s convenience and certainly not if used punitively. Approximately 25% of a specially selected study cohort of 511 pediatric dentists considered passive protective stabilization “always acceptable” for emergency patients and 23% approved of its use for children with special health care needs.45 Only 4% considered it “always acceptable” for routine operative care and 51% believed it to be “never acceptable.” Protective stabilization has been reclassified as an advanced behavior guidance technique, recommended for use only by specialists or individuals with advanced training. A series of negative news stories focusing on parents who claimed inappropriate use as well as a negative public perception about the practice was the justification for the policy change by

the AAPD, which called for judicious use. Considering the decrease in the use of physical discipline among many contemporary parents and the concern about emotional trauma, protective stabilization is expected to continue its decline in acceptability and use.

Parental presence in the operatory has also demonstrated a shift over the past two decades. Parental absence was the norm in the past. Children were expected to respond positively to an adult authority that was not the parent.

With the guideline for first dental visit

Use of protective stabilization is not considered appropriate if used for the practitioner’s convenience and certainly not if used punitively.

changing from age 3 to age 1 in the mid-1980s, parents were expected to be present in the dental operatory to provide comfort to their infants and toddlers during oral examination. By the time of the 2004 dataset, more than 60% of dentists appeared to have a practice (greater than 75% of the time) of allowing parents to be in the operatory for emergency visits and for children with special health care needs. Beyond that, 40% would enlist parental assistance in restraining their children. However, only 43% had a routine of allowing parents to be present during routine examination and 33% for restorative procedures.

Parental absence was enforced by 45% of pediatric dentists for sedation procedures and by 24% for surgical

procedures. A secondary data analysis of the same dataset indicated a 30% to 40% increase in the presence of parents in the operatory over the previous five years43 while 10% to 20% of the same subject population indicate a decrease in parental presence. Of the eight options given as reasons for the increase in parental presence, two appeared to be for the patients’ benefit — 9% thought that patients behaved better with parents present and 51% appreciated being able to consult with parents about evolving treatment needs during the appointment. Four options were related to parent motivators — 78% indicated that parents preferred to be present, 53% that parents insisted on being present and 21% expressed that parents would not consent to treatment without their presence.

Sadly, concern about legal action was the motivator for increasing parental presence for 35% of the respondents.

Interestingly, only 7% of participants thought they would further increase parental presence in the years to come.

A much smaller follow-up study 10 years later indicated continuing trends toward increased parental involvement, with parental presence for routine examination increasing from 43% in 2004 to approximately 53% 10 years later and from 33% to 43% for routine operative appointments.42 By this time, 55% of providers included parents to help in “basic communication, reinforcement and occasionally stabilization” and 26% indicated that “parents can observe but not be a part of the doctor-patient interaction.”

Parental attitudes about advanced behavior guidance techniques using pharmacological restraint have shown a substantial change in the past two decades. In 2004, 62% of the pediatric dentists who responded to the study O C TOBER 2 0 2 1

621

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

used conscious sedation, of which 27% indicated was lower than in the past.43 Another 21% indicated use that was higher than the past. Regarding general anesthesia use, 71% of providers used this form of patient management, with 38% indicating that this was an increase over the previous five years and 12% indicating a decrease.

Parental approval shows inconsistency in ratings, but parents seem to prefer oral conscious sedation and general anesthesia over passive restraint,40,46 with increasingly positive parental attitudes and understanding regarding oral conscious sedation.47 The 2004 expectation among pediatric dentists of increasing use of advanced behavior guidance techniques has proven to be true with more recent studies reporting increased use of oral conscious sedation and general anesthesia,48 with younger providers more likely to use pharmacologic restraint than more experienced providers.42 This may be a generational difference in an emerging parent population resistant to inflicting hardship on their children or it may reflect response to a generational difference among the providers themselves.

In sum, trends in parental approval indicate an increased expectation among parents to be allowed in the treatment area. Providers appeared to have responded to these expectations, possibly reluctantly. With higher numbers of parents participating in dental treatment for their children, the increasing approval for positive communicative techniques and decreasing approval for aversive techniques such as voice control and use of protective stabilization requires that the dental provider have a robust armamentarium of basic behavior guidance techniques in their skillset.

622 OC TOBER

2021

Although providers with advanced training may be able to take advantage of certification in pharmacologic restraint, this may not guarantee the ability to provide definitive restorative care in all cases. Contemporary parents appear to have very different responses to the concept of treatment under conscious sedation or general anesthesia. Some parents appear to embrace pharmacological options as an alternative to what they believe may otherwise be a difficult experience for their children. Other parents indicate

Behavior guidance techniques must take an individualized, person-centered approach, considering the child and their parents’ emotional and mental statuses. reservations about the use of sedative agents. Thus, the selection of behavior guidance techniques must take an individualized, person-centered approach, considering the child and their parents’ emotional and mental statuses.

Some of the changing trends in use and approval of behavior guidance techniques are supported with shifts in the parenting literature regarding the use of power assertion with children.

In later publications, Baumrind concluded that there were significantly different general outcomes for children depending on parenting typology.

Children of parents who use the authoritative style have better outcomes in demonstrating interpersonal skills, social responsibility and self-efficacy

than those of authoritarian parents.

Baumrind concluded that “the kind of power that characterizes authoritarian parents is coercive (arbitrary, peremptory, domineering and concerned with marking status distinctions),” whereas “the kind of power that characterizes authoritative parents is confrontive (reasoned, negotiable, outcomeoriented and concerned with regulating behaviors).”49 She concluded that “the effects of power assertion are detrimental only when coercive, so that the common presumption that power-assertive disciplinary practices per se are harmful is unjustified.”

Applying this conclusion to the changes in use of behavior guidance techniques over the past 10 to 15 years, it might be proposed that the decline in the use of aversive techniques such as hand-over-mouth, voice control and protective stabilization not only meets the changing demands of contemporary parenting, but could be considered beneficial, considering longer-term studies of the influence of power assertion on child well-being.

Over the past decade, some criticisms of the Baumrind parenting typology have emerged. One criticism is that it lacks predictive validity.

Focused only on warmth and behavioral control, the typology does not address psychological control — control of the emotional state of the child.50,51 Applied to the concepts of behavior guidance, it might be concluded that the historical focus on selecting and applying behavior guidance techniques can likewise be expected to lack predictive validity.

The behavior guidance techniques are techniques — ones developed to elicit cooperation and control behaviors without addressing the emotional state of each patient. Although the psychological control aspect appears

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Upper Brain: Neocortex

Cerebral Cortex

Functions: Decision-making and planning, balancing emotions and body, reflection, empathy and morality

Middle Prefrontal Cortex

Lower Brain: Limbic System

Hippocampus Amygdala

• Alarm systems: RAGE, FEAR and PANIC/GRIEF • Calm systems: CARE (attachment), SEEK and PLAY • Functions: autonomic processes, fight-or-flight response, sensory memories and emotions

RIGHT BRAIN : Functions: Meaning and feel of experience, emotions and personal memories

LEFT BRAIN : Functions: Logical, literal, linguistic, linear

FIGURE 1. General summary of brain functions relative to human behavior. (Adopted from Siegel DJ, Bryson TP. The Whole Brain Child:12 Revolutionary Strategies to Nurture Your Child’s Development. New York: Bantam Books; 2011).

to have a negative outcome, the importance of addressing emotions has become an emerging concept in the parenting literature and should play an important role in person-centered care.

Behavior Guidance of the Future

Cline and Fay were among the earliest to explicitly address the mass market audience regarding the typologies described by Baumrind in their book “Parenting With Love and Logic: Teaching Children Responsibility.”

Although the book described a number of techniques to achieve behavioral control, the authors were very clear on addressing the importance of empathy. Since then, the fields of interpersonal neurobiology (the study of how relationships affect brain development) and affective neuroscience (the study of the neural mechanisms of emotion) have flourished, giving rise to both scientific and mass-market

publications focused on helping parents cultivate the growth of their children’s brains. The dental provider could benefit from applying “brain-based” parenting strategies to the guidance of behavior in the dental setting, again moving toward a more individualized, personcentered care model for each child.

Daniel Siegel and Tina Bryson’s bestselling book “The Whole Brain Child: 12 Revolutionary Strategies To Nurture Your Child’s Development”52 explains the neurobiology of a child’s brain, which can be divided into the upper and lower brain functions discussed previously (FIGURE 1 ). The “upstairs” or higher brain is responsible for decision-making and planning, balancing emotions, selfreflection, empathy and morality.52 The higher brain remains underdeveloped in young children and is proposed to mature in the context of a healthy parent/child relationship.17,52 The “downstairs” or

lower brain is responsible for autonomic function, the fight-or-flight response, sensory memories and emotions.52 As suggested previously, events perceived to be threatening can activate the lower brain via the FEAR or PANIC/GRIEF system, along with the RAGE system.

Parents and caregivers develop emotional regulation in children by helping them make sense of the perceived threat and engaging the higher brain as it matures.

Thus, a precooperative child younger than age 3 is not likely to be able to process a threat rationally. An older child can benefit from guidance in engaging the higher brain, but may still lose control over emotions and body. Whether by FEAR- or PANIC/GRIEF-driven fightor-flight response or by RAGE-driven “downstairs tantrum,” stress hormones interfere with higher brain function and the child cannot be reasoned with.52 Brain-based parenting strategies with O C TOBER 2 0 2 1

623

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

TABLE 1

Potential Applications of Brain-Based Parenting Strategies to Behavioral Reactions by Age Grouping Right brain reactions

Description

0–3 years

3–6 years

6–12 years

12+ years

Chaos. The child is responding to the situation with loss of control over their emotions.

Connect and redirect.* Choose facial expressions and touch that demonstrate empathy.

Connect and redirect.* Choose facial expressions and touch that demonstrate empathy.

Connect and redirect.* Choose facial expressions and touch that demonstrate empathy.

Connect and redirect.* Choose facial expressions and touch that demonstrate empathy.

Name it to tame it.* Acknowledge and label the feelings the child is exhibiting. Tell the child the story of their experience to allow the left brain to make sense of the right brain emotions.

Name it to tame it.* Acknowledge and label the feelings the child is exhibiting. Tell the child the story of their experience to allow the left brain to make sense of the right brain emotions.

Name it to tame it.* Acknowledge and label the feelings the child is exhibiting. Allow the child to tell the story of their experience by asking leading questions.

Use it or lose it.* Engage the upstairs brain by helping the child make simple choices to engage higher-order thinking.

Move it or lose it.* Engage the upstairs brain (and disengage the downstairs brain) by having the child move their body.

Use it or lose it.* Engage the upstairs brain by presenting questions or playing logic games.

Move it or lose it.* Engage the upstairs brain (and disengage the downstairs brain) by having the child move their body.

Use it or lose it.* Engage the upstairs brain by presenting questions or playing logic games.

Engage, don’t enrage.* Engage the upstairs brain by helping the child create a plan, make choices and take more control of thinking rather than reacting.

Downstairs brain reactions

Fight-flight-freeze. A stress response. The child is responding with loss of impulse control.

Left brain reactions

Rigidity. The child is responding to the situation with loss of control over adaptability.

Connect and redirect.* Listen and acknowledge the child’s experience.

Use empathy to connect and use problem solving and boundary setting.

Collaborative problem solving.** Help the child reconcile their concerns about the issues with the adult’s concerns and work toward an agreeable solution.

Collaborative problem solving.** Help the child reconcile their concerns about the issues with the adult’s concerns and work toward an agreeable solution.

Upstairs brain reactions

A planned response. The child is responding with planned control over impulses. A conscious choice to act out.

Engage, don’t enrage.* Avoid commanding, demanding to avoid triggering the downstairs brain. Give the child a choice to engage higherorder thinking.

Connect through conflict.* Emphasize relational concerns, helping the child see a human perspective to reengage the positive portions of downstairs brain function.

Connect through conflict.* Emphasize relational concerns, helping the child see a human perspective to reengage the positive portions of downstairs brain function.

* Siegel DJ, Payne Bryson T. The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Mind. Bantam, 2012. ** Greene RW. The Explosive Child. HarperCollins World, 1999.

mnemonics such as “engage don’t enrage” and “use it or lose it” involve engaging the higher brain in order to regulate the activity of the lower brain (TA BLE 1 ).

Giving children choices to involve them in the decision-making process can aid a child during a difficult experience while also facilitating the development of the upstairs brain to engage in the future.

624 OC TOBER

2021

Siegel and Bryson also distinguish between the “left brain,” which is “logical, literal, linguistic (it likes words) and linear (it puts things in a sequence or order),” and the “right brain,” which identifies the “meaning and feel of an experience” and specializes in “images, emotions and personal memories”52 (FIGURE 1 ). Young children lack the ability to integrate the

functions of the two hemispheres and often overreact to difficult situations with either right brain “chaos” or left brain “rigidity.” Parents and caregivers can promote “horizontal integration” by identifying which hemisphere of the brain is in function during conflict and engaging appropriately, either with logic and solutions or with empathy and

C D A J O U R N A L , V O L 4 9 , Nº 1 0

emotion.52 Integration of the emotional and logical brain is proposed to give the child more empowerment and mastery in difficult situations.52 The brain-based parenting strategies when a child is emotional could be to “name it to tame it” by identifying the emotion to engage the child’s left brain and externalizing the abstract. Parents are also encouraged to “connect and redirect,” which may involve gentle touch, a calm tone of voice, empathetic facial expressions, empathy and pausing (TA BLE 1).

Once a child’s emotional needs are met, they can then be redirected to use their left brain by giving them solutions, planning, providing logical explanations or setting boundaries.52 While the evidence base for behavior guidance techniques grounded in children’s neurobiological development is very limited in the pediatric dentistry literature, there is strong evidence in psychology literature supporting brain-based, parent-driven child behavior therapies such as the well-established ParentChild Interaction Therapy.54 Overall, the emerging brain-based parenting concepts could easily be applied to the dental setting. The dental provider must recognize what a child is experiencing in the moment before attempting to control uncooperative behaviors. Diagnosing the “why” of child behavior with the brain in mind becomes the first step in guiding unproductive behaviors in the dental setting. A reasonable next step is understanding the context from which the parent interacts with child and dentist. Finally, the dental provider can choose to employ classic behavior guidance techniques or apply contemporary parenting strategies to address the root of the child’s misbehavior (TA BLE 2 ).

Discussion

parents of children with disruptive behavior are seldom given credit for their children’s strengths, but are often blamed for their children’s shortcomings or misbehavior.54 This, in turn, may limit a child’s ability to express themselves appropriately or regulate their emotions and could interfere with psychosocial maturation.55 There is some relationship between parental fear and the level of fear demonstrated by the child, so a fearful parent may predispose their own child to dental fear. Overall, because the dental environment can feel like a very invasive space, both contemporary parent and child are susceptible to overactivation of the lower brain alarm systems (RAGE, FEAR, PANIC/GRIEF). The aversive The dental provider must behavior guidance techniques have been recognize what a child is demonstrated to be decreasing in use by pediatric dentists and acceptability by experiencing in the moment parents. Moreover, techniques such as before attempting to control hand-over-mouth exercise, protective uncooperative behaviors. stabilization or passive restraint, parental absence or voice control could actually activate these lower brain alarm systems in both parent and child.17 Rather the shifts in parental characteristics than initiating behavioral control, a and values. And finally, the millennial more productive focus may be to guide generation is about to overtake Gen X as emotional regulation with communicative a representative proportion of parents. behavior guidance approaches such as Lukianoff and Haidt’s concept of tell-show-do, descriptive praise, parental presence (in some cases) and positive “paranoid parenting” can provide a reinforcement. Appreciating that delays framework for understanding both the in emotional regulation may be at the contemporary child and their parent, root of what seems to be a difficult child particularly parents representing the millennial generation. The “overparenting” or parent can help guide dentists with that is proposed to take place in the context a more empathetic approach to both the parent and child experience. of increased imagined risk can lead to low The concerns of Lukianoff and Haidt self-esteem as adults.55 Some studies have suggested that mothers use their children about the decline of free play and the to confirm their role as parents and to increase in anxiety and depression seem create a positive self-presentation, which to be rooted in a shift in contemporary life increases their own subjective well-being.54 from the physical to the virtual. This will Fear of judgement by the dentist or dental also have an impact on the relationship staff may trigger a more intrusive parenting between dental provider, child patient and style to ensure patient cooperation. Further, parent. Children with limited physical play The last major wave of scientific publications of the early 2000s that described changes in behavior management could have been related to the transition from one generation of children to the next. And now, dental professionals who provide care to children are on the verge of a fascinating period of transition. Family structure has continued to evolve, the effects of parenting on child development have been more clearly described and use of and approval of classic behavior guidance techniques have changed with

O C TOBER 2 0 2 1

625

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

TABLE 2

Potential Adaptations of AAPD Behavior Guidance Techniques* to Brain-Based Parenting Strategies by Age Grouping Description

0–3 years Piaget’s sensorimotor stage. Reacting with senses and movement.

3–6 years Piaget’s preoperational stage. Learning mental representations of objects and concepts.

6–12 years Piaget’s concrete operations stage.

Learning to think logically about events.

12+ years Piaget’s formal operations stage.

Learning to think hypothetically about events.

Right brain reactions

Chaos. The child is responding to the situation with loss of control over their emotions.

Use nonverbal communication and positive reinforcement to show empathy while the child is reacting to the procedure in progress.

Use nonverbal communication, positive reinforcement and tell-show-do to show empathy and help the child understand and make sense of their emotions about the proposed or in-progress procedures.

Use nonverbal communication, positive reinforcement, tell-showdo and ask-tell-ask to show empathy and discuss the implications of the child’s reaction to the proposed or inprogress procedures.

Use nonverbal communication, positive reinforcement and ask-tell-ask to show empathy and discuss the implications of the child’s reaction to the proposed or in-progress procedures.

Downstairs brain reactions

Fight-flight-freeze. A stress response. The child is responding with loss of control over body and emotions.

Use audio or visual distraction to decrease the perception of unpleasantness for the child.

Use physical distraction to help the child gain control over their body.

Use audio or visual distraction to help the child gain control over emotions.

Use physical distraction to help the child gain control over their body.

Use audio or visual distraction to help the child gain control over emotions. Use desensitization to help a fearful child gain familiarity with proposed procedures.

Use enhancing control to give a fearful child the opportunity to participate in the procedure by signaling discomfort.

Use audio or visual distraction to help the child gain control over emotions. Use desensitization to help a fearful child gain familiarity with proposed procedures.

Use enhancing control to give a fearful child the opportunity to participate in the procedure by signaling discomfort.

Use ask-tell-ask to help the child develop their own coping strategy.

Left brain reactions

Rigidity. The child is responding to the situation with inflexibility.

Use positive reinforcement and descriptive praise to encourage adaptability toward productive behaviors.

Use ask-tell-ask to work with the child to develop a mutually agreeable solution for the treatment need. Use positive reinforcement and descriptive praise to encourage adaptability toward productive behaviors.

Use ask-tell-ask to work with the child to develop a mutually agreeable solution for the treatment need. Use positive reinforcement and descriptive praise to encourage adaptability toward productive behaviors.

Upstairs brain reactions

A planned response.

The child is responding with planned control over body and emotions.

A conscious choice to act out.

Use positive reinforcement and descriptive praise to engage the pro-social functions of the lower brain.

Use ask-tell-ask and enhanced control to determine the root of the child’s choice to act out.

Use positive reinforcement and descriptive praise to engage the pro-social functions of the lower brain.

Use ask-tell-ask and enhanced control to determine the root of the child’s choice to act out.

Use positive reinforcement and descriptive praise to engage the pro-social functions of the lower brain.

* aapd.org/research/oral-health-policies--recommendations/behavior-guidance-for-the-pediatric-dental-patient

626 OC TOBER

2021

C D A J O U R N A L , V O L 4 9 , Nº 1 0

opportunities can demonstrate decreased activation of the prosocial PLAY and SEEKING systems in the lower brain, which in turn can lead to heightened impulsive behaviors, decreased risk tolerance, overactivity and decreased stress regulatory mechanisms.17 Limited free play also comes with limited opportunities to negotiate conflict. The contemporary child may find the highly physical world of the dental setting to be challenging and may not be accustomed to expressing concerns in a productive manner. The increase in use of handheld electronic devices for entertainment exacerbates the effects of less physical play. Virtual play does not activate the PLAY and SEEKING systems as effectively as physical play. Beyond that, the millennial parent has grown with technology and connectivity as a fundamental way of life. Parental distraction by their own handheld devices has implications on the social interactions for their children. As providers, communicative behavior guidance techniques like tellshow-do allow the dentist to model “an energized engagement” with the child17 that may activate the brain’s SEEKING system and stimulate the activity of the upstairs brain — the rationale, decisionmaking and planning brain.52 Playful and responsive interactions within the context of communicative behavior management approaches can also activate the brain’s PLAY system. Positive reinforcement and descriptive praise can also be effective in engaging the SEEKING system. Young children will work hard for praise and the feeling of self-mastery that accompanies the successful completion of a challenging task. The behaviors or qualities the adult praises are more likely to be displayed by the child in the future.54 Appreciating that limited interpersonal interactions may also factor into behavioral response can likewise guide dentists toward a more integrated and positive approach to care.

Conclusions

Person-centered care requires more than a set of skills in behavioral control.

In the context of the emerging millennial/ generation alpha parent/child dyads, the dental professional must be aware of the underlying circumstances that manifest as behaviors for both patient and parent. Dentists can use empathy, empowerment and strategies for vertical or horizontal brain integration of the upper and lower brain and the right and left brain respectively to help manage the child experience while also assuring the parent of attention beyond oral health to the whole brain and the whole child.

Ultimately, providers must improve their ability to assess the child-parent experience to offer an individualized and efficient child-specific care plan that improves the efficacy of currently accepted behavior guidance techniques. n RE FEREN CE S 1. Barroso A, Parker K, Bennet J. As Millennials Near 40, They’re Approaching Family Life Differently Than Previous Generations. Pew Research Center, Washington D.C., May 27, 2020. www.pewresearch.org/social-trends/2020/05/27/ as-millennials-near-40-theyre-approaching-family-life-differentlythan-previous-generations.

2. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2020:292–310.

3. American Academy of Pediatrics. Patient- and FamilyCentered Care and the Pediatrician’s Role: Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Pediatrics 2012 Feb;129 (2):394–404. doi: 10.1542/ peds.2011-3084. Epub 2012 Jan 30.

4. Walji MF, Karimbux NY, Spielman AI. Person‐centered care: Opportunities and challenges for academic dental institutions and programs. J Dent Educ 2017 Nov;81(11):1265–1272. doi: 10.21815/JDE.017.084.

5. Reed-Fitzke K, Duncan J, Lucier‐Greer M, Fixelle C, Ferraro A. Helicopter Parenting and Emerging Adult Self-Efficacy: Implications for Mental and Physical Health. J Child Fam Stud 2016 Oct 25:3136–3149. doi.org/10.1007/s10826-0160466-x.

6. Foster C, Fay J. Parenting With Love and Logic : Teaching Children Responsibility. Colorado Springs, Colo.: Piñon Press; 1990.

7. Howe N, Strauss W. Millennials Rising: The Next Great Generation. New York: Vintage Books; 2003.

8. Howe N. Meet Mr. and Mrs. Gen X: A new parent generation: Strategies for school leaders when dealing with

customer-service expectations, self-interest and stealth-fighter tactics. AASA. www.aasa.org/SchoolAdministratorArticle. aspx?id=11122.

9. Nicholas A. Preferred learning methods of the millennial generation. Faculty and Staff - Articles and Papers vol. 18, 2008.

10. Swanzen R. Facing the generation chasm: The parenting and teaching of generations Y and Z. Int J Child Youth Family Stud 2018 9(2):125–150. doi: 10.18357/ ijcyfs92201818216.

11. LeMoyne T, Buchanan T. Does hovering matter? Helicopter parenting and its effect on well-being. Sociol Spectr 2011 31 4:399–418. doi: 10.1080/02732173.2011.574038.

12. Kantrowitz B, Peg T. The fine art of letting go. Newsweek 2006 May 22;147(21):48–9, 52–4, 56–8 passim. PMID: 16752495.

13. Sandeen C. Boomers, Xers and millennials: Who are they and what do they really want from continuing higher education? Continuing Higher Education Review 2008 72, 11–31.

14. Monaco M, Martin M. The millennial student: A new generation of learners. Athl Train Educ J 2007 2(2): 42–46. doi.org/10.4085/1947-380X-2.2.42.

15. Lukianoff G, Haidt J. The coddling of the American mind: How good intentions and bad ideas are setting up a generation for failure. New York: Penguin Books; 2019 Aug 20.

16. Lukianoff G, Haidt J. The coddling of the American mind.

The Atlantic Sep 2015.

17. Sunderland M. The science of parenting: How today’s brain research can help you raise happy, emotionally balanced children. New York: Penguin; 2016 Jul 5.

18. Furedi F. Paranoid parenting: Why ignoring the experts may be best for your child. Chicago: Chicago Review Press; 2002 Sep. 19. Shonkoff JP, Levitt P, Boyce T, Cameron J, Duncan G, Fox N, Gunnar M, Mayes L, McEwen B, Nelson C, Thompson R. Persistent fear and anxiety can affect young children’s learning and development. Natl Sci Council Dev Child 2010;9:1–3.

20. Twenge JM. iGen: Why today’s super-connected kids are growing up less rebellious, more tolerant, less happy — and completely unprepared for adulthood — and what that means for the rest of us. New York: Simon and Schuster; 2017 Aug 22.

21. Twenge JM, Joiner TE, Rogers ML, Martin GN. Increases in depressive symptoms, suicide-related outcomes, and suicide rates among U.S. adolescents after 2010 and links to increased new media screen time. Clin Psychol Sci 2018 Jan;6(1):3–17. doi.org/10.1177/2167702617723376.

22. Casamassimo PS, Wilson S, Gross L. Effects of changing U.S. parenting styles on dental practice: Perceptions of diplomates of the American Board of Pediatric Dentistry.

Pediatr Dent 2002;24(1):18–22. PMID: 11874053.

23. Harper DC, D’Alessandro DM. The child’s voice: Understanding the contexts of children and families today.

Pediatr Dent 2004 Mar 1;26(2):114–20. PMID: 15132272.

24. Long N. The changing nature of parenting in America.

Pediatr Dent 2004 Mar 1;26(2):121–4. PMID: 15132273.

25. Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent 2004 Mar 1;26(2):111–3. PMID: 15132271.

26. Adair SM, Waller JL, Schafer TE, Rockman RA. A survey of members of the American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr Dent O C TOBER 2 0 2 1

627

behavior guidance C D A J O U R N A L , V O L 4 9 , Nº 1 0

2004 Mar 1;26(2):159–66. PMID: 15132279.

27. Law CS. The impact of changing parenting styles on the advancement of pediatric oral health. J Calif Dent Assoc 2007 Mar 1;35(3):192–7.

28. Baumrind D. Effects of authoritative parental control on child behavior. Child Dev 1966 Dec 1:887–907. doi. org/10.2307/1126611.

29. Majeski RA. The Life Span: Human Development for Helping Professionals: A Review. Broderick P, Blewitt P. Upper Saddle River, N.J.: Prentice Hall; 2006 ISBN: 0-1317-0684-5.

30. Maccoby EE, Martin JA. Socialization in the context of the family: Parent-child interaction. In: Mussen PH, Hetherington EM, eds. Handbook of Child Psychology: vol. 4. Socialization, Personality and Social Development. New York: Wiley; 1983:1–101.

31. Asl Aminabadi N, Mostofi Zadeh Farahani R. Correlation of parenting style and pediatric behavior guidance strategies in the dental setting: Preliminary findings.

Acta Odontol Scand 2008 Apr;66(2):99–104. doi: 10.1080/00016350802001322.

32. Umof N, Law CS. Impact of Parenting Style on Pediatric Dental Behavior Guidance Techniques. Poster presentation AAPD Annual Session. 2013.

33. Lee DW, Kim JG, Yang YM. The influence of parenting style on child behavior and dental anxiety. Pediatr Dent 2018 Sep 15;40(5):327–33. PMID: 30355427.

34. Tsoi AK, Wilson S, Thikkurissy S. A study of the relationship of parenting styles, child temperament, and operatory behavior in healthy children. J Clin Pediatr Dent 2018;42(4):273–278. doi: 10.17796/1053-4628-42.4.6. Epub 2018 May 11.

35. Nimbulkar G, Deolia SG, Gupta A, Barde N, Sakhre P, Reche A. Relationship of Parenting Styles and dental operatory behavior in children. Eur J Mol Clin Med 2020 Dec 22;7(7):1970–7.

36. Buldur B. Pathways between parental and individual determinants of dental caries and dental visit behaviours among children: Validation of a new conceptual model.

Community Dent Oral Epidemiol 2020 Aug;48(4):280–7. doi. org/10.1111/cdoe.12530.

37. Wu L, Gao X. Children’s dental fear and anxiety: Exploring family related factors. BMC Oral Health 2018 Jun 4;18(1):100. doi: 10.1186/s12903-018-0553-z.

38. Quek SJ, Sim YF, Lai B, Lim W, Hong CH. The effect of parenting styles on enforcement of oral health behaviours in children. Eur Arch Paediatr Dent 2021 Feb;22(1):83–92. doi: 10.1007/s40368-020-00537-7. Epub 2020 May 16.

39. Viswanath S, Asokan S, Geethapriya PR, Eswara K. Parenting styles and their influence on child’s dental behavior and caries status: An analytical cross-sectional study. J Clin Pediatr Dent 2020;44(1):8–14. doi: 10.17796/1053-462544.1.2.

40. Eaton JJ, McTigue DJ, Fields HW, Beck FM. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent 2005 Mar 1;27(2):107–13. PMID: 15926287.

41. Meyer CSA, Sim MS, Law CS. Influence of Parental Temperament on Approval of Behavior Guidance Techniques.

Poster presentation. 2020 AAPD Annual Session.

42. Wells MH, McCarthy BA, Tseng CH, Law CS. Usage of behavior guidance techniques differs by provider and practice characteristics. Pediatr Dent 2018 May 15;40(3):201–8.

PMID: 29793567.

43. Adair SM, Schafer TE, Waller JL, Rockman RA. Age

628 OC TOBER

2021

and gender differences in the use of behavior management techniques by pediatric dentists. Pediatr Dent 2007 Sep 1;29(5):403–8. PMID: 18027775.

44. American Academy of Pediatric Dentistry Guidelines: Use of protective stabilization for pediatric dental patients. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2020:311–7.

45. Wells M, McTigue DJ, Casamassimo PS, Adair S. Gender shifts and effects on behavior guidance. Pediatr Dent 2014 Mar 15;36(2):138–44. PMID: 24717752 46. Patel M, McTigue DJ, Thikkurissy S, Fields HW. Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry. Pediatr Dent 2016 Feb 15;38(1):30–6.

PMID: 26892212.

47. White J, Wells M, Arheart KL, Donaldson M, Woods MA. A questionnaire of parental perceptions of conscious sedation in pediatric dentistry. Pediatr Dent 2016 Apr 15;38(2):116– 21. PMID: 27097859.

48. Wilson S, Houpt M. Project USAP 2010: Use of sedative agents in pediatric dentistry — a 25-year follow-up survey. Pediatr Dent Mar-Apr 2016;38(2):127–33. PMID: 27097861.

49. Baumrind D. Differentiating between confrontive and coercive kinds of parental power-assertive disciplinary practices. Hum Dev 2012;55(2):35–51. doi.org/10.1159/000337962.

50. Kuppens S, Ceulemans E. Parenting styles: A closer look at a well-known concept. J Child Fam Stud 2019;28(1):168– 181. doi: 10.1007/s10826-018-1242-x. Epub 2018 Sep 18.

51. Darling N. Is your parenting psychologically controlling?

Psychology Today 2012 Oct 24. psychologytoday.com/ us/blog/thinking-about-kids/201210/is-your-parentingpsychologically-controlling.

52. Siegel D, Bryson TP. The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Mind. New York: Delacorte Press; 2011.

53. Isaacson L. We all know that perfect parenting does not exist. lanaisaacson.com/the-gifts-of-imperfect-parenting-10guideposts-to-wholehearted-families.

54. Eyberg SM, Boggs SR, Algina J. Parent-child interaction therapy: A psychosocial model for the treatment of young children with conduct problem behavior and their families.

Psychopharmacol Bull 1995;31(1):83–91. PMID: 7675994.

55. Chapman HR, Kirby-Turner N. Psychological Intrusion — An Overlooked Aspect of Dental Fear. Front Psychol 2018 Apr 17;9:501. doi: 10.3389/fpsyg.2018.00501. PMID: 29719519; PMCID: PMC5913370.

TH E CO RRE S P ON DIN G AU T HOR , Clarice Law, DMD, MS, can be reached at claw@dentistry.ucla.edu.

C D A J O U R N A L , V O L 4 9 , Nº 1 0

C .E. CREDIT QUESTIONS

October 2021 Continuing Education Worksheet This worksheet provides readers an opportunity to review C.E. questions for the article “The Millennial Family: Adapting Behavior Guidance to Contemporary Parenting” before taking the C.E. test online. You must first be registered at cdapresents360.com to take the test online. This activity counts as 1.0 of Core C.E. 1. Drs. Law and Genish discuss which of the following in their article (mark all that apply): a. The social shifts that have influenced the current living generations. b. The remarkable consistency in parenting styles from generation to generation. c. The changes in behavior guidance over the past 20 years. d. New approaches to child behavior management in the dental practice.

2. The primary lower “reptilian” brain systems that function as “calm systems” and promote higher brain development when activated are which of the following (mark that all that apply): c. CARE (attachment) a. PLAY d. REST b. SEEKING 3. Which of these is not a function of the lower brain PLAY system (mark all that apply): a. Activates neurotransmitters that promote higher brain development b. Increases impulsivity and overactivity c. Activates antistress mechanisms d. Develops emotional regulation 4. Which of these are associated with the SEEKING system (mark all that apply): a. Motivates exploration b. Releases opioids that have an anti-anxiety effect c. Is activated by virtual gaming d. Is activated by interpersonal interaction 5. The shift in contemporary life from the physical to the virtual and an associated decline in free play may result in decreased activation of the prosocial PLAY and SEEKING systems, which in turn can lead to which of the following in children (mark all that apply): a. Decreased stress regulatory mechanisms b. Decreased risk tolerance c. An increase in impulsive behaviors d. An increase in anxiety and depression 6. True or False: The authors suggest that dental professionals who provide care to children are on the verge of a period of transition, where evolving family structure, the effects of parenting on child development and the use of and approval of classic behavior guidance techniques have changed with the shifts in parental characteristics and values.

7. According to American Academy of Pediatric Dentistry guidance, which of the following is not applicable to “protective stabilization” for children: a. Includes both active restraint (physical limitation by an individual) and passive restraint (physical limitation by restrictive equipment such as the papoose board) b. Has been reclassified as an advanced behavior guidance technique, recommended for use only by specialists or individuals with advanced training c. Is considered appropriate when used for practitioner’s convenience d. Is contraindicated in a cooperative nonsedated patient or those with nonemergent needs 8. True or False: According to an American Academy of Pediatrics policy statement, families should be a child’s primary source of strength and support.

Consequently, in a person-centered care approach to providing dental care, parental approval of care techniques is an essential component of high-quality clinical decision-making.

9. Research shows that rather than utilize methods such as passive restraint that may activate the lower brain’s alarm systems, a more productive focus may be to guide a child’s emotional regulation with which of the following communicative behavior techniques (mark all that apply): c. Positive reinforcement a. Descriptive praise d. Tell-show-do b. Voice control 10. Emerging science on the developing brain suggests that young children lack the ability to integrate the functions of the “left brain,” which is logical, linear and linguistic (likes words), and the “right brain,” which identifies the “meaning and feel of an experience.”

Which of the following are suggested by the authors’ discussion on right- and left-brain function in children (mark all that apply): a. A child may overreact to difficult situations with either right brain “chaos” or left brain “rigidity.” b. Parents and caregivers can assist the “horizontal integration” of the two hemispheres by identifying which hemisphere of the brain is in function during conflict and engaging appropriately, either with logic and solutions or with empathy and emotion. c. Regardless of a child’s emotional response, they should be quickly redirected to use their left brain by giving them solutions, providing logical explanations, or setting boundaries. d. This brain-based parenting concept can be applied to the dental setting.

O C TOBER 2 0 2 1

629

®

STRENGTH + TRUST.

More membership value through Endorsed Services.

At the California Dental Association, we leverage the strength of our large membership to deliver more value to practices of every size. Through Endorsed Services, find support to control expenses, generate revenue, streamline operations and achieve compliance. Every one of our Endorsed Services has been vetted by CDA. Discover member-exclusive offers on products, services and expertise for the business side of practice at cda.org/endorsedservices.

Control Expenses

Generate Revenue

Streamline Operations

patient-centered care C D A J O U R N A L , V O L 4 9 , Nº 1 0

Pediatric Patient-Centered Care in General Dentistry: We’re Closer Than You Might Think Kimberly J. Hammersmith, DDS, MPH, MS; Susan A. Fisher-Owens, MD, MPH; and Paul S. Casamassimo, DDS, MS

abstract Patient-centered care (PCC) respects the individual and interacting contributions of the patient, family, community and environment to disease manifestation and health maintenance. This paper gives an overview of PCC in general health care, explains PCC aspects already in play in the prevention and treatment children receive from pediatric dentists and serves as a primer for general dental practitioners to incorporate PCC principles into their care of children.

Keywords: Patient-centered care, pediatric dentistry, dental caries

AUTHORS Kimberly J. Hammersmith, DDS, MPH, MS, is an associate professor and the director of the advanced education program in pediatric dentistry at The Ohio State University College of Dentistry in Columbus.

She is also a member of the section of dentistry at Nationwide Children’s Hospital.

Conflict of Interest Disclosure: None reported.

Susan A. Fisher-Owens, MD, MPH, is a professor in the department of pediatrics at the University of California, San Francisco, School of Medicine and the department of preventive and restorative dental sciences in the School of Dentistry.

Conflict of Interest Disclosure: None reported.

Paul S. Casamassimo, DDS, MS, is a member of the section of dentistry at Nationwide Children’s Hospital and a professor emeritus of pediatric dentistry at The Ohio State University College of Dentistry in Columbus.

Conflict of Interest Disclosure: None reported.

H

ealth interventions have evolved from a time when widespread illness, lack of scientific understanding and limited effective interventions ruled health care with a one-size-fits-all approach to today’s more sophisticated understanding of diseases, individual susceptibility and the role of social factors in their acquisition and management.

Dental caries in children exemplifies a disease that has transitioned in the U.S. from a pandemic to a condition selectively affecting children due to individual characteristics and social circumstances.

For dental practitioners, this means tailoring prevention and therapy to the child and family rather than applying rigid models of care that may be wasteful and ineffective. In pediatric dentistry, patient-centered care (PCC), or more aptly, family-/child-centered care, has

evolved due to more than a half-century of caries-focused epidemiology, research into treatment advances building upon the Keyes caries initiation model (a triad that requires host, substrate and cariogenic bacteria)1 and development of evidence-based guidelines as the basis of the standard of care.2 Caries risk assessment, selective use of fluorides, nonsurgical caries management, culturally and socially driven interventions to prevent or mitigate caries and other focused approaches characterize contemporary pediatric dental care.

The purpose of this paper is to provide the general dental community, which treats most of the children in the U.S., with some background and understanding of PCC for children as used in contemporary pediatric dentistry practice. We provide the rationale and basic tools to begin to tailor care to O C TOBER 2 0 2 1

631

patient-centered care C D A J O U R N A L , V O L 4 9 , Nº 1 0

individual patient, family and community circumstances to maximize positive outcomes. Case examples are included to compare the two approaches.

Definitions of Patient-Centered Care and Relevance to Pediatric Dentistry

The National Academy of Sciences, Engineering and Medicine, formerly called the Institute of Medicine, defined PCC as care “that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”3 In medicine, this concept of PCC, which has been around since the 1990s, has been associated with greater satisfaction for health care workers, less litigation4 and reduced utilization of care and health care charges.5 The concept has been widely explored in medicine. Dimensions of PCC include: ■ Respect for patients’ values, preferences and expressed needs.

■ Coordination and integration of care.

■ Information, communication and education.

■ Physical comfort.

■ Emotional support (relieving fear and anxiety).

6 ■ Involvement of family and friends.

PCC can be practiced systematically by initiating the partnership and simply asking the patient to express concerns and experiences. Next comes shared decision-making (SDM) and working the partnership, and the last practice involves documenting the narrative and safeguarding the partnership.7 Hoffman explored and explained the interdependence between the concepts of evidence-based medicine and SDM8 and Forrest built on this to describe evidence-based decision-making.9 Further, Stewart devised a model for the patient-centered 632 OC TOBER

2021

clinical method, which includes six interactive components: ■ Exploring both the disease and the illness experience.

■ Understanding the whole person.

■ Finding common ground.

■ Incorporating prevention and health promotion.

■ Enhancing the relationship.

10 ■ Being realistic.

Ekman and colleagues go so far as to describe differences between personcentered care, patient-centered care and personalized medicine. Their preferred

PCC can be practiced systematically by initiating the partnership and simply asking the patient to express concerns and experiences.

term, person-centered care, gives credence that patients are foremost people and should not be reduced to their diseases or objectified as the recipient of medical services.7 With children, parents are integral and so the concept involves consideration of the parent-child dyad within whatever definition one chooses.

PCC in Dentistry

The concept of PCC is messier in dentistry, as we have had a hard time even defining it.11,12 Two systematic reviews found that person-centered and patientcentered are used interchangeably at times, and PCC definitions are diverse, broad and sometimes absent.11,12 One review even used expanded search terms of empowerment, patient-centered care and SDM when selecting articles.11

While concluding that PCC entails treating the patient as a person or individual, with a holistic nonjudgmental approach and free of dentist-patient relationship barriers, primary research on PCC in dentistry has largely originated from dental providers and staff without exploring patient perspectives.11,12 It is unclear if dental professionals embrace the idea of patients having control over their treatment.12 Additionally, published PCC research relates to specialty practices or populations, not general dental practice,12 and we don’t have much evidence for improved patient satisfaction or oral health outcomes.11,12 This dearth is likely because dental PCC research does not emphasize the involvement of family and friends, coordination and integration of care or physical comfort — three important dimensions of medical PCC. While dentists, largely alone in practice, may not need to coordinate or integrate care to the level that medical providers do, ensuring patient comfort and family/friend involvement has surely been a missed dimension in dental PCC research and practice.12 Dentistry has not embraced this concept to the degree medicine has, but in the last decade, some dental-specific models of PCC have emerged. Lee created a model whereby three key players are needed for optimized person-centered care in dentistry: the person or primary caretaker, the provider or coach and the care designer, which is an entity or system that frames, supports and incentivizes PCC and aids in sustainability. Each key player has a role within the actions of learn/examine, relate/share, plan/ design, act/provide/track/evaluate and revise.13 Scambler developed a model with building blocks and a hierarchy of patientcentered care (information; information and choice; information, choice and tools for informed choice; patient in full

C D A J O U R N A L , V O L 4 9 , Nº 1 0

control).14 Deciphering where patients want to be on this hierarchy is part of the PCC process, as not all patients want to be in full control and PCC does not dictate that patients must be in control.11

The Beginnings of PCC in Dental Practice

Many patients now prefer to seek their own health information using the internet; rather than discouraging this, dentists should partner with patients, make decisions together and guide patients toward reputable and trusted resources when seeking their own information.15 Similarly, the ethics code prescribed by the American Dental Association highlights patient autonomy, or the dentist’s duty to respect patients’ rights to self-determination, and involve patients in treatment decisions in a meaningful way, considering their needs, desires and abilities.16 Dentists must also consider determinants of health, which can include personal, social, economic and environmental factors that influence health status.17 In dentistry, we agree that PCC is about humane care delivered alongside good communication and patient autonomy, but dentistry is far behind medicine in linking PCC with patient satisfaction or treatment outcomes.11 As the dental care system becomes somewhat disrupted by new care models, including corporate entities and disease prevention and management rather than surgical treatment, PCC may be a way to improve health outcomes and quality of care.13 Allen suggests that the overlap between value-based care and PCC is shared decision-making.18 Care will be value based when dentists respond to patientreported outcome measures and patientreported experience measures, and that can only be done by sharing the decisionmaking responsibility with patients.18

Parent

Child

Dentist’s knowledge Patient-centered care

Dental care system

Community Scientific evidence

FIGURE . A framework for pediatric patient-centered care in dentistry.

In order to embody PCC, dentists will also have to adopt certain skills.

Motivational interviewing and evidence-based decision-making (EBDM) are two techniques within patient-centered care.19 Motivational interviewing is a collaborative tool to guide communication, with the practitioner telling less and asking more and the patient/interviewee deciding on their process and motivation for change toward a specific goal. EBDM involves critical thinking skills.8 It is the intersection of patients’ values and preferences, evidence-based conclusions, the practitioner’s expertise and judgment and clinical/patient circumstances.9,20 A new framework (FIGURE ), derived from

the Fisher-Owens model for children’s oral health,21 suggests how inclusion of key areas not traditionally considered in dental care can work in synergy to advance a pediatric PCC approach.

Caries and oral health are influenced by child-level factors (biology, health behavior and practices, insurance, etc.), family-level factors (social support, culture, health status of parents, etc.), and community-level factors (physical environment, social capital, dental and health care system characteristics, etc.).

Pediatric Dentistry Was a Good Place To Pilot PCC

We have many reasons to move away from a one-size-fits-all approach and O C TOBER 2 0 2 1

633

patient-centered care C D A J O U R N A L , V O L 4 9 , Nº 1 0

TABLE 1

Examples of Societal Changes Emphasizing the Relevance of Patient-Centered Care Cause

Effect

Dental Outcome

Sugar-sweetened beverages in childhood42

Higher frequency and amount of sugar intake

Increased caries experience

Lid-top beverages, snack-size packaging

Increase in sipping and snacking; grab-and-go culture

Increased caries experience

Parenting shifts/nonauthoritative model43

Uncertain success of nonadvanced behavioral guidance techniques in dental office

Parental preference toward general anesthesia

Parents using the internet to seek information

Reputable sources arm parents with information on which to build additional questions; some parents guided by misinformation15

Shared decision-making becomes facilitated or more difficult

Parental concerns about materials used in dentistry

Less than technically optimal prevention and restorative care

Recurrent and new caries; repeat treatment visits

Lack of trust in health care providers

Challenging providers’ treatment recommendations

Shared decision-making more difficult

Medical advances in managing childhood Illnesses

Higher survival rate of medically complex children

New and more complex child health needs

Dental general anesthesia cases provide low reimbursements for hospitals44

Pediatric dentists not able to secure OR block time to treat dental patients44

General anesthesia done in office or parents/providers choose minimally invasive dentistry

Risky behaviors in adolescents such as vaping, smoking, drugs

Risks to life and health of child; can affect dental treatment

Dental neglect and challenges to the dentist’s relationship with child and family

TABLE 2

Billing Codes Related to Social Determinants of Health in Medicine and Dentistry Medicine35

Dentistry36

Z55.X – Problems related to education and literacy Z56.X – Problems related to employment and unemployment Z57.X – Occupational exposure to risk factors Z59.X – Problems related to housing and economic circumstances Z60.X – Problems related to social environment Z62.X – Problems related to upbringing Z63.X – Other problems related to primary support group, including family circumstances Z64.X – Problems related to certain psychosocial circumstances Z65.X – Problems related to other psychosocial circumstances

D9991 – Addressing appointment compliance barriers D9992 – Care coordination D9993 – Motivational interviewing D9994 – Patient education to improve oral health literacy

instead adopt PCC in general dentistry for children. For one, oral health disparities among lower-income and minority children are pervasive and persistent.22,23 Although the Affordable Care Act from 2010 expanded Medicaid access for children, oral health 634 OC TOBER

2021

disparities remain across socioeconomic groups, with children in lower-income households and children of color having higher odds of untreated caries.24 Additionally, pediatric dentists have long noted the need to shift our practices to welcome more racially, ethnically and

economically diverse patients25,26 to model changes in the U.S. population. The number of children considered underserved is expected to increase.27 Over the next 40 years, the percentage of non-Hispanic white children is projected to decrease from about half to 36%, while Hispanic children are expected to increase from 25% to 32%. The population of children of two or more races is expected to double to 11% in that time. International migration will account for slightly more than half of expected population growth.28 Ethnic and cultural differences may affect acceptance of necessity of care, behavior guidance techniques for dental treatment,29 dental care-seeking behaviors,30 views on health and illness31 and patient-provider relationships.26 Previously underappreciated mainstream social factors need to be considered, such as the association of consumption of sugar-sweetened beverages and untreated tooth decay in young children.32 California just began its 10-year plan to improve oral health via addressing determinants of health, including sugarsweetened beverages and low intake of fruits and vegetables. The plan will provide dental providers with tools to screen for these and community resources for patients to mitigate them.33 Middle- and higher-income families, whose children are not the ones to usually experience barriers to care, may have concerns about mercury,34 fluoride, dye or nitrous oxide. TA BLE 1 illustrates some societal changes over the past few decades that affect our pediatric patient population and how this has affected our roles in managing children’s disease.

Systemic barriers in dentistry limit adoption of PCC in its true sense.

Dentistry lacks integrated medicaldental records and has weak health information technology platforms to collect sociodemographic data.13

C D A J O U R N A L , V O L 4 9 , Nº 1 0

TABLE 3

Possible Patient-Centered Care Application Compared to Traditional Approach in Children Dental Condition or Procedure

Diagnostics

Caries risk assessment

Traditional Approach

Possible PCC Application Child Characteristics

Parental or Familial Characteristics

Community Characteristics

Radiographs per professional guidelines

Movement/radiation burden

Fear of radiation exposure

Clinical examination

Movement/restraint

Decline physical restraint/ use of stabilization devices

Cultural nonacceptance of restraint

In-person examination

Inaccessibility

Transportation and work based

School based Teledentistry

Keyes Model1

Fisher-Owens Model21

Preventive therapies Fluoride/hygiene/diet

Sensitivity to additives Allergy to milk/casein

Decline fluoride

Absence of community water fluoridation

Dietary advice

Sugar control

Special needs/activity Physician recommendation for high-carbohydrate supplements

Family culture or traditions

Food availability

Recall frequency

Six months

Low or high caries risk

Compliance Opportunity costs Family structure

Accessibility (e.g., rural/distance)

Variable schedule

Nonsurgical caries management protocol

Culture Oral health literacy

Availability of dentists/specialists

Caries risk/age/nonsurgical approaches Allergies

Caries risk status/economics/ compliance Mercury concerns BPA concerns Aesthetics

Access/distance/facility availability Culturally and socially acceptable appearance

Restorative dentistry Traditional coded choices36

Orthodontics/ growth and development

Traditional assessment and management procedures

Behavior Compliance Metal allergies

Cost Clear aligner preference Treatment time length Family traits/phenotypes

Culturally and socially acceptable appearance Availability/access

Behavior guidance

Per AAPD Behavior Guidance best practices45

Size Development Health

Religious and cultural norms Philosophy of child rearing Safety concerns

Religious and culturally acceptable contact Availability of services

While International Classification of Diseases, 10th revision (ICD-10) codes related to social determinants of health have been introduced in medicine,35 dentistry only has four case management codes, added in 2017, but they do not parallel the ICD-10 (TA BLE 2).36 If dentistry can overcome its barriers, PCC may ultimately perform in dentistry as it has in medicine. Along with improvements in national health measures, PCC can show gains in individuals’ health as well as population health.13 One manifestation of the interest of government and medicine in this concept, and an indicator of its

likely expansion, is Medicaid’s primary care case management (PCCM) model, which has 16 states utilizing it as of 2016.

Currently restricted to medical care, the PCCM approach encourages primary care providers to use patient-focused care with traditional fee-for-service compensation as well as financial support for case management.37 Applied to dentistry, that model would engage dental care in the pursuit of value-based care and PCC.

Translating PCC to the Practice of General Dentistry for Children

Applying PCC principles blended with advances in science and our understanding

of a complex, multidimensional etiology of dental disease often just expands what pediatric dentists already do. TA BLE 3 depicts a comparison of some aspects of traditional clinical dentistry approaches with PCC modifications for selected procedures and management. Applying PCC concepts should be seen more as an overriding process than as a procedure.

Using an application of the FisherOwens model21 as a touchstone for dental caries management, one approach would be to overlay the following considerations on decision-making for any dental finding.

This model creates layers of consideration departing from the traditional biological O C TOBER 2 0 2 1

635

patient-centered care C D A J O U R N A L , V O L 4 9 , Nº 1 0

view of the condition that includes bacteria, a susceptible tooth and sugar, but then looks at the child’s characteristics, any parental concerns, the readiness or capability of the community to support decisions and the dental care system’s ability to support trends such as the increased need for advanced behavior guidance. The following explains this stepwise approach in more detail.

What is indicated for a clinical situation starting with a traditional dentistry approach?

Dental caries or risk for dental caries may be the presenting problems in an initial pediatric dental intervention.

The best practices and policies of the American Academy of Pediatric Dentistry would be a primary gateway to PCC by offering evidence-based, widely accepted interventions.2 Preventive, behavioral, restorative and growth and development management would be the basis upon which to build PCC.

How do this child’s characteristics alter, if at all, the application of traditional dentistry?

We already do this in pediatric dentistry. The specialty’s almost universal acceptance of children with special health care needs suggests that inclusion of differing abilities and needs across all children is not a giant step. The major hurdle for practitioners might be to see children as a continuum rather than as special needs or not or caries-prone or not.

The more we learn about socialization, behavioral health, dietary restrictions and differing intelligences and their influences on health, the more sense this makes.

Do family circumstances require modification of usual approaches?

Reality dictates that parents control the health of their child and 636 OC TOBER

2021

are the pivots on which evidence meets expectation. Social, financial, educational and other characteristics of parents are pieces of the PCC model, and the challenge is to integrate familial realities with the child’s clinical needs.

Do community, culture and compliance alter traditional approaches?

The child and family will return to a family and community environment shaped by many factors relevant to oral health. Diet, including access to healthy food options, is a prime example of

The major hurdle for practitioners might be to see children as a continuum rather than as special needs or not or caries-prone or not.

additional obstacles or opportunities relative to caries management, beyond those inherent in the child. Culturally driven food choices, access to food sources and water fluoridation are examples of these considerations in a PCC model.

Can the practice model sustain individualized oral health?

PCC means more permutations and combinations for care and a departure from an assembly-line approach. This has implications ranging from record-keeping through recall frequency/monitoring and demands a health record and patient management system beyond what is traditional. Pediatric dentistry practice is geared toward PCC, but a general dental practice might not be able to sustain the variations required in individualized care.

The Business of PCC in Dentistry

The evolution of dental care for children to a PCC model has already begun with the development and acceptance of best practices of the AAPD, the embrace of evidence-based dentistry for several pediatric dental procedures,38,39 creation of case management codes36 and expansion of the Keyes caries initiation model1 to a more complex but more useful model espoused by Fisher-Owens et al.21 Practice patterns, compensation and support services lag behind this evolution and challenge practices to implement a philosophy that supports both patient and practice health.

Issues like data management, quality measurement and shifting a traditional standard of care all need to be addressed in a care model that distributes risk differently across patients, practices and payers.

It would be naïve to assume that movement toward a PCC approach is not without fiscal impact. The cost-efficiency of routine application of services across a patient pool stands to be altered. Patient management will require more attention to individualized monitoring — a need already apparent and growing in choices of nonsurgical management of dental caries with repeated silver diamine fluoride (SDF) application and more frequent visits. Billing codes supporting case management exist but are not universally covered, and more frequent monitoring visits may require prior authorization and justification of medical necessity.

Training staff in advanced caries risk assessment and nonsurgical management techniques may be necessary and practice software may not support variance from traditional approaches. Physical structure of the dental office may change: The COVID-19 pandemic altered our approach to open-bay dental offices and provides some stimulus to envision a newer mixed counseling-treatment environment for future office design that fosters PCC.

C D A J O U R N A L , V O L 4 9 , Nº 1 0

A major step in moving a PCC model forward is the ability to measure outcomes of care. Dentistry is woefully behind medicine in establishing meaningful and quantifiable measures of quality care and having data support tools to assess effectiveness of care. The Dental Quality Alliance of the American Dental Association has developed and tested several pediatric-oriented quality measures that are based on science and would indicate quality care and positive health outcomes, such as sealants on permanent molars.40 The challenge and opportunity are there for organized dentistry and the software industry to partner on converting office management software to more comprehensive management systems that link to general health and allow individual providers to measure effectiveness of care in a PCC model; being able to document using team-based care is a natural first step. Technology advances such as a toothbrush that generates data on hygiene performance may be an illustrative next step in integration of patient outcomes with data collection and management for improved health.41 Finally, as mentioned earlier in this paper, is the ethical challenge17 of placing PCC into a practice and community standard for care that might challenge a differing approach. Nonsurgical management of caries is currently being evaluated against traditional restorative care and illustrates how PCC might work in the future. The evidencedbased aspect of PCC can support a choice to begin to shift in this direction and relieve anxiety about doing so.

Building on Current PCC Practice Characteristics in General Dentistry for Children

A running theme in this article is that pieces of PCC are already operational in pediatric dentistry and can be adapted

to general dental practice for the care of children. The following case studies complete this overview of PCC and provide descriptions of how a PCC approach might compare with a more traditional dental experience for child and family. It is likely that a PCC approach would result in better rapport with parents and thus strengthen the dentist’s ability to manage disease — certainly a hypothesis to be tested.

Case 1: A medically healthy, 26-monthold child with severe early childhood caries. Parents live in a rural setting,

Nonsurgical management of caries is currently being evaluated against traditional restorative care and illustrates how PCC might work in the future. are young, vegan, work outside the home and are currently uninsured with limited income. Child sleeps with sugar-sweetened-liquid bottle at night.

Traditional approach: General anesthesia and restoration, intensive fluoride therapy and sugar restriction. More frequent recall schedule until stable.

PCC approach: Absence of pain allows nonsurgical management for immediate care, which also respects their lack of insurance and limited income. Parental concerns about fluoride toxicity and lack of community water fluoridation negotiate a compromise to use a fluoridated dentifrice and dietary management of caries factors such as frequency of sugar consumption. Treatment of existing caries

using SDF and more frequent monitoring is agreeable. Parental dietary counseling within constraints of dietary preferences.

PCC comment: This case illustrates consideration of all layers of factors influencing disease (the wishes of the family, the caries characteristics of the individual and fluoride availability in the community). It also shows an effective management approach respectful of all parties while remaining workable in the care system.

Case 2: A 7-year-old male with autism spectrum disorder, who normally is combative in new situations, is resistant to oral examination. Parents adhere to behavioral modification and pharmacological management as well as restriction of sugar and coloring agents of any kind.

Traditional approach: Place the child in protective stabilization for clinical examination and fluoride application and then treat as needed using advanced behavior guidance techniques.

PCC approach: Hold several desensitizing visits using recommended pacing and environmental adjustments; after this, the dentist is able to complete an oral examination with parents’ assistance simulating toothbrushing. Absence of visual caries allows deferral of further dental diagnostics and treatment until a coordinated general anesthesia visit with ENT and laboratory blood drawing.

Noncolored fluoride agents found for prevention. More frequent recall examinations to maintain familiarity.

PCC comment: This case management draws on opportunities to respect patient dignity and wishes of family and improve health care collaboration.

O C TOBER 2 0 2 1

637

patient-centered care C D A J O U R N A L , V O L 4 9 , Nº 1 0

Case 3: A 4-year-old non-English

speaking child recently adopted by U.S. English-speaking parents is referred by their pediatrician for dental examination for early childhood caries.

They have public insurance coverage.

Traditional approach: Attempt in-office care using nitrous oxide, excluding parents from the operatory, followed by routine prevention.

PCC approach: Consider general anesthesia to minimize behavioral issues and support parent/child attachment. Explore familial or cultural dietary habits that could perpetuate disease. Follow-up management with parents engaged at all visits.

PCC comment: This case and its management illustrate the extension of oral health considerations into the family and the community by respecting the immediate and long-term influence of management choices.

Summary and Directions

This brief description of PCC in pediatric dentistry is meant to broaden general dental practitioners’ understanding of the greater influences of social and environmental factors on oral health.

Health care improvement and systemic change rest on addressing biologic as well as social and environmental factors to improve outcomes. As research suggests, consideration of nondental issues in PCC stands to result in better outcomes. n

638 OC TOBER

2021

RE FE RE N CE S 1. Keyes PH, Jordan HV. Factors influencing initiation, transmission and inhibition of dental caries. In: Harris RJ ed.

Mechanisms of Hard Tissue Destruction. New York: Academic Press; 1963.

2. American Academy of Pediatric Dentistry. The Reference Manual of Pediatric Dentistry; 2020.

3. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001. doi: 10.17226/10027.

4. Irwin RS, Richardson ND. Patient-focused care: Using the right tools. Chest 2006 Jul;130(1 Suppl):73S–82S. doi: 10.1378/chest.130.1_suppl.73S. 5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med May-Jun 2011;24(3):229–39. doi: 10.3122/ jabfm.2011.03.100170.

6. Gerteis M, Picker/Commonwealth Program for PatientCentered Care. Through the patient’s eyes: Understanding and promoting patient-centered care. 1st ed. San Francisco: Jossey-Bass; 1993.

7. Ekman I, Swedberg K, Taft C, et al. Person-centered care — ready for prime time. Eur J Cardiovasc Nurs 2011 Dec;10(4):248–51. doi: 10.1016/j.ejcnurse.2011.06.008.

Epub 2011 Jul 20.

8. Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decisionmaking. JAMA 2014 Oct 1;312(13):1295–6. doi: 10.1001/ jama.2014.10186.

9. Forrest JL, Miller SA. Translating evidence-based decisionmaking into practice: EBDM concepts and finding the evidence. J Evid Based Dent Pract 2009 Jun;9(2):59–72. doi: 10.1016/j.jebdp.2009.03.017.

10. Stewart M, et al. Patient-centered medicine: Transforming the clinical method. Thousand Oaks, Calif.: Sage Publications; 1995.

11. Scambler S, Delgado M, Asimakopoulou K. Defining patient-centred care in dentistry? A systematic review of the dental literature. Br Dent J 2016 Oct 21;221(8):477–484. doi: 10.1038/sj.bdj.2016.777.

12. Mills I, Frost J, Cooper C, Moles DR, Kay E. Patientcentred care in general dental practice — a systematic review of the literature. BMC Oral Health 2014 Jun 5;14:64. doi: 10.1186/1472-6831-14-64.

13. Lee H, Chalmers NI, Brow A, et al. Person-centered care model in dentistry. BMC Oral Health 2018 Nov 29;18(1):198. doi: 10.1186/s12903-018-0661-9.

14. Scambler S, Asimakopoulou K. A model of patient-centred care — turning good care into patient-centred care. Br Dent J 2014 Sep;217(5):225–8. doi: 10.1038/sj.bdj.2014.755.

15. Glick M. The internet-informed patient: Opportunities for patient-centered care. J Am Dent Assoc 2013 Mar;144(3):239–40. doi: 10.14219/jada. archive.2013.0104.

16. American Dental Association. Patient autonomy. hwww.ada. org/en/about-the-ada/principles-of-ethics-code-of-professionalconduct/patient-autonomy. Accessed March 13, 2021.

17. Social Determinants of Health. Healthy People 2020. www.healthypeople.gov/2020/topics-objectives/topic/socialdeterminants-of-health. Accessed March 13, 2021.

18. Allen M. The value of values: Shared decision-making in person-centered, value-based oral health care. J Public Health Dent 2020 Sep;80 Suppl 2:S86–S88. doi: 10.1111/

jphd.12394. Epub 2020 Sep 7.

19. Mitchell SH, Overman P, Forrest JL. Critical thinking in patient-centered care. J Evid Based Dent Pract 2014 Jun;14 Suppl:235–9.e1. doi: 10.1016/j.jebdp.2014.04.002. Epub 2014 Apr 4.

20. Rosen E, Nemcovsky CE, Tsesis I. Evidence-Based Decision Making in Dentistry: Multidisciplinary Management of the Natural Dentition. Cham, Switzerland: Springer International Publishing; 2017.

21. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children’s oral health: A conceptual model. Pediatrics 2007 Sep;120(3):e510–20. doi: 10.1542/peds.2006-3084.

22. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA 2000 Nov 22– 29;284(20):2625–31. doi: 10.1001/jama.284.20.2625.

23. Satcher D, Nottingham JH. Revisiting Oral Health in America: A Report of the Surgeon General. Am J Public Health 2017 May;107(S1):S32–S33. doi: 10.2105/ AJPH.2017.303687.

24. Gupta N, Vujicic M, Yarbrough C, Harrison B. Disparities in untreated caries among children and adults in the U.S., 2011–2014. BMC Oral Health 2018 Mar;18(1):30. doi: 10.1186/s12903-018-0493-7.

25. Casamassimo PS. Dental disease prevalence, prevention and health promotion: The implications on pediatric oral health of a more diverse population. Pediatr Dent Jan–Feb 2003;25(1):16–8.

26. Crystal YO. Gender and racial issues that affect delivery of care: Are we prepared for the future changes? Pediatr Dent Jan–Feb 2003;25(1):23–5.

27. Surdu S, Dall TM, Langelier M, et al. The pediatric dental workforce in 2016 and beyond. J Am Dent Assoc 2019 Jul;150(7):609–617.e5. doi: 10.1016/j.adaj.2019.02.025.

Epub 2019 May 29.

28. Vespa J, Medina L, Armstrong DM. Demographic Turning Points for the United States: Population Projections for 2020 to 2060. Current Population Reports, P25-1144. Washington, D.C.: U.S. Census Bureau; 2020.

29. Chang CT, Badger GR, Acharya B, et al. Influence of ethnicity on parental preference for pediatric dental behavioral management techniques. Pediatr Dent 2018 Jul;40(4):265–72.

30. Ng MW. Multicultural influences on child-rearing practices: Implications for today’s pediatric dentist. Pediatr Dent Jan–Feb 2003;25(1):19–22.

31. Scrimshaw SC. Our multicultural society: Implications for pediatric dental practice. Keynote speaker, 17th annual symposium. Denver: May 25, 2002. Pediatr Dent Jan–Feb 2003;25(1):11–5.

32. Laniado N, Sanders AE, Godfrey EM, Salazar CR, Badner VM. Sugar-sweetened beverage consumption and caries experience: An examination of children and adults in the United States, National Health and Nutrition Examination Survey 2011–2014. J Am Dent Assoc 2020 Oct;151(10):782–789. doi: 10.1016/j.adaj.2020.06.018.

33. Kumar J, Jackson R. California Oral Health Plan, 2018– 2028. California Department of Oral Health; 2018.

34. United States Food and Drug Administration. Dental amalgam fillings. 2021. www.fda.gov/medical-devices/dentaldevices/dental-amalgam-fillings. Accessed March 13.

35. American Hospital Association. ICD-10-CM coding for social determinants of health. November 2019. www.aha. org/system/files/2018-04/value-initiative-icd-10-code-socialdeterminants-of-health.pdf.

C D A J O U R N A L , V O L 4 9 , Nº 1 0

36. American Dental Association. CDT 2021: Current Dental Terminology. 2021.

37. Gilchrist-Scott DH, Feinstein JA, Agrawal R. Medicaid managed care structures and care coordination. Pediatrics 2017 Sep;140(3):e20163820. doi: 10.1542/peds.20163820.

38. Dhar V, Marghalani AA, Crystal YO, et al. Use of vital pulp therapies in primary teeth with deep caries lesions. Pediatr Dent 2017 Sep 15;39(5):146–59.

39. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs.

Pediatr Dent 2017 Sep;39(5):135–45.

40. American Dental Association. Dental quality measures. www.ada.org/en/science-research/dental-quality-alliance/ dqa-measure-development-reports/dqa-dental-quality-measures.

Accessed March 20, 2021.

41. Wiggers K. Beam raises $55 million for a connected toothbrush that lowers dental premiums. May 29, 2019. venturebeat.com/2019/05/29/beam-raises-50-million-for-aconnected-toothbrush-that-lowers-dental-premiums. Accessed March 20, 2021.

42. Healthy Drinks, Healthy Kids. Healthy Eating Research.

healthydrinkshealthykids.org. Accessed March 20, 2021.

43. Howenstein J, Kumar A, Casamassimo PS, et al. Correlating parenting styles with child behavior and caries. Pediatr Dent Jan–Feb 2015;37(1):59–64.

44. Vo AT, Casamassimo PS, Peng J, et al. Denial of operating room access for pediatric dental treatment: A national survey.

Pediatr Dent 2021 Jan;43(1):33–41.

45. Behavior Guidance for the Pediatric Dental Patient. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2020:292–310.

T H E CO RRE S P ON DIN G AU T HOR , Paul S. Casamassimo, DDS, MS, can be reached at Paul.Casamassimo@nationwidechildrens.org.

Search and post on DentalPost, the nation’s #1 dental job board & community with more than 900,000 dental professionals.

O C TOBER 2 0 2 1

639

Keep up with regulatory compliance.

Get expert guidance from CDA Practice Support analysts on the latest regulations affecting your practice, plus new resources to make it easier to keep pace.

Benefit from dentistry-centered forms, required docs, checklists, a compliance calendar and more.

Explore your CDA member resources at cda.org/regulatorycompliance.

Dr. Robert Frey Member since 2019

®

PRACTICE SUPPORT

Dental Benefit Plans Employment Practices Regulatory Compliance Practice Management

teledentistry C D A J O U R N A L , V O L 4 9 , Nº 1 0

Teledentistry: Opportunities and Recent Developments in Pediatric Dentistry Jean Marie Calvo, DDS, MPH; Paul Glassman, DDS, MA, MBA; Lisa Berens, DDS, MPH; Enihomo Obadan-Udoh, DDS, MPH, DrMedSc; and Ray E. Stewart, DMD, MS

abstract Pediatric dentistry has experienced an increase in the utilization of telehealth advances to serve children’s dental needs. Teledentistry describes the umbrella of services that dentistry can provide through telehealth technology. The COVID-19 pandemic resulted in UCSF Pediatric Dentistry and many other dental practices in California applying teledentistry in their care models. This article describes the uses of teledentistry, motivation for its use and UCSF Pediatric Dentistry’s current and future plans to implement teledentistry in clinics and the community.

Keywords: Pediatric dentistry, public health, telehealth

AUTHORS Jean Marie Calvo, DDS, MPH, is a health sciences assistant clinical professor in the division of pediatric dentistry, department of orofacial sciences at the University of California, San Francisco, School of Dentistry.

Paul Glassman, DDS, MA, MBA, is a professor and the associate dean for research and community engagement at California Northstate University College of Dental Medicine.

Lisa Berens, DDS, MPH, is the John C. Greene professor in primary care dentistry; chair, division of oral epidemiology and dental public health; vice chair for research in the department of preventive and restorative dental sciences; and the chair of the summer research fellowship program at the University of California, San Francisco, School of Dentistry.

Enihomo Obadan-Udoh, DDS, MPH, DrMedSc, is an assistant professor and the director of the dental public health postgraduate program, division of oral epidemiology and dental public health in the department of preventive and restorative dental sciences at the University of California, San Francisco, School of Dentistry.

Ray E. Stewart, DMD, MS, is a professor and chair of the division of pediatric dentistry, department of orofacial sciences at the University of California, San Francisco, School of Dentistry.

Conflict of Interest Disclosure for all authors: None reported.

T

he term teledentistry is a discipline-specific application of the more general term telehealth. In 2011, California adopted Assembly Bill (AB) 415, which converted all instances in California law referring to the older term telemedicine to telehealth.1 These terms have often continued to be used interchangeably to describe a collection of technologies and strategies to virtually deliver a broad range of medical services, such as diagnosis and monitoring of health conditions, education and interprofessional communication.2

Telehealth is now described in California law as: “The mode of delivering health care services and public health via information and communication technologies to O C TOBER 2 0 2 1

641

teledentistry C D A J O U R N A L , V O L 4 9 , Nº 1 0

facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes both synchronous interactions and asynchronous store-andforward transfers.”3 The Health Resources and Services Administration (HRSA) defines telehealth more broadly as: “The use of electronic information and telecommunications technology to support long-distance clinical health care, patient and professional health-related information, public health and health administration.”4 Multiple definitions such as these and inconsistent adoption of enabling laws, regulations and guidance in state, regional and insurance organizations have resulted in significant variation in policy environments and created considerable confusion among health care providers regarding systems, practices, policies and regulations in teledentistry.

The COVID-19 pandemic has led to the rapid and broad acceptance of telehealth services as a means of providing safe and economically feasible services while simultaneously minimizing the risk of exposure to the SARS-CoV-2 virus by patients and staff.5,6 Furthermore, the increase in virtual visits was inspired by the need to preserve personal protective equipment (PPE) and other resources that were under tremendous demand by the rapid spread of the SARS-CoV-2 virus across all populations.7 Prior to the COVID-19 pandemic, there had been a limited and tepid acceptance of telehealth by patients, providers and third-party 642 OC TOBER

2021

insurers such as private insurance companies and governmental agencies responsible for the administration of Medicare and Medicaid programs.8–11 With the onset of the pandemic and all of the attendant shelter-in-place restrictions and avoidance of face-toface contact whenever possible, there has been a rapid transition to a broader acceptance of telehealth as a necessary and vitally important method of delivering acute and chronic care services as well as primary and specialty care services to patients and families who are

Teledentistry has been a significant lifeline for many pediatric dental practices when many parents were reluctant to bring their children to the dental office ... unable or reluctant to have an in-person visit with their health care provider.

With the one-year milestone of the onset of the COVID-19 pandemic behind us, there is no doubt that our entire health care system has experienced profound changes, many of which are reasonably expected to persist even with the resolution of the pandemic. With the endorsement of many professional medical and dental societies, which very rapidly pivoted to promote and provide their membership with guidelines and recommendations as to how to ethically and legally engage in the provision of telehealth services to their patients, it was only natural that dentistry would see the advantages of this technology and begin to adopt it.12,13 Teledentistry has been a significant lifeline for many pediatric

dental practices when many parents were reluctant to bring their children to the dental office for preventive and restorative care for fear of exposing the child and/or themselves to the SARS-CoV-2 virus.14

Teledentistry Use Cases

As the interest in teledentistry increases, it has been adapted to a variety of uses. A general description of the ways it is being used includes the following categories: ■ Triage advice and referral. This refers to the ability of patients or parents to capture records such as a photograph and send those records to a dentist who can review the records and provide advice.

Most often these interactions result in a recommendation to seek care in a dental office.

■ The teledentistry call center.

Several companies have developed business models where a patient or parent can go to a website and for a fee have a real-time video consultation with an on-call dentist. Again, these interactions often result in a recommendation to seek care in a dental office.

■ Records sharing/consultation.

Teledentistry systems have facilitated the ability of dentist-to-dentist records sharing and consultation.

■ Increased office efficiency. Many practices have used teledentistry as an approach to increase office efficiency by transferring some patient interactions from in person in the office to teledentistry interactions.

■ Limited community care. Some companies and providers are using teledentistry to deploy some members of their team to community sites where they can

C D A J O U R N A L , V O L 4 9 , Nº 1 0

perform limited data gathering and preventive procedures and facilitate a referral to a dental office for care.

■ Full-service community care. Some providers are using teledentistry to deploy members of their team to community sites, collect diagnostic records, have the practice dentist complete an examination and have the community team perform preventive and early intervention services in an effort to keep as many patients healthy in the community as possible.

Examples of adoption of some of these use cases in pediatric dentistry are presented below.

Increased Office Efficiency and Other Potential Advantages

Anecdotally, many practices rapidly turned to virtual care technology as a means of providing safe and socially distanced care that allowed them to maintain contact and interact virtually with their patients. Within a few months of the onset of the pandemic, the rapid policy changes adopted by third-party payers that accepted virtual dental visits as a valid modality of providing oral health services was critically important to the survival of many practices. This shift allowed them to maintain some cash flow, making it possible to retain staff and assist in covering some of the ongoing overhead expenses.

The extent to which teledentistry was adopted varied considerably among practices. Some simply triaged emergencies using asynchronous, storeand-forward technology wherein images, messages or other data are collected at the patient source by a parent taking and transmitting information, such as electronic photos of the problem or lesion, to the provider for interpretation and recommendations for care.11 Other

practices elected to engage more actively in fully synchronous visits including real-time telephone and/or live audio/ video interactions with families using smartphones, tablets or computer cameras to engage in more direct contact by viewing and coaching toothbrushing sessions and application of fluoride varnish by the parents at the direction of the provider.11 Zoom became widely used due to the secure versions offered by that platform that are compliant with HIPAA regulations.15 Some practices took teledentistry technology to a

Teledentistry should not and could not replace the need for all in-person visits with the dentist.

higher level by transmitting creative, age-appropriate, educational videos for patients adapted and attuned to distance learning so patients and families could receive messages about the importance of oral health and how to prevent disease.

As teledentistry has become more popular and widely used, it has become apparent that this technology offers several advantages for a dental practice over the way in which dentistry was practiced prior to the COVID-19 pandemic. These potential advantages will certainly contribute to its continued growth and expanded utilization even after the pandemic ends. These advantages include: ■ Increased access for patients to dental care by omitting time and cost to travel to dental offices.

Cost savings to providers by reduced use of PPE and disposable supplies.

■ Increased access to specialists for consultation and diagnostic services that are not easily accessible in more remote or rural areas.

■ Better continuity of care by the use of teledentistry-based, postoperative follow-up care following surgery or other procedures.

■ Increased patient contact and engagement in between necessary in-person visits.

■ Reduced stress and desensitization for patients with special health care needs by having some aspects of their care in the comfort of their home.

Existing evidence has demonstrated some of the feasibility and benefits of incorporating telehealth into the practice of dentistry. Studies have demonstrated that the use of teledentistry for caries diagnosis can be comparable to the diagnosis of caries by traditional dental visits.16 Beyond being an effective means of diagnosis, teledentistry has also been shown to increase access to care for children who have never seen a dentist and could be a viable option for providing early screening for dental caries.17 Additionally, care with teledentistry has been shown to help individuals improve their oral hygiene through decreased plaque and improved gingival index.18 Most recently, one study showed that over 90% of patients were satisfied with their dental visits through telehealth during the COVID-19 pandemic.19 And another recently published report demonstrated teledentistry can be a cost-saving mechanism by reducing unnecessary in-person dental visits and triaging patients to prioritize those who need care most urgently.20 Teledentistry should not and could not replace the need for all in-person ■

O C TOBER 2 0 2 1

643

teledentistry C D A J O U R N A L , V O L 4 9 , Nº 1 0

visits with the dentist. In an office-based practice, teledentistry can supplement face-to-face visits, the frequency of which is determined by the unique treatment needs and clinical conditions for each patient. As an example, the presence of an eruption hematoma or the ectopic eruption of a mandibular permanent incisor in a child could be diagnosed effectively using either real-time video or store-and-forward photographs of the area, depending on the availability of an internet connection and photography devices, and dealt with appropriately without an in-person visit.

and use of care coordination strategies were presented at a recent symposium.24

Teledentistry Platforms

The interest in and need for teledentistry technology during the recent COVID-19 pandemic has accelerated. This has resulted in the emergence of several companies that are designing and building software platforms designed for a telehealth environment and focused on disease-specific disciplines including dentistry.25–27 HIPAAcompliant platforms such as these allow providers and affiliates to share, access

Community-Based Care

One example of a full-service, community-based teledentistry care system is the virtual dental home (VDH). The VDH system of care uses allied oral health personnel, including dental hygienists and assistants, to bring care to community sites, involve dentists in the care through a telehealth system and maintain the oral health of most individuals through treatments provided at the community sites.21 It has demonstrated the ability to keep most people healthy in community sites, refer people to dental offices when they need advanced surgical services that require that environment and increase patient and caregiver adoption of “daily mouth care” routines that are critical for maintaining oral health.

The VDH system was tested in a sixyear, state-authorized Health Workforce Pilot Project and showed that about two-thirds of low-income children could receive all the services they needed to remain healthy in a school environment through the VDH service model.22 The program and policy considerations from this model have been summarized.23 Results of several four-year, state-sponsored local dental pilot projects that included expansion and adoption of the VDH model 644 OC TOBER

2021

The interest in and need for teledentistry technology during the recent COVID-19 pandemic has accelerated.

and protect electronic data from dental visits without the burdensome steps of physically transmitting records. This allows for a network of providers and community partners to participate in teledentistry through cloud-based telehealth accessibility.

These platforms are also encouraging direct-to-consumer participation in teledentistry by allowing patients to contact their providers through these platforms including sending photos for asynchronous review, self-scheduling video and in-person visits, completing online forms and data collection and even using these platforms for synchronous teledentistry video appointments with waiting room capacity.

Teledentistry Financial Considerations As innovation has driven dentistry’s ability to provide care through

teledentistry platforms, payers have also been advancing in their acceptance of virtual modes of dental care delivery.

As of Sept. 27, 2014, AB 1174, Dental Professionals: Teledentistry Under MediCal, was approved by the California governor. Following this legislation, several procedures were made billable to the Medi-Cal Dental Program through the use of teledentistry including examinations and radiographs. MediCal Dental also acknowledges dental codes for synchronous and store-andforward methods of teledentistry and has also increased the teledentistry resources available on its website as a result of the COVID-19 pandemic.28 Private payers have also initiated reimbursement for care delivered using teledentistry. Delta Dental of California reimburses for dental examinations completed using teledentistry.29 Furthermore, Delta Dental of California is exploring the future role of teledentistry in the provision of dental care by initiating its own direct-to-consumer teledentistry service. As of February 2021, Delta Dental of California announced a new offering for its members. This new program offers store-and-forward and live video consultation with Delta Dental dentists for its PPO and Premier plan members.30 Teledentistry has the ability to not only increase access to care for patients by allowing them to access dental care but to also become an additional production source for dental providers.

Dentists have the ability to partner with community sites, such as schools and day cares, and for nonpediatric dentists, other adult residential facilities.

Allied dental personnel can collect dental radiographs, photographs and notes on-site to be forwarded for review by the dentist at a later time. These are all billable procedures. The use of teledentistry has the potential to become

C D A J O U R N A L , V O L 4 9 , Nº 1 0

an additional source of production for dental practitioners without using in-office chairtime. It is encouraging to see payers providing reimbursement mechanisms for synchronous and asynchronous delivery of teledentistry services, as the payment for these services will only further drive their implementation to increase access to care.

Teledentistry at UCSF

UCSF Pediatric Dentistry, like many other practices in California and the nation, embraced telehealth technology out of necessity during the COVID-19 pandemic. UCSF Pediatric Dentistry has applied this technology to several areas of its practice over the past year with plans of expanding its use in the future using synchronous and asynchronous methods.

We have implemented the use of synchronous telehealth consult visits for patients with special health care needs and/or those who live a significant distance from San Francisco who are referred for advanced pediatric dental care. Using synchronous live visits with the patient and parent, we are able to gather medical history, dental history and chief complaint and perform a limited oral exam of the child. Often, the referring dental provider has also provided dental radiographs prior to the telehealth visit. Through this application of the teledentistry technology, we are in most cases able to recommend a treatment plan for the patient such as in-office with nitrous oxide, oral conscious sedation or treatment with general anesthesia. This use of synchronous telehealth precludes the need for the family to travel a significant distance to San Francisco for an initial consultation and reduces the number of in-person visits needed while conserving PPE, disposables and auxiliary staff time.

Furthermore, evidence has shown that the use of teledentistry is effective for

accurately recommending treatment modalities for pediatric dentistry.31,32 This methodology is especially important for patients with special health care needs who face an increased expense and inconvenience of having to travel for medical and dental visits.33 For children with autism spectrum disorder and other neurodevelopmental disorders (ASD/NDDs), UCSF Pediatric Dentistry has used an integrated hybrid approach to desensitize children to the dental environment and improve their home oral hygiene.34 UCSF Pediatric

UCSF is now expanding its use of teledentistry to support oral health care for children in community settings.

Dentistry uses telehealth visits for initial consultations with parents and children with ASD/NDDs who have been referred due to difficult behavior in the dental office. In this consult, providers learn about medical history, dental history, the patient’s existing educational and behavioral supports, communication styles, patient preferences and patient sensitivities. These visits are conducted jointly by UCSF pediatric dental providers and a board-certified behavioral analyst.

UCSF also uses live and prerecorded videos of the pediatric dental clinical space to desensitize patients to the clinic before their first in-person visit.

Telehealth is also used to improve home oral hygiene. During synchronous and asynchronous oral hygiene coaching sessions, providers work with parents/

caregivers and children with ASD/NDDs to observe how oral hygiene is provided in their home environment and provide instruction and guidance on how to improve. Observing how oral hygiene is done at home by the family and child is extremely valuable in helping to provide specific individualized interventions to improve oral hygiene and prevent oral disease for children with ASD/NDDs. These video visits are used to supplement in-person visits at the pediatric dental clinic. The goal of this hybrid approach of in-person and teledentistry visits for children with ASD/NDDs is to enable all children to complete a traditional dental visit and guide them toward optimal home oral hygiene regimens.

Expanding UCSF’s Teledentistry Systems to Community Sites

UCSF Pediatric Dentistry initially embraced the value and effectiveness of teledentistry to enhance its clinicbased activities. UCSF is now expanding its use of teledentistry to support oral health care for children in community settings. One such example is the development of a virtual dental home system that will use store-and-forward asynchronous telehealth through a grant-funded project (HRSA grant #D88HP37553) in partnership with UCSF Dental Public Health. In this project, UCSF is collaborating with the California Northstate University College of Dental Medicine and Paul Glassman, DDS, MA, MBA, the developer of the VDH system of care, and his team who are providing consultation and educational support for this grant.

As part of this project, UCSF is developing a VDH program with a rural-based elementary school as a pilot site. Through this model, a communitysite provider team composed of an advanced practice dental hygienist O C TOBER 2 0 2 1

645

teledentistry C D A J O U R N A L , V O L 4 9 , Nº 1 0

(RDHAP) and dental assistant will be on-site at the school and will collect complete diagnostic records including intraoral photos, radiographs, charting, health history and consent information.

UCSF is using Teledentix,25 a cloudbased teledentistry platform, in this pilot project to enable an effortless communication and review of records from the school-based site and pediatric dental providers. The community team will also provide preventive care such as prophylaxis and fluoride varnish at the guidance of pediatric dental faculty. Once the diagnostic records are reviewed by UCSF pediatric dental faculty and residents, when appropriate, they will make recommendations for additional noninvasive treatment at the school site such as sealants, silver diamine fluoride and interim therapeutic restorations to be completed by the dental hygienist. Children with advanced and urgent dental needs will be referred to a partnering local dental provider. Through this use of the VDH, children in rural California with extremely limited access to dental care will be provided specialized pediatric dental services at their school through teledentistry. This model of integrating pediatric dental providers, RDHAP dental hygienists and local dental partners could be implemented in many rural areas to increase access to provide preventive and early interventional dental services without having to relocate dental providers into rural areas.

Furthermore, UCSF has integrated a training component to teach pediatric and dental public health residents about the VDH model and how to function in the model with the hopes that they can apply their knowledge and experience to the future use of this revolutionary technology to increase access to care for underserved children in California.

646 OC TOBER

2021

Future Expansion

In spite of the advantages and growing interest, full acceptance of teledentistry faces significant challenges, both by the profession and by the public at large.35 If the concept is to be widely and generally accepted and adopted as a standard of care, it should be made available to all members of society, regardless of their access to broadband internet or smartphone technology. While there are still vast access-to-care barriers for dentistry in the United States today, teledentistry has the potential to reduce these barriers and increase access to care for remote and vulnerable populations.

Although teledentistry has been broadly accepted and is convenient to both providers and consumers, it is not yet readily accessible to large segments of the population.36 Currently, nationwide only 43% of families have access to video-based technology and many do not have access to high-speed internet required to support most platforms.37 In these situations, a text-based model of telehealth could provide a compromise and permit some access to virtual services for families who have limited access to videoconferencing capabilities.38 In addition, there are potential issues with security, privacy and HIPAA compliance with the numerous video-based platforms that have been used by providers in their efforts to provide telehealth services to their patients.15 An additional potential barrier will be the problems in navigating the ever-evolving reimbursement policies, which vary from state to state.39 It is always prudent for providers to contact their principal third-party payer’s provider service department and inquire regarding their teledentistry policies.

It will also take a concerted effort by all stakeholders to increase awareness of the benefits of the telehealth systems described here and continued

advocacy efforts to create an optimal policy environment. Finally, even with broad awareness and an optimum policy environment, deploying effective teledentistry systems, especially fullservice, community-based systems, can be complex. There will be a continued need for education, consultation and technical support as the use of this technology expands. n AC KN OW L E DG M E N T The virtual dental home is part of a project supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3.2M with 0% percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. government.

RE F E RE N C E S 1. Center for Connected Health Policy. Telehealth Advancement Act of 2011 (AB 415). www.cchpca.org/telehealth-policy/ telehealth-advancement-act.

2. Daniel SJ, Kumar S. Teledentistry: A key component in access to care. J Evid Based Dent Pract 2014 Jun;14 Suppl:201–8. doi: 10.1016/j.jebdp.2014.02.008. Epub 2014 Mar 5.

3. California Department of Health Care Services (Business and Professions Code section 2290.5(a)(6)). leginfo. legislature.ca.gov/faces/codes_displaySection.xhtml?sectionN um=2290.5.&lawCode=BPC. 4. Health Resources and Services Administration. Telehealth: Health care from the safety of our homes. telehealth.hhs.gov.

5. Wright JH, Caudill R. Remote treatment delivery in response to the COVID-19 pandemic. Psychother Psychosom 2020;89(3):130–132. doi: 10.1159/000507376. Epub 2020 Mar 26.

6. U.S. Health Resources and Services Administration.

Telehealth: Delivering Care Safely During COVID-19. www.hhs. gov/coronavirus/telehealth/index.html. telehealth.hhs.gov.

7. Russi CS, Heaton HA, Demaerschalk BM. Emergency medicine telehealth for COVID-19: minimize front-line provider exposure and conserve personal protective equipment.

Mayo Clin Proc 2020 Oct;95(10):P2065–2068. doi. org/10.1016/j.mayocp.2020.07.025.

8. Kim JH, Desai E, Cole MB. How the rapid shift to telehealth leaves many community health centers behind during the COVID-19 pandemic. Health Affairs Blog June 2, 2020. doi: 10.1377/hblog20200529.449762.

9. Neufeld JD, Doarn CR, Aly R. State policies influence Medicare telemedicine utilization. Telemed J E Health 2016 Jan;22(1):70– 4. doi: 10.1089/tmj.2015.0044. Epub 2015 Jul 28.

10. Brown NA. State Medicaid and private payer reimbursement for telemedicine: An overview.

J Telemed Telecare 2006;12 Suppl 2:S32–9. doi: 10.1258/135763306778393108.

11. California Department of Health Care Services. Medi-Cal Provider Manual: Telehealth. files.medi-cal.ca.gov/pubsdoco/ Publications/masters-MTP/Part2/mednetele.pdf.

C D A J O U R N A L , V O L 4 9 , Nº 1 0

12. American Dental Association. ADA Updates Teledentistry Policy. www.ada.org/en/publications/ada-news/2020archive/november/ada-updates-teledentistry-policy.

13. Kemery DC, Goldschmidt K. Can you see me? Can you hear me? Best practices for videoconference-enhanced telemedicine visits for children. J Pediatr Nurs Nov–Dec 2020;55:261–263. doi: 10.1016/j.pedn.2020.08.015.

Epub 2020 Aug 28.

14. Nasseh K, Vujicic M. Modeling the impact of COVID-19 on U.S. dental spending. Health policy institute research brief; American Dental Association 2020.

15. Zoom for Healthcare. zoom.us/healthcare.

16. Estai M, Kanagasingam Y, Tennant M, Bunt S. A systematic review of the research evidence for the benefits of teledentistry.

J Telemed Telecare 2018 Apr;24(3):147–156. doi: 10.1177/1357633X16689433. Epub 2017 Jan 24.

17. Kopycka-Kedzierawski DT, Billings RJ. Teledentistry in innercity child-care centres. J Telemed Telecare 2006;12(4):176– 81. doi: 10.1258/135763306777488744.

18. Fernández CE, Maturana CA, Coloma SI, Carrasco-Labra A, Giacaman RA. Teledentistry and mHealth for Promotion and Prevention of Oral Health: A Systematic Review and Metaanalysis. J Dent Res 2021 Mar 26;220345211003828. doi: 10.1177/00220345211003828.

19. Rahman N, Nathwani S, Kandiah T. Teledentistry from a patient perspective during the coronavirus pandemic. Br Dent J 2020 Aug 14;1–4. doi: 10.1038/s41415-020-1919-6.

Online ahead of print.

20. Tranby E, Thakkar Samtani M. Teledentistry is an effective tool to triage patients and save money. Boston: CareQuest Institute for Oral Health; 2021.

21. Glassman P, Harrington M, Namakian M, Subar P. The virtual dental home: Bringing oral health to vulnerable and underserved populations. J Calif Dent Assoc 2012;40(7):569–77.

22. University of the Pacific, School of Dentistry. Report of the Virtual Dental Home Demonstration. lms.dentalmedicine.cnsu.edu/ VDH/VirtualDentalHome_Report_FullReport_2016-0614.pdf.

23. The DentaQuest Partnership for Oral Health Advancement.

Expanding Oral Health: Teledentistry; 2019. www.carequest.org/ system/files/DQ_Whitepaper_Teledentistry%20(9.19).pdf.

24. California Northstate University College of Dental Medicine. The California Dental Transformation Initiative Local Dental Pilot Projects. dentalmedicine.cnsu.edu/researchcommunity/research-dti.

25. Teledentix. Mobile dentistry software. get.teledentix.com.

26. MouthWatch LLC. Teledent. www.mouthwatch.com/ teledent-software.

27. Teledentistry and Open Dental. opendental.blog/ teledentistry-and-open-dental.

28. California Department of Health Care Services.

Teledentistry Resources. 2020. www.dental.dhcs.ca.gov/ Dental_Providers/Medi-Cal_Dental/Teledentistry_Resources.

29. Delta Dental of California and Affiliates. Important Information For Our Providers About Teledentistry. 2020. www1.deltadentalins.com/newsroom/releases/2020/03/ important-information-for-our-providers-about-teledentistry.html.

30. Delta Dental of California and Affiliates. Delta Dental of California and its affiliates announce new teledentistry offerings. 2021. www1.deltadentalins.com/newsroom/ releases/2021/02/delta-dental-of-california-and-its-affiliatesannounce-new-teled.html.

31. McLaren SW, Kopycka-Kedzierawski DT. Compliance with

dental treatment recommendations by rural paediatric patients after a live-video teledentistry consultation: A preliminary report. J Telemed Telecare 2016 Apr;22(3):198–202. doi: 10.1177/1357633X15590705. Epub 2015 Jun 26.

32. McLaren SW, Kopycka-Kedzierawski DT, Nordfelt J. Accuracy of teledentistry examinations at predicting actual treatment modality in a pediatric dentistry clinic.

J Telemed Telecare 2017 Sep;23(8):710–715. doi: 10.1177/1357633X16661428. Epub 2016 Aug 9.

33. Karp WB, Grigsby RK, McSwiggan-Hardin M, et al. Use of telemedicine for children with special health care needs.

Pediatrics 2000 Apr;105(4 Pt 1):843–7. doi: 10.1542/ peds.105.4.843.

34. Luscre DM, Center DB. Procedures for reducing dental fear in children with autism. J Autism Dev Disord 1996 Oct;26(5):547–56. doi: 10.1007/BF02172275.

35. Gawel R. 58.0% of patients afraid of getting infected at the dentist. Dentistry Today; Sept. 5, 2020.

36. Nouri S, Khoong EC, Lyles CR, Karliner L. Addressing equity in telemedicine for chronic disease management during the COVID-19 pandemic. NEJM Catalyst Innovations in Care Delivery 2020;1(3).

37. Zhai Y. A call for addressing barriers to telemedicine: Health disparities during the COVID-19 pandemic. Psychother Psychosom 2021;90(1):64–66. doi: 10.1159/000509000.

Epub 2020 Jun 4.

38. Ojo A, Chatterjee S, Neighbors HW, et al. OH-BUDDY: Mobile phone texting based intervention for diabetes and oral health management. Paper presented at Hawaii International Conference on System Science; 2015.

39. Jampani ND, Nutalapati R, Dontula BSK, Boyapati R. Applications of teledentistry: A literature review and update.

J Int Soc Prev Community Dent 2011 Jul;1(2):37–44. doi: 10.4103/2231-0762.97695.

T H E CO RRE S P ON DIN G AU T HOR , Ray E. Stewart, DMD, MS, can be reached at Ray.Stewart@ucsf.edu.

O C TOBER 2 0 2 1

647

NEVER STOP LEARNING. Let’s go! Tap into dentistry-centered education beyond CDA’s convention.

Discover year-round opportunities to learn new skills, fuel your practice and boost your career through CDA Presents 360º.

Learn the way that works for you. Experience our flagship CDA Presents events in San Francisco and Anaheim, interactive virtual events, live courses on hot topics and 24/7 on-demand options.

Find flexible formats that fit your schedule and support your busy practice.

CDA Presents Online Learning offers a full course catalog. Plus, CDA members enjoy exclusive offerings and preferred pricing.

Explore all your learning options today at cda.org/learning.

New CDA member benefit: Access to education anytime Online Learning is your destination for 24/7 education.

Enjoy waived fees and big discounts on popular courses, including:

• The Path to Practice Ownership two-part series $150 total value – free for CDA members

• Coach to Success three-part series for leaders 50% discount for members

• Three Keys to Website Accessibility $75 value – free for CDA members

IT’S EASY TO GET STARTED! Already a CDA member?

Set up your Online Learning account with the same email you use to access your cda.org account to ensure access to the member-only catalog and special pricing. Then, sign in any time to explore all your course options and start learning!

Not yet a member? Set up your account and sign in to access select courses, or join CDA to benefit from discounts and expanded learning options.

Making your transition a reality.

Dr. Thomas Wagner

Dr. Russell Okihara

LIC #01418359

LIC #01886221

(916) 812-3255 45 Years in Business

(619) 694-7077 38 Years in Business

Jim Engel LIC #01898522

(925) 330-2207 46 Years in Business

Jay Harter LIC #01008086

(916) 812-0500 36 Years in Business

Kerri McCullough LIC #01382259

(949) 300-0312 35 Years in Business

Gina Miller LIC #02015193

(707) 391-7048 30 Years in Business

Steve Caudill LIC #00411157

(951) 314-5542 30 Years in Business

Jaci Hardison LIC #01927713

(714) 318-4911 26 Years in Business

Kim Ta LIC #02085576

(408) 687-5001 16 Years in Business

Thinh Tran LIC #01863784

(949) 675-5578 11 Years in Business

PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA ALAMEDA COUNTY SOUTH-ORTHO: New Listing! 3 Chairs, below-market rent with over 50% Net profit and 2020 GR of $505K. Orthowave and Digital Pan/Ceph.

Great satellite office or for first-time buyer. #CA2785 EAST BAY AREA PEDO: Well-established with 8 Ops, Digital, plumbed for Nitrous, and high NP count. Associate-driven with Delta PPO. 2019 GR $832K on 3-4 days/wk., 2020 Production $560K. #CA2523 FAIRFIELD AREA: High traffic area, 7 Ops Digital, Pano/CB, 23+ NP/mo. with 8+ Hyg. days/wk. Room to grow with specialties.

2019 GR $1.7M and 2021 on track to exceed 2019. #CA1824 FAIR OAKS/CITRUS HEIGHTS AREA: Successful practice w/ 38 yrs. Goodwill. Nice décor, Digital, 6 hyg days/wk. Growth potential with Ortho/Implants. 4 Ops in 1,100 sf. 2019 GR $970K+ on 32 hrs/wk. #CA656 FREMONT ORAL SURGERY: New Listing! 34 yr history, diverse high-tech community. 4 Ops Digital, 7-10 y/o equipment, Pano. 2019 GR $548K on 3.5 days/wk. #CA2754 GREATER SONORA AREA: Rural lifestyle GP/Real Estate, 5 Ops, Dentrix, Strong hyg prog in stable community. 2019 GR $698K. #CA1713 HAYWARD: New Listing! Great neighborhood practice +RE opportunity.

4 Ops, digital, updated. 2019 GR $730K. #CA2771 LAKE TAHOE AREA: 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715 LAKE TAHOE AREA: GP practice with 5 Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf. 2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 NORTHERN CA PERIO: 4 Ops, Consult Rm, Upgraded Tech with Digital, LANAP, Paperless. 2019 GR $900K+. Draws from lg area with little competition. #CA1553 NORTHERN SACRAMENTO: Busy location, Paperless, 3 Ops+4th shared, CEREC, Digital Pano. 2019 GR $671K on 24-32 hrs/wk. #CA1745 OAKLAND: New Listing! Pill Hill area, walk to BART, 2019 GR $473K + postCOVID recovery $595K in 12 months since reopening. 3 Ops, Digi X-rays and Pano. #CA2839 REDDING AREA: Price reduced by $100K under valuation price! Modern office with 5 Ops, 4 Eq., Digital, Newer CEREC, 23 NP/ mo with no marketing. Strong Hygiene, specialties referred. 2019 GR $558K. #CA1742 ROSEVILLE/CITRUS HTS: New Listing!

6 Ops, high traffic area, 13 yrs goodwill, Digital, lasers, 26 NP/mo, 5 days Hygiene, specialties referred. Seller will work back. #CA2749 SACRAMENTO: New Listing! 5 Ops+RE in a busy medical/dental/retail area. Digital, 50 yrs Goodwill, 6 hyds/wk. and 3.5 Dr. days/ wk. 2019 GR of $697K with specialties referred. #CA2620

SAN JOSE: New Listing! Est for 35 yrs, 2019 GR of $1.3M with Adj. Net of 38%.

6 Ops, Digital d-rays and Pan, CAD/CAM, Laser. Upscale building near shopping. Seller can stay on P/T.#CA1140 SAN MATEO: New Listing! 5 Ops, Digital, iTero Scan, CEREC, Laser, Paperless, Microscope. Seller-owned stand-alone building to lease. $1.4M GR on 4 days/wk. #CA2596 SONOMA COUNTY: New Listing! 4 Ops with room to expand into suite next door. GR over $1M for last 3 yrs. Est. 30+ years. Strong hygiene, digital, space available to lease or buy. #CA2790 SONOMA COUNTY: 4 Ops in spacious layout in heart of the area off main highway.

Est 22 yrs with 5 star Google reviews, Paperless with CEREC, Scope, Laser, Strong Hyg. Retiring seller. 2019 GR $782K with good post-COVID recovery. #CA2594 SONOMA COUNTY: Stand-alone 3,000 sf, 72 NP/mo. & 10 hyg days. 6 Ops, Pano, Dexis, Cameras, Laser, Dentrix. Business & RE for sale or Lease. Doctor Retiring. 2019 GR $2.3M+. #CA544 VACAVILLE AREA: Price Reduced over $35K! Seller will work back for up to 6 mo.

Centrally-located & hi-traffic location with 25 + yrs goodwill. 5 Ops in 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 VACAVILLE AREA: 4 Ops, 3 equipped, 45 years goodwill, Digital, paperless, most specialties referred. 2019 GR $723K on 30 hour week. #CA2748

CENTRAL CALIFORNIA CENTRAL COAST: 5 Ops, digital, 25+ yrs Goodwill. Newly renovated, practice sees 30 NP/mo. Strong hyg prog. 2019 GR $1.1M+. #CA1218 CENTRAL VALLEY/MODESTO: New Listing! 8 Ops, high visibility retail, Open 20+ yr, Digital, soft/hard tissue lasers, 3,300+ active pts., 24+ NP/mo., 4 hyg days/ wk., 18.5 hour Dr. work week. 2019 GR $852K, 2020 84% of 2019. #CA2721 MODESTO AREA: Est. area with 60+ yrs. goodwill. 5 Ops, 2019 GR $1.1M+ on 3 days/ wk. Dental Condo also available for purchase or lease, Seller may consider financing. #CA635 MONTEREY: New Listing! 4 Ops, Paperless, Digital, Pano. 2019 GR $1.1M with Adj. Net over $450K. Post-COVID revenue has grown even more! RE for sale, non-Delta Premier office, FFS and some PPOs. #CA2614 SANTA CRUZ COUNTY: New Listing!

4 Ops Close to beach in strip center. Digital Pano and x-rays, CEREC, 40 years goodwill.

2019 GR $392K on 3.5 days. #CA2822 SANTA CRUZ/APTOS PERIO: New Listing! 4 Ops+RE, Paperless, Digital, CBCT, 27 years goodwill. Seller will help with smooth transition of strong referral base. #CA2725 STOCKTON: Practice+RE available, 5 Ops, 5 Hyg. Days/wk. 2019 GR $812K on 32 hr. week. High level of Ortho, seller can work back. #CA2006

Northern California Office

800.519.3458

Henry Schein Corporate Broker #01230466

SOUTHERN CALIFORNIA BAKERSFIELD PEDO: New Listing! Rare Opportunity-10 chairs with Pedo and Ortho/ OS in-house Ops, Digital x-rays and Pan/ Ceph. High grossing practice. #CA2794 BAKERSFIELD: 6 Ops, 40 yrs Goodwill, great reputation in the area. 6 hyg ds/wk and most specialty work referred. Digital pano, digital X-rays. 2019 GR $600K. RE also for sale. #CA1274 BAKERSFIELD: New Listing! 6 Ops, 5 Equipped, Digital, 2020 Collections $1M+ with 6 days hygiene and 2 P/T associates. #CA2587 BURBANK: Big opportunity for large practice merger, 6 Ops, Digital, seller retiring.

6 days of hygiene, specialties referred. Seller will transition, open to financing options. 2019 GR $918K. #CA2632 COASTAL ORANGE COUNTY: New Listing! 5 Ops, 4 Equipped, Digital Pano and X-rays, well-established neighborhood, very desired area. 2019 GR over $1M. #CA2787 CORONA: 4 Ops, Digital, excellent growth opportunity. Main street location in small strip center. 2019 GR $280K. #CA2002 HUNTINGTON BEACH: PRICE REDUCED FOR QUICK SALE! 5 Ops, desirable loc, Digital, Strong hyg prog. 2019 GR $604K. #CA685 INDIO: 4 Ops, single-story medical/retail center. Digital, CEREC w/milling unit and oven. GR $764K in 2019 and $535K in 2020.

7 Hyg days/wk. Great Opportunity. #CA2619 LONG BEACH: RE Ownership an option!

Upper middle-class residential practice est. in 1950. Existing 4 Ops, 3 Equip, Digital, Easy expansion next door to add 3 Ops, 2 are equip.

Most Specialty referred. Strong post-COVID production. 2019 GR $696K. #CA671 LOS ANGELES: Cash/PPO office in great DTLA Location. 3 Ops with low rent. Digital with scanner and lasers. 2020 GR $299K on 2 days/wk. #CA2493 MONTEBELLO: New Listing! 3 Ops in busy strip center location with 2 Associates, Digital x-rays, and all specialty work referred out. #CA2786 ORANGE COUNTY: Price Reduced! 5 Ops, Digital, Retiring seller. Excellent reputation, affluent area, high quality care. Modern, welcoming office with strong hyg prog. Room to grow specialties. 2019 GR $642K. #CA1676 ORANGE COUNTY: Strip center location at a major intersection. 2019 GR $329K with low overhead and great take-home Net. 5 Ops, 3 equipped, seller works average 16 hrs./wk. by choice. Denti-Cal. Great potential, low asking price of $150K. #CA1728 ORANGE COUNTY: New Listing! 4 Ops in sought-after area. 34 yrs Goodwill, many hiend procedures done in-house but room to grow other specialties. Digital. FFS/Cash. #CA2704 OXNARD: 4 Ops, Digital X-rays, Est. 35+ yrs ago. Seller owned it for 3 yrs and has a primary office in LA. 2019 GR $662K. #CA1164

www.henryscheinppt.com

PALM DESERT: 4 Ops 27 yrs Goodwill.

Strong hyg prog w/ hi-end patient base of locals/ snowbirds. 2019 GR $809K on only 16 days/mo. with low overhead. Call today! #CA691 PALMDALE/LANCASTER: New Listing! 7 Op office in fast-growing community. Paperless with Dentrix, digital x-rays, 8 days of hyg./week and dedicated staff. Room to grow with specialties! #CA2612 SOUTH BAY LOS ANGELES: Ready to retire! 7 Ops, real estate for sale also. 50% DentiCal, some HMO and PPO. 2019 GR $568K. #CA1050 SANTA BARBARA: 4 Ops in beautiful setting.

Digital, FFS, strong hygiene, and room to grow with specialties. Consistently collects $1M+/yr. with manageable overhead. #CA2531 SANTA BARBARA: 4 Ops with Digital xrays, 5 hygiene days/wk. Most specialties referred, beautiful area. 2019 GR $790K with attractive net. #CA2722 TORRANCE: New Listing! 3 Ops, retiring seller with 34 yrs goodwill. Ready to take to the next level with technology of your choosing.

Amazing location in desired area. 2019 GR of $300K with low expenses, a wonderful opportunity to grow. #CA2807

SAN DIEGO DEL MAR: New Listing! 4 Ops, Digital, Open Dental, Conservative Practitioner who refers out specialties. 4 days of hygiene per week. Seller is eager for a quick sale.

Excellent opportunity in a very desirable location. #CA2724

OUT OF CALIFORNIA BIG ISLAND, HAWAII: 3 Ops, nondigital, excellent location plus rare option to purchase office space. Room to grow! #HI1929 PORTLAND, OR: New Listing! Great location. 5 Ops, 4 equipped, Digital, Pano, 50% Medicaid. Turn-key practice on main road. 2019 GR $646K. #OR2757 SOUTHERN OREGON: New Listing! 5 Ops, Paperless, CEREC, Laser, and much more. Doctor is available to stay on for transition, if desired. Turn-key office. 2020 GR $1.5M. #OR2688 SOUTHERN OREGON: Quaint GP in ideal location in desirable town. 4 Ops with room to grow adding days and specialties. Open 31 yrs. Digital with EagleSoft. $276K GR in 2020. #OR2574 TRI-CITIES, WASHINGTON: New Listing! Small modified start up, fully equipped! Access to 1500 patient records, Open Dental software, laser, x-ray sensors.

Desirable location, affordable rent. #WA2629

Southern California Office

888.685.8100

covid-19 and children C D A J O U R N A L , V O L 4 9 , Nº 1 0

Impact of COVID-19 on the Pediatric Population Jessica Y. Lee DDS, MPH, PhD; Janice A. Townsend, DDS, MS; and Eva C. Ihle, MD, PhD

abstract In March 2020, the U.S. declared a state of emergency and stay-at-home orders were issued. This included school closures and limitation of dental practice to emergency treatment only. While public health measures were very much needed, it was not without unintended consequences. School closures only compound the economic, health and achievement inequities, disproportionately affecting disadvantaged children, which also includes access to dental care. As we emerged from the stay-at-home orders, dental practices have had to adapt and evolve.

Keywords: COVID-19, pediatric dentistry, child health

AUTHORS Jessica Y. Lee DDS, MPH, PhD, is the Demeritt distinguished professor of pediatric dentistry and chair of the division of pediatric and public health at the University of North Carolina.

She is also a professor in the department of health policy and management in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. Dr. Lee is the current president of the American Academy of Pediatric Dentistry.

Conflict of Interest Disclosure: None reported.

Janice A. Townsend, DDS, MS, is the chief of pediatric dentistry at Nationwide Children’s Hospital and chair of the division of pediatric dentistry at The Ohio State College of Dentistry. Dr. Townsend previously served as an associate professor and chair of the department of pediatric dentistry at the Louisiana State Health Sciences Center School of Dentistry, where she is also the Blue Cross Blue Shield of Louisiana professor in pediatric dentistry. She is a diplomate of the American Board of Pediatric Dentistry.

Conflict of Interest Disclosure: None reported.

Eva C. Ihle, MD, PhD, is the interim medical director of the division of infant, child and adolescent psychiatry at the Zuckerberg San Francisco General Hospital and Trauma Center. She also directs the hospital’s program to enhance access to psychiatric care for underserved populations by partnering with primary care clinics. Dr. Ihle studied social behaviors in songbirds and a mouse model for autism.

She also has examined the mechanisms that support health and well-being in individuals under stress.

Conflict of Interest Disclosure: None reported.

T

he COVID-19 pandemic is a generation-defining event with unprecedented human, social and economic implications.

This global health crisis has become the focal point of concerted efforts by international and state agencies, industry and the civil society. Amid the pandemic, optimizing care and health outcomes for COVID-19 patients and their communities remain top priority — at the same time, operating in “the new normal” is a pressing challenge for virtually all sectors. COVID-19 is arguably the most disruptive change that health care education has ever encountered.

Within this adverse and rapidly changing environment, pediatric health care providers are faced with unique challenges that not only affect their clinical practices but also the well-being, development and mental health of an entire generation.

O C TOBER 2 0 2 1

651

covid-19 and children C D A J O U R N A L , V O L 4 9 , Nº 1 0

On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.1 On March 13, 2020, the United States declared a national emergency.2 This was the first time such a declaration had been issued over an infectious disease outbreak since the 2009 H1N1 influenza pandemic. The declaration also instructed state governments to set up emergency operations centers, directed hospitals nationwide to activate emergency preparedness contingency plans and allowed health secretary Alex Azar to waive regulations that could hinder health professionals’ response capabilities. Soon after, states issued stay-at-home orders and schools began to close. Early in the pandemic, school closure was associated with decreased COVID-19 incidence and mortality. Those states that closed schools earlier had the largest relative reduction in incidence and mortality.3

widening disparities. There is no doubt that these public health measures were essential, but the social and economic impacts must also be understood.

Effects on Children’s Development

As social creatures, developing humans depend on social interaction beyond their immediate family in order to learn fundamentals, such as expressive and receptive language and how to behave in society.5 When these social and developmental supports are curtailed for prolonged periods, severe physical

The consequences of isolation fall along a continuum for children contending with distance learning and sheltering in place.

Stay-at-Home Orders

Children with COVID-19 may be asymptomatic or only express mild symptoms that are indistinguishable from other common childhood respiratory tract infections. This presentation allows them to spread the virus more easily, as they are often feeling well. Studies have demonstrated an association between school closure and reduced transmission of viral respiratory illnesses.4 Due to these concerns, all states closed schools in mid-March 2020. The importance of school for child development, growth and overall well-being cannot be understated.

While public health measures were very much needed, it was not without some unintended consequences. School closures only compound the economic, health and achievement inequities, disproportionately affecting disadvantaged children.

Additionally, limited access to technology and school meals contributed to the 652 OC TOBER

2021

and mental health consequences in children are predicted to ensue.6,7 The consequences of isolation fall along a continuum for children contending with distance learning and sheltering in place.

Thus, although we do not have data yet to trace the precise impact of the isolation caused by the COVID-19 pandemic on children’s development, it is reasonable to conclude that it will be significant.8

Psychological Consequences of the Pandemic

Considerable evidence already exists to demonstrate that humans respond to trauma, be they natural or manmade, in predictable ways.8 These ways are partly related to the stress response. The adverse psychological consequences of natural disasters, such as pandemics, are

typically not observed in the immediate aftermath of the event. The response to a disaster can be positive, reflecting the adaptive nature of the stress response and our capacity for altruism and salutogenesis.9 Unfortunately, there are some longer-term consequences of the stress associated with natural disasters that can be devastating in their impact. These negative psychological consequences had mental health experts predicting that there would be surges not only in infections, but also in psychological distress/suffering associated with the protracted COVID-19 pandemic.7,10 Early evidence of this phenomenon was demonstrated in a Morbidity and Mortality World Report (MMWR) finding from the summer of 2020.11 In a web-based representative panel survey conducted in June 2020, adult participants were found to have reported increased rates of affective disorders, substance use disorders and suicidal ideation.

Thus, the adversity of social isolation was already apparent in adults roughly three months after the nationwide shelter-in-place edict was imposed.

Different Age Groups Manifest Consequences Differently

Numerous observations of the impact of trauma on youth have demonstrated that the mostly negative responses to psychological stressors differ depending on the age of the child. Younger children can manifest behaviors that suggest that they have experienced disrupted attachment, can demonstrate deficits in cognitive and/or socioemotional development and can have regression of milestones (especially in toileting), clinginess and difficulty sleeping.8 Older children often express worries (about their safety or the safety of their caregivers), complain about physical symptoms like stomachache and headache

C D A J O U R N A L , V O L 4 9 , Nº 1 0

and have academic difficulties (separate from those associated with distance learning). For many children, school is a safety net. Practically, schools can provide everything from subsidized meals to aftercare programs, peer support and the support of other caring adults in their lives. When schools close, children are abruptly cut off from these essential psychosocial and programmatic supports.

Children exhibit the consequences of having suffered these losses through difficulty with emotional and physical regulation.6 Mental health clinicians have reported increased complaints of depressive symptoms including worsening social withdrawal (from peers and family) even when given the opportunity to interact in socially distanced or outdoor settings, changes in appetite and sleep and worsening apathy. For example, children who are struggling with depression and anxiety may begin to fully retreat from all familial interaction and exhibit decreased interest in activities that used to be enjoyable. These symptoms are all prototypical signs of neurovegetative depression, where depression begins to manifest in a patient’s body. The changes are physiological, not only in a patient’s moods and feelings. Some manifest this anxiety and fear behaviorally, throwing tantrums and being more defiant.

Behavioral dysregulation occurs when routines like following the schedule of a school day are disrupted. Others are more fearful and clingier with their parents, not wanting to venture outside the home, possibly because they are afraid of being in a world without the sources of comfort and support they were previously able to depend on.

Children with special needs and their parents rely on public schools to provide speech, occupational and physical therapy as well as teachers who are specialized in providing emotional

and educational support. When schools closed, access to these specialized resources effectively vanished and could not be replicated through virtual care. In theory, community clinics could have filled the gap and provided virtual resources, but they are not necessarily free nor were they as readily available as public schools, especially as demand increased. Many children with special needs require their interactions to be scaffolded by a trained therapist, and this training could not be effectively taught online to caregivers (who were then expected to be the proxy

Disordered eating is another behavioral manifestation of adolescent distress...

therapists), nor were many families in the financial position to provide full-time support. While schools remained closed, children with special needs and their families were uniquely disadvantaged.

Adolescents and transitional-age youth as a group also experienced severe consequences, a finding predicted from previous observations.12 Adolescents suffering from the impact of trauma can become more socially isolated, experience worsening irritability or sense of guilt and engage in hostile acts toward themselves and others (such as deliberate or subconscious self-destructive behavior or increased rates of gun violence, respectively), express thoughts of suicide and demonstrate these thoughts through self-harm behaviors such as cutting. Disordered eating is another

behavioral manifestation of adolescent distress, a mechanism implemented to help manage difficult feelings. While some youth restricted their food intake in order to gain a sense of control over their environment, some youth were restricting their nutritional intake to consciously sacrifice their own nourishment in the hopes that the rest of their family could eat when they no longer received schoolsubsidized meals.12 Others followed an established pattern of overconsuming hyperpalatable food and gaining excessive weight. Additionally, they missed the important milestones of their academic careers (graduations, sporting events, prom) and had to mourn the losses of quintessential high school events that they were not able to experience. The preliminary evidence regarding the psychological distress of adults during the COVID-19 pandemic was already dire, and then another report confirmed what was anticipated from the data summarized above. In a report on mental health-related emergency department visits of youth between January and October 2020, Leeb and colleagues13 revealed that there was a proportional increase over the numbers from the same month one year prior. They also found that adolescents were more impacted (31% increase) than children (24%).

Impact of COVID Is Not Homogenous When summarizing the effect of the COVID-19 pandemic on children’s development, we can sort the outcome into three categories: those who survive, those who strive and those who thrive.

The majority of youth who experienced the pandemic were able to manage the discomfort of their trauma adequately and survive the struggle, especially when they had family support. Those children who already suffered with depression or anxiety or who had moderate/severe O C TOBER 2 0 2 1

653

covid-19 and children C D A J O U R N A L , V O L 4 9 , Nº 1 0

neurodevelopmental disorders had to strive to endure the pandemic with amplified symptoms. It should be noted that not every child was able to access the standard mental health services that they needed during this difficult time. They had to turn to ancillary support services, like their pediatric clinics, or they had to suffer alone, leading to the ER visits documented by Leeb and colleagues.13 Remarkably, for all of the recognition of the negative outcomes of the pandemic on children’s development, a subset of youth was actually able to thrive. These children were likely able to fare reasonably well because their preexisting conditions could be ameliorated by distance, namely social distancing and distance learning.

Routine dental exams may be the first time children venture out of their homes.

Effects on Pediatric Dentistry

The practice of dentistry has adapted to the new COVID-19 environment.

This holds true for not only the practice of dentistry but for dental education as well. Guidelines for personal protective equipment and environmental infection control in health care facilities have long existed, but these were used for patients with a confirmed infection transmitted through secretions from the respiratory tract, such as Mycobacterium tuberculosis.14 The need for emergent dental treatment in these patients with an active infection was rare and a hospital setting was indicated. However, due to the asymptomatic nature of COVID-19 in early stages and the lack of information about transmission during this period, dental offices have been required to treat all patients as potentially infectious.15 Thus, dentists had to navigate a patchwork of COVID-19 guidelines issued by different agencies to replicate hospital settings in dental offices that were not designed for that purpose.16 Guidelines 654 OC TOBER

2021

have recommended a litany of changes such as delay of nonemergent procedures based on the local environment, teledentistry, preprocedural screening of patients for symptoms, room rest time before cleaning, limitation of visitors, use of face masks, use of physical barriers, removal of shared items in the waiting room, use of four-handed dentistry, use of rubber dam, alternatives to aerosol, use of high-volume suction, preprocedural mouthwashes, N-95 respirators or equivalent devices for aerosol-generating procedures, use of individual patient rooms

Current advice to dentists is that, despite full vaccination, they should continue to follow CDC guidance.

and use of HEPA filtration to supplement air turnover times.17 Dentists were asked to monitor themselves for symptoms and to implement flexible leave policies for staff, which was a challenge prior to the pandemic18 and even more difficult during a period when small businesses were facing financial catastrophe.

Pediatric dentists have had to navigate additional complexities. While there was guidance on management of aerosolgenerating procedures, these guidelines failed to address bioaerosols produced during difficult patient behaviors such as forceful crying, spitting and coughing.19 Guidelines stated that visitors to the office should be limited, but individual dentists were forced to decide when children could be separated from their caregivers and subsequently manage

the repercussions of these decisions.19 Early in the pandemic, when pediatric dentists were managing emergencies with no access to general anesthesia, guidance on the safety of nitrous oxideoxygen inhalation sedation was lacking.20 Finally, children and adults with special health care needs who need access to general anesthesia have been impacted by changes resulting in reduced access.

Prior to the pandemic, pediatric dentists were already struggling to access operating rooms for dental treatment.21 With competition from medical specialties, general anesthesia resources are scarcer and the specter of infection transmission due to aerosol-generating dental procedures may be an additional pretext for cutting these low-reimbursement procedures.21 As a result, dental care in the pandemic presented unique challenges for dentistry for children.

As the pandemic continues, it is unclear how the interim guidance for infection control17 will evolve or potentially become permanent. Infectivity for dentists remains below 1% with no identified cases of transmission in the dental office.22 Likely, these results are evidence that infection control practices have been successful but further studies are needed regarding the role of aerosols in dentistry in infectious disease transmission.23 Currently, no guidance suggests what level of community spread will be adequate to relax these interim guidelines. Current advice to dentists is that, despite full vaccination, they should continue to follow CDC guidance.24 With many predicting that COVID-19 is only the first of a future of similar pandemics, one may conjecture that these emergency measures will be activated more rapidly in the future or that this is the new normal level of prevention.

In addition to infection control measures, other recommendations

C D A J O U R N A L , V O L 4 9 , Nº 1 0

have suggested a fundamental shift in the practice of dentistry. Namely, delay of nonemergent procedures, use of teledentistry as an alternative to traditional care and avoiding aerosolgenerating procedures when possible. Early in the pandemic when many offices faced restrictions on elective procedures, dentists had to define the term elective care.

Emergency care was defined as swelling that restricts swallowing and extends to the eye, uncontrolled bleeding or facial trauma.25 However, classification of urgent cases was more challenging and dependent on patient-specific circumstances (ADA guidance emergency). Worldwide, health care utilization has decreased by one-third during the pandemic.26 Preliminary reports suggested that nearly half (46.7%) of U.S. adults had delayed going to the dentist, with 12.4% delaying care to address a specific problem.27 This reduction is likely still present, as the most currently available practice patterns suggest that 61.2% of pediatric dentists are seeing lower patient volume than usual, according to the ADA Health Policy Institute (HPI). The impact of this deferral of care is yet to be determined, but anecdotal experiences show that it has resulted in more severe disease. More concerningly, the perception that dental care is a danger that can safely be delayed has led to deferral of care until it reached emergency status. If this concept of deferred care becomes the norm, pediatric dentistry could revert to symptom-driven care-seeking in conflict with the dental home concept. The dental profession should use this opportunity to construct an evidence-based framework for deferral of care that accounts for an extended duration emergency such as COVID-19.

Teledentistry and the broader umbrella of telemedicine was lauded as a way to allow optimal triage and ongoing medical care during the pandemic.28

Teledentistry specifically has been used for limited evaluations and triage and to continue ongoing preventive care.29 Data on practice patterns from an ADA HPI survey show that pediatric dentists are most likely to be using virtual technologies or telecommunications compared to the other specialties and are primarily using them to triage emergencies and for post-ops. Although third-party payers and regulatory bodies eventually implemented flexibility to permit and cover these services, there is no certainty that teledentistry funding will become

There is a race currently between getting the population vaccinated and reducing transmission and mortality.

permanent. If these frameworks are effectively dismantled, dental offices may be forced to provide some of these services necessary for appropriate triage with no reimbursement. Without this infrastructure in place, precious time could be lost in a new pandemic and leave dental providers less likely to invest in this teledentistry in the future.

As the CDC has recommended avoiding aerosol-generating procedures and prioritizing minimally invasive/ atraumatic restorative techniques (use of hand instruments only), recommendations specific to pediatric dentistry were to use approaches such as Hall technique crowns, silver diamine fluoride and/ or interim therapeutic restorations.15 A shift toward noninvasive procedures in a biological approach to carious lesions was

already underway in pediatric dentistry and COVID-19 has only catalyzed this transition.30 The pandemic provides the opportunity to study these approaches indepth. However, it should not be used as an excuse to entirely shift from traditional approaches to pediatric dentistry and for third parties to pressure dentists to use the “least expensive treatment” audit benchmark as a substitute for clinical judgement.31 Wholesale implementation without rigorous trials may place children dependent on public funding at risk for a separate tier of care than their private-pay counterparts.

Hope for the Future: COVID-19 Vaccine for Children

Rapid development of an efficacious and safe vaccine against COVID-19 began early in the pandemic. Following the identification of the genetic sequence of COVID-19, the rapid emergence of research and collaboration among scientists and biopharmaceutical manufacturers has been unprecedented.

As of September 2021, the PfizerBioNTech vaccine was the only vaccine with full approval from the U.S. Food and Drug Administration for people over 16 years of age and authorized for emergency use (EUA) for those 12–15 years old. Vaccines developed

by Moderna and J&J/Janssen are also approved under the emergency use authorization.32 Pfizer-BioNTech vaccine developed in the U.S. and reported to be 95% effective in those over age 16 and 100% effective in those aged 12-15 The Moderna vaccine was 94.1% effective at preventing laboratory-confirmed COVID-19 illness in people who received two doses who had no evidence of being previously infected. Both PfizerBioNTech and Moderna vaccines require two shots. The third vaccine, the J&J/ Janssen vaccine, is recommended for O C TOBER 2 0 2 1

655

covid-19 and children C D A J O U R N A L , V O L 4 9 , Nº 1 0

people aged 18 and older and was 66.3% effective in clinical trials.

There is a race currently between getting the population vaccinated and reducing transmission and mortality.

It is estimated that nearly 75% of the population needs to gain immunity by either developing antibodies or vaccinations. As of July 2021, nearly half (49.4%) of the U.S. population was fully vaccinated, so the goal of 75% or higher is an achievable goal.33 Among children ages 12 to 18, nearly 60% were fully vaccinated. This holds promise for the upcoming school year.

The COVID-19 pandemic will have lasting impact on society and its children.

As we begin to reemerge from the pandemic, we must be prepared to address not only the physical but also the emotional, psychological and developmental impacts it has had on children. n RE FEREN CE S 1. World Health Organization. Timeline: WHO’s COVID-19 response. www.who.int/emergencies/ diseases/novel-coronavirus-2019/interactive-timeline#.

Accessed April 12, 2021.

2. Liptak K. Trump declares national emergency — and denies responsibility for coronavirus testing failures. www. cnn.com/2020/03/13/politics/donald-trump-emergency/ index.html. Accessed April 12, 2021.

3. Tull M, Edmonds K, Scamaldo K, Richmond J, Rose J, Gratz K. Psychological Outcomes Associated with Stay-at-Home Orders and the Perceived Impact of COVID-19 on Daily Life. Psychiatry Res 2020 Jul;289:113098. doi: 10.1016/j. psychres.2020.113098. Epub 2020 May 12.

4. Cauchemez S, Valleron AJ, Boëlle PY, et al. Estimating the impact of school closure on influenza transmission from sentinel data. Nature 2008 Apr 10;452(7188):750–4. doi: 10.1038/nature06732.

5. Gopnik A, Meltzoff AN, Kuhl P. The Scientist in the Crib.

New York: Harper Collins; 1999.

6. de Figueiredo CS, Sandre PC, Portugal LCL, Mázala-deOliveira T, da Silva Chagas L, Raony Í, Ferreira ES, Giestal-deAraujo E, Dos Santos AA, Bomfim PO. COVID-19 pandemic impact on children and adolescents’ mental health: Biological, environmental and social factors. Prog Neuropsychopharmacol Biol Psychiatry 2021 Mar 2;106:110171. doi.org/10.1016/j.pnpbp.2020.110171.

7. Shah K, Mann S, Singh R, Bangar R, Kulkarni R. Impact of COVID-19 on the Mental Health of Children and Adolescents.

Cureus 2020 Aug 26;12(8):e10051. doi: 10.7759/

656 OC TOBER

2021

cureus.10051.

8. Dye H. The impact and long-term effects of childhood trauma. J Hum Behav Soc Environ 28(3):381–392. doi.org/1 0.1080/10911359.2018.1435328.

9. Braun-Lewensohn O. Coping and social support in children exposed to mass trauma. Curr Psychiatry Rep 2015 Jun;17(6):46. doi: 10.1007/s11920-015-0576-y.

10. Ihle EC. Psychiatry is an essential medical service during the COVID-19 pandemic. Journal of Psychiatry Reform. 2020 May 15. journalofpsychiatryreform.com/2020/05/15/ psychiatry-is-an-essential-medical-service-during-the-covid-19pandemic.

11. Czeisler MÉ, Lane RI, Petrosky E, Wiley JF, Christensen A, Njai R, Weaver MD, Robbins R, Facer-Childs ER, Barger LK, Czeisler CA, Howard ME, Rajaratnam SMW. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 2020 Aug 14;69(32):1049–1057. dx.doi. org/10.15585/mmwr.mm6932a1.

12. van der Kolk B. The developmental impact of childhood trauma. In: Kirmayer L, Lemelson R, Barad M, eds. Understanding trauma: Integrating biological, clinical and cultural perspectives. Cambridge, U.K.: Cambridge University Press; 2007: 224–241. doi.org/10.1017/ CBO9780511500008.016.

13. Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health-Related Emergency Department Visits Among Children Aged < 18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep 2020 Nov 13;69(45):1675–1680. doi: 10.15585/mmwr.mm6945a3.

14. Hopewell PC, Reichmann LB, Castro KG. Parallels and mutual lessons in tuberculosis and COVID-10 transmission, prevention and control. Emerg Infect Dis 2021 Mar;27(3):681–686. doi: 10.3201/eid2703.203456. Epub 2020 Nov 19.

15. Jayaraman J, Dhar V, Moorani Z, Donly K, Tinanoff N, Mitchell S, Wright T. Impact of COVID-19 on pediatric dental practice in the United States. Pediatr Dent 2020 May 15;42(3):180–183.

16. Benzian H, Beltran-Aguilar E, Niederman R. Systematic management of pandemic risks in dental practice: A consolidated framework for COVID-19 control in dentistry.

Front Med (Lausanne). 2021 Feb 24;8:644515. doi: 10.3389/fmed.2021.644515. eCollection 2021.

17. Centers for Disease Control and Prevention. Guidance for Dental Settings. www.cdc.gov/coronavirus/2019-ncov/hcp/ dental-settings.html.

18. Townsend JA, Peng J, Miller M, Yu Q, Babin V, Fournier SE. Characteristics of pediatric dentists who work when sick.

Pediatr Dent 2019 Nov 15;41(6):464–71.

19. Centers for Disease Control and Prevention. Guidance for Dental Settings. Accessed March 28, 2021.

20. Gupta K, Emmanouil D, Sethi A. Use of nitrous oxideoxygen inhalation sedation in the COVID-19 era. Int J Paediatr Dent 2021 May;31(3):433–435. doi: 10.1111/ipd.12745.

Epub 2021 Mar 9.

21. Vo AT, Casamassimo PS, Peng J, Amini H, Litch CS, Hammersmith K. Denial of operating room access for pediatric dental treatment: A national survey. Pediatr Dent 2021 Jan 15;43(1):33–8.

22. Estrich CG, Mikkelsen M, Morrissey R, Geisinger ML,

Ionnidou E, Vujicic M, Araujo MWB. Estimating COVID-19 prevalence and infection control practices among U.S. dentists. J Am Dent Assoc 2020;151(11):815–24. doi. org/10.1016/j.adaj.2020.09.005.

23. Geisinger ML, Iaonnidou E. Up in the air? Future research strategies to assess aerosols in dentistry.

JDR Clin Trans Res 2021 Apr;6(2):128–131. doi: 10.1177/2380084420982506.Epub 2021 Jan 29.

24. American Dental Association Health Policy Institute.

COVID-19: Economic impact on dental practices specialist report – week of February 15. Accessed March 28, 2021.

25. Amante LFLS, Alfonso JTM, Skrupskelyte G. Dentistry and the COVID-19 outbreak. Int Dent J 2020 (20), Dec 19. doi: 10.1016/j.identj.2020.12.010. Online ahead of print.

26. Moynihan R, Sanders S, Michaleff ZA, Scott AM, Clark J, To EJ, Jones M, Kitchener E, Fox M, Johansson M, Lang E, Duggan A, Scott I, Albarqouni L. Impact of COVID-19 pandemic on utilization of healthcare services: A systematic review. BMJ Open 2020 Mar 16;11(3):e045343. doi: 10.1136/bmjopen-2020-045343.

27. Kranz AM, Gahlon G, Dick AW, Stein BD. Characteristics of U.S. adults delaying dental care due to the COVID-19 pandemic. JDR Clin Trans Res 2021;6(1):8–14. doi: 1 0 .1 1 7 7 / 2 3 8 0 0 8 4 4 2 0 9 6 2 7 7 8 .

28. Smith AC, Thomas E, Snoswell CL et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID‐19). J Telemed Telecare 2020 Jun;26(5):309–313. doi: 10.1177/1357633X20916567. Epub 2020 Mar 20.

29. Suter N. Teledentistry applications for mitigating risk and balancing the clinical schedule. J Public Health Dent 2020 Sep;80 Suppl 2:S126–S131. doi: 10.1111/jphd.12421.

30. Casamassimo PS, Townsend JA, Litch CS. Pediatric dentistry during and after COVID-19. Pediatr Dent 2020 Mar 15;42(2):87–90.

31. BaniHani A, Gardener C, Ragio DP, Santamaria RM, Albadri S. Could COVID-19 change the way we manage caries in primary teeth? Current implications on paediatric dentistry. Int J Paediatr Dent 2020 Sep;30(5):523–525. doi: 10.1111/ipd.12690.

32. Center for Disease Control and Prevention. Difference COVID-19 vaccines. www.cdc.gov/coronavirus/2019-ncov/ vaccines/different-vaccines.html. Accessed on April 12, 2021.

33. Center for Disease Control and Prevention. COVD-19 vaccinations in the United States. covid.cdc.gov/covid-datatracker/#vaccinations_vacc-total-admin-rate-total. Accessed on April 12, 2021.

T HE CORRE S P ON DIN G AU T HOR , Jessica Y. Lee DDS, MPH, PhD, can be reached at jessica_lee@unc.edu.

RM Matters

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Ransomware on the Rise: Steps To Protect Your Practice and Systems From Cyber Disruption TDIC Risk Management Staff Over the past two years of practice disruption due to the pandemic, dentists have become attuned to navigating new challenges and balancing complex risks. However, there are some issues that blindside even the most seasoned practice owners. Imagine coming in ready to start the day, booting up your computer to check the schedule and then … nothing. There’s just a blank screen, or worse yet, a message stating that your system has been locked and a demand for a payment to gain access.

When a ransomware attack hits, your practice comes to a screeching halt. A compromised system can mean no access to schedules, billing or patient records.

Cybercriminals have been leveraging practice disruptions to launch ransomware attacks in skyrocketing numbers. California dentists must proactively protect their practice systems, be prepared for the eventuality of receiving a demand and follow sound steps to recover from an attack.

In just one case handled by The Dentists Insurance Company, the total costs to conduct a forensic IT investigation, get systems back online and cover lost business neared $100,000. When the dentist could not access his files, it soon became clear that the system had been hacked and the practice was a victim of ransomware. As patient data was stored in the cloud, the dentist didn’t believe that there had been a data breach but was still paralyzed from doing business because his systems and files were locked.

By the time a forensic IT firm was engaged to regain access to the system,

get it back up and running again and unlock the data, the dentist had already paid a $25,000 ransom demand. The insurance claim reflected more than $70,000 in costs due to the amount of time the practice operations were down plus the expertise needed to investigate and reconcile the records and data.

In cases like this, recovering data and reimbursement for the associated financial loss is crucial to practice sustainability. But the investigation into how the system was accessed can be priceless in helping to support and train the practice team in mitigating future crises. In today’s high-risk climate,

answers

From one-on-one risk management advice by phone to informed consent forms to expert-led seminars, we’re here to help you practice with confidence.

We are The Dentists Insurance Company.

Learn more at tdicinsurance.com/rm

Protecting dentists. It’s all we do.

®

800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783

O C TOBER 2 0 2 1

657

OCT. 2021

RM MAT TERS

everyone on the team should understand the potential implications of clicking on an attachment from an untrusted source or opening a malicious email.

Prevention

The analysts who answer The Dentists Insurance Company’s Risk Management Advice Line field calls from CDA members and TDIC policyholders on navigating practice challenges — everything from patient care to documentation to employment to property. These experts have also developed tools that policyholders can access at any time by logging into their accounts online through TDIC’s newly enhanced website.

Resources to support cyber incident prevention include: ■ A comprehensive Cyber Liability Guide for an overview of risks and targets, data breach and cyberattacks, investigations, preparation and prevention.

■ A Cyber Event Checklist to plan for how your practice should respond to a cyberattack or incident.

■ A full library of articles, including expert guidance on the many aspects of cyber awareness and risk management in dentistry.

These tools, in addition to guidance from your IT professional, can help you train your staff on recognizing and mitigating cyber risks.

Protection

A proactive approach also means having the right type and amount of insurance coverage in place. To keep pace with today’s evolving risks, owners — regardless of practice size — need insurance that goes beyond data breach. Look for a policy that is built to help you respond to and recover from a broad range of cyber incidents.

658 OC TOBER

2021

C D A J O U R N A L , V O L 4 9 , Nº 1 0

CDA members who are TDIC Business Owner’s insurance policyholders can apply to add Cyber Suite Liability coverage at any time. If you don’t yet have cyber insurance or are unsure about your coverage, request a free policy review to compare your options and determine the solution that best fits your practice needs. Don’t wait until a ransomware attack to learn what your policy does or doesn’t cover.

Response

With ransomware attacks on the rise, even well-prepared and wellprotected practices will still be targeted.

If you do experience an incident, it can be difficult to maintain the presence of mind to respond in a way that mitigates further risk.

While every incident is different, these six steps are sound guidance to support you: 1. Don’t pay a ransomware demand until you consult a professional.

2. Contact your IT provider right away for assistance. Let an expert assess the situation.

3. Document without clicking on links or deleting information. Take a picture of the screen and note what it said at the time of the incident.

Capture when it happened and how it occurred, if known.

4. Save network security logs that indicate the date, time and device used. Collect facts and gather information from your staff and IT provider.

5. Call your professional insurance provider or log in to your account to report the incident as soon as possible and initiate a claim.

6. Report a data breach to appropriate agencies.

■ For ransomware: Federal (FBI) and state law enforcement agencies.

■ The internet crime complaint center (IC3).

■ Security breach notifications required by law in California.

■ For data breaches: Department of Health & Human Services.

Following a response plan and sharing accurate information with your insurer are both crucial to your recovery and initiating the claim process. Know that you’re not alone when faced with a cyberattack or ransomware demand. TDIC recognizes the stress and disruption that are created when these cyber events occur and has created resources to assist with implementing a proactive approach for your practice. Stay informed of cybercrime trends and reach out to the experts at your professional insurance company for guidance on setting up prevention plans to lessen the risks of future incidents. n The Dentists Insurance Company’s Risk Management Advice Line is a benefit. available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/ RMconsult or call 800.733.0633.

Regulatory Compliance

C D A J O U R N A L , V O L 4 9 , Nº 1 0

Compliance With HIPAA Rules Supports Cybersecurity CDA Practice Support

M

alicious cyber actors are much in the news and the public consciousness these days because their actions are having a broader impact on everyday life. For example, the ransomware attack on Colonial Pipeline earlier this year disrupted the fuel supply and created widespread panic-buying of gas.1 Although the federal government is growing its cybersecurity response,2 individuals and smaller organizations must take steps to ensure the security of their own systems. For health care organizations, the HIPAA Security Rule provides minimum standards for safeguarding electronic information systems.

Malicious cyber actors may seem like the “scary strangers” of horror stories, but they can also be an unaware insider in an organization who, either purposely or by accident, figuratively leaves the door open for a thief to slip through. This is the employee who clicks on a phishing email or uses an easy-toguess password. The HHS Office for Civil Rights (OCR) noted that an analysis of health care data breaches determined 61% were perpetrated by outside entities and 39% by insiders.3 Two HIPAA Security Rule standards govern what a covered entity should do to ensure access to patient information is appropriate. These standards include access control and information access management.

Access control is a technical standard with four implementation specifications: ■ Unique user identification.

■ Emergency access procedure.

■ Automatic logoff.

■ Encryption/decryption.

The first two items are required and the second two items are “addressable.”

An addressable specification must be implemented unless the covered entity has a good reason not to and will instead implement an alternative that is similarly effective.

Having unique user credentials for access to a network and to individual applications is a fundamental security

O C TOBER 2 0 2 1 LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1

659

5/24/2017 9:21:40 PM

OCT. 2021

REG. COMPLIANCE

practice. Sharing usernames and passwords may seem easier and convenient for system users, but it makes it difficult to identify a responsible party to an impermissible action or identify who may have been the target of a phishing attack. For an extra layer of security, consider implementing two-factor authentication. Emergency access procedures are necessary for situations in which normal procedures for obtaining electronic patient health information are limited or simply not available. Dental practices that had these procedures were prepared when COVID-19 work restrictions were instituted last year. Staff could securely access patient information from locations outside a dental practice and continue to bill and follow up with patients.

Automatic logoff and encryption/ decryption reduce the risk of unauthorized access and potential destruction or alteration of information.

IT systems have progressed since the HIPAA Security Rule became effective in April 2005, thus the technical capability to implement these two addressable safeguards is a low barrier today. However, some covered entities retain legacy systems for operational reasons and may need to implement alternatives that are similarly effective.

Information access management is an administrative standard that requires a covered entity to implement policies and procedures that are consistent with the HIPAA rules on access to electronic protected health information (ePHI) for required, authorized and permitted uses and disclosures. For example, a dental practice with cloud-based electronic health records (EHRs) should have a written policy and procedures that authorize and describe how contracted IT support may access the practice’s information systems remotely to only 660 OC TOBER

2021

C D A J O U R N A L , V O L 4 9 , Nº 1 0

perform necessary and requested tasks to ensure the continued operation of the EHR. The procedures would identify how access is established, documented, reviewed and modified.

To develop effective information access management policies and procedures, a covered entity must know what ePHI it possesses, how it is used and disclosed and by whom in the workforce it is used and disclosed. The covered entity also needs to consider how their HIPAA business associates access and use ePHI. The policies provide the parameters for which an individual in their specific job may be granted access to specified data or applications. For example, a dental assistant typically does not need access to a patient’s financial information unless the assistant’s assigned job responsibilities include some aspect of billing. The policies should be clear that individual workforce members may only have access to the information necessary to do their job. Procedures may include how requests to access information systems with ePHI are made, who is responsible for granting the request and the criteria for granting access.

The HIPAA Security Rule is flexible, scalable and technology-neutral. Covered entities may consider a variety of methods to prevent unauthorized access to ePHI. OCR notes that access controls need not be limited to computer systems:4 Firewalls, network segmentation and network access control (NAC) solutions can also be effective means of limiting access to electronic information systems containing ePHI. Properly implemented, network-based solutions can limit the ability of a hacker to gain access to an organization’s network or impede the ability of a hacker already in the network from accessing other information systems — especially systems containing sensitive data. n

RE F E RE N C E S 1. 10 of the biggest ransomware attacks of 2021 — so far. searchsecurity.techtarget.com/feature/The-biggestransomware-attacks-this-year. Accessed Aug. 1, 2021. Pipeline attack yields urgent lessons about U.S. cybersecurity. New York Times May 14, 2021. www.nytimes.com/2021/05/14/us/ politics/pipeline-hack.html. Accessed Aug. 1, 2021.

2. Healthcare IT News. Biden calls for improved critical infrastructure cybersecurity. July 19, 2021. www. healthcareitnews.com/news/biden-calls-improved-criticalinfrastructure-cybersecurity.

3. HHS Office for Civil Rights. Summer 2021 Cybersecurity Newsletter. Controlling access to ePHI: For whose eyes only? www.hhs.gov/hipaa/for-professionals/security/guidance/ cybersecurity-newsletter-summer-2021/index.html.

4. Ibid.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices.Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

Tech Trends

C D A J O U R N A L , V O L 4 9 , Nº 1 0

A look into the latest dental and general technology on the market

Ruggard EDC-30L Electronic Dry Cabinet (30L) ($149.95, Gradus Group LLC) In a busy practice, protecting existing equipment is paramount; after all, while new equipment is nice, it often comes with the headaches of setup, training and support. Camera equipment specifically needs to be cared for beyond protective cases, as humidity over 65% can induce fungal spores to grow on lenses or camera bodies and ruin image quality. Dry cabinets can serve as a moisture-controlled, dust-free environment for practitioners to store and hopefully extend the life of their camera equipment. In the dry cabinet space, Ruggard has gained a reputation for creating affordable equipment protection solutions, and its EDC-30L dry cabinet is among its most popular products.

The EDC-30L is a simple device: It is a lockable cabinet with a 30L capacity and a clear door that can control relative humidity within itself from 35% to 60%. Just plug it into the wall and start putting camera gear in it. Controls at the top of the device allow users to adjust where they want the relative humidity to sit, and at its default settings, most moisture damage should be prevented. LED lights illuminate what is inside, but they are puzzlingly placed only on the right side of the cabinet, so the lighting can be blocked if there is too much equipment. What is most impressive about the EDC-30L is its silence and ease of operation: There are no fans to make noise, no need to empty water containers and no further need for interaction for it to function. Given the protection the EDC-30L brings, especially to those practicing in humid environments, this device is a must have for anyone looking to extend the life of their camera equipment.

— Alexander Lee, DMD

Signal (Free, Signal) Instant messaging has evolved significantly over the past several decades. Sending real-time messages back and forth between individuals or groups has become a primary method of communication today. Businesses also use messaging to communicate efficiently with many of their customers. With the recent concerns surrounding cybersecurity and data privacy, users are looking for messaging platforms they can trust. Signal is an open-source, cross-platform messaging software developed by an independent, nonprofit organization focused on privacy without sacrificing features.

Signal works on iOS/iPadOS, Android, Windows, macOS and Linux desktops. A mobile phone number is required to register. Users can set up their profile with a name and photo. Everything in Signal, including profiles and messages to other Signal users, are end-to-end encrypted and completely secure. To start messages, users tap on “Compose” and choose recipients from their Signal contact list, which is automatically populated from the sharing of their device contact list with the app. Groups can be created with multiple Signal users.

Popular messaging features such as voice messages, sending pictures, videos, GIFs and files are also included. Voice or video calls may be made from any direct or group conversation through the phone or video camera icon. Multiple devices can be linked to the same registration. Specific only to Android devices, Signal can serve as a unified messenger to send SMS/MMS messages to non-Signal users.

SMS/MMS messages from Signal are not secure because they are sent through the mobile provider of the Android device. iOS/iPadOS and desktop devices cannot send or receive SMS/MMS messages.

With internet access, Signal can be used internationally because calling and messaging are done through data. When users receive messages from other users who are not in their Signal contact list, they will receive a request letting them know who is trying to get in touch with them and can choose whether to accept, block or delete the request. The service is extremely reliable with an interface that should be familiar to all.

Messaging is an incredible and useful tool to stay connected with friends, family, co-workers and colleagues. Keeping communications safe and private has become ever more important as companies face security challenges in responding to major data breaches. Signal is a full-featured messaging solution that provides the end-to-end encryption necessary to maintain privacy.

— Hubert Chan, DDS O C TOBER 2 0 2 1

661

Journa C A L I F O R N I A

D E N TA L

A S S O C I AT I O N