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CONTENTS PRESIDENT'S MESSAGE 4 OFFICIAL PUBLICATION OF THE UTAH DENTAL ASSOCIATION
Navigating Your Practice
ASSOCIATION
CONTRIBUTING WRITERS
5
A Dentist’s Guide to the Law
8
A New Day at the ADA: Principles and Priorties for Shaping Our Future
ADA News
14
Quality Controls in Dentistry
Dr Ken Baldwin
17
American Dental Association – Political Advocacy
David Burger – ADA News
20
Association Tackles Mental Health With Sense of Urgency
Records, Records, Records
Dr Darren Chamberlain Dr Kay Christensen Dr Raymond A. Cohlmia Lauren Neufeld RDH, BSDH TDIC Risk Management Dr Mark A. Vitale
COVER PHOTO Photo by James Lewis on Unsplash
PUBLISHER: Mills Publishing, Inc. PRESIDENT Dan Miller OFFICE ADMINISTRATOR Cynthia Bell Snow GRAPHIC DESIGNERS Ken Magleby Patrick Witmer
ART DIRECTOR Jackie Medina
ADVERTISING REPRESENTATIVES Paula Bell Paul Nicholas
The Utah Dental Association holds itself wholly free from responsibility for the opinions, theories or criticisms herein expressed, except as otherwise declared by formal resolution adopted by the association. The UDA reserves the right to decline, withdraw or edit copy at its discretion. UDA Action is published bi-monthly. Annual subscriptions rates are complimentary to all UDA members as a direct benefit of membership. Non-members $30. Utah Dental Association, 801-261-5315 1568 500 W Ste. 102, Woods Cross, Utah 84010 uda@uda.org. UDA Action is published by Mills Publishing, Inc. 801-467-9419; 772 East 3300 South, Suite 200, Salt Lake City, Utah 84106. Inquiries concerning advertising should be directed to Mills Publishing, Inc. Copyright 2022.
HEALTH 12
Oral Health Changes Reported by 70% of Utahn Long-COVID Patients
PRACTICE 6
Now What Do I Do?
10
Dental Insurance Confusion and Inequity
15
Kids and Early Dental Visits
16
New ADA Guide Created For Ensuring Accuracy of Claims Made on Behalf of Treating Dentists
18
A Patient Refused to Pay For What His Insurance Refused to Cover. What Can I Do?
19
Improve Patient Safety With a Timeout Policy
PRESIDENT'S MESSAGE NAVIGATING YOUR PRACTICE As I saw footage of the floodwaters in Yellowstone, and observed the power of the raging rivers, I was reminded of our UDA past president, Greg Gatrell, and his passion for running rivers, and navigating turbulent waters. Greg has spent a lot of time on many rivers and has become proficient in navigating the various obstacles and challenges the river throws his way. The new graduates from our two Utah dental schools will also undoubtedly face some occasional rough waters through their upcoming careers, and I think they may be ready to navigate those waters. I recently had opportunities of participating in activities at each of the two dental schools which we have in Utah. At Roseman University’s College of Dental Medicine I attended a ribbon cutting and toured their new clinical facilities. At the University of Utah School of Dentistry, I attended the graduation ceremony for the 2022 graduating class of dental students. I was impressed with what I saw and heard and am confident that dentistry is improving and that we are receiving well trained and prepared new dentists who will strengthen our profession in years to come. Kudos to the dental schools, and thanks to the educators for a job well done! One other thing I observed was, that in spite of these two dental schools being located in our state, the vast majority of graduates are leaving Utah to pursue their professional lives somewhere else. Didn’t they like it here? Or do they have families elsewhere? Do they feel that Utah doesn’t have as much to offer as other areas of the country? Or do they feel that the local economy and effects of inflation make it easier to make a go of it and provide for their families somewhere else? There is no one answer for everyone’s individual choice in the matter. The influencing factors may be many and vary widely. But perhaps one common factor influencing the choice of where to practice might be Utah’s history of income for dentists in our state being lower than that of dentists practicing elsewhere. A big part of the reason for that comes down to something I’ve heard and witnessed over and over and over again in the more than thirty years I’ve been practicing in the state, and that’s how dentists deal with and participate in various dental benefit plans. We all feel the pains and frustrations of dealing with “dental insurance” in Utah, and that is the last time I will refer to benefit plans in this article as “insurance”, as it is not “insurance” in the true definition of the word. I wish I had a better answer and solid solution to our woes other than what the association has been preaching over the years. Carefully analyzing benefit plans with their various levels of compensation and participation is a cumbersome task for any office, but it’s currently a necessary 4
burden, if we are looking out for the health and well-being of a practice. The ADA has reopened its concierge service which will help guide a practitioner through the process of evaluation of a particular plan to see if it’s wise to accept and participate, or not. I believe if we keep communication open with our colleagues, we can also learn of successes and failures of others in dealing with our challenges and learn things which can help us make the hard decisions and choices of accepting plans, rejecting plans, or renegotiating plans. Dental benefit plan reimbursements to dentists in Utah are dismally low, especially as we see the reimbursements given in other states, including our closest neighbors. You know this. Nationally, Utah has ranked among the lowest 2-5 in plan reimbursements, and why? The reason Utah has the lowest reimbursement rates has been shown by the Health Policy Institute of the ADA to be due to the high numbers of dental providers on each plan. It’s a supply and demand situation. Utah has many providers signed up on PPO plans, therefore the dental benefit plans do not need to increase payment to attract providers. The high numbers of willing dentists to take cuts in reimbursements is why reimbursement rates are declining rather than keeping up with the escalating cost of living, overhead increases or inflation. Sadly, voicing complaints to plan providers, and even providing them with logical evidence of needed changes has been shown over the years to simply not work in an effort to increase reimbursement to a fair and just compensation across the board. It seems that as long as there is an adequate supply of plan participants, the plan providers feel no demand to increase their payout. Effective actions will hopefully speak louder than words. But again, it is up to each individual to make that decision to decline participation or stop participation in a particular plan which is unhealthy for, harmful to, or just plain bad for the practice. Be wise and educated in making your practice decisions. Benefit plans come with many levels of participation and variations in different areas. It may be easier and less stressful to not sign up for a plan than to cancel participation in a plan. A plan that works in Washington may be terrible in Tremonton. Or a plan that’s successful in Sandy may be miserable in Moab. Learn the pros and cons for your area and practice. Use the resources offered through the ADA to assist in your decision making. We are grateful to all of you who have chosen to practice in our great state, and for your support and participation in organized dentistry. Together we can be stronger in our efforts to help each other, and to help and serve our patients and communities. We wish our new dentist graduates, and all our more seasoned dentists the greatest success as you navigate the waters of your career! Dr Kay Christensen UDA President
July / August 2022
ASSOCIATION RECORDS, RECORDS, RECORDS
An example of this includes the aspect of confirming appointments. When a patient changes their phone number or email address, your front desk has no way of contacting that individual to make sure they are coming to their appointment. That lack of correct information can lead to down production time, which in turns costs you money. Another example involves insurance, how many times do you hear from your front desk or office manager that Mrs. Jones did not tell them she had new insurance. The claim is submitted to her previous insurance company, after waiting weeks for a response from that insurance that she is no longer covered. Then your office has to contact Mrs. Jones and collect the correct information and then resubmit to the correct insurance company. Then wait for the allotted time to receive any sort of payment for a procedure or procedures that was completed months ago. This lack of correct information again has cost you more time and money, by having your office manager have to contact Mrs. Jones and collect the new information and then resubmit the insurance.
email from dental school. Which he no longer ever looked at. Thus, he was missing out on important information that would greatly benefit him and his practice. The Utah Dental Association has decided it is time to “clean up” the records and get accurate information for you. This will help us in making sure you are receiving up to date information whether that be a cell phone number or email address that you will access and be able to see. The UDA has hired a temporary employee to contact every dentist in the state and update their contact information. This phone call contact will most likely be through your front desk or office manager. It will be a brief phone call, verifying the current information the UDA has and update any information that might be incorrect. Please let your office staff know that they will be receiving a phone call from the UDA Office’s Crista McCord. This “clean up process” will occur over the next few months. This effort will be very beneficial to you, by allowing the UDA to keep you up to date with dental issues and concerns in Utah.
Correct information and record keeping is also vital to the Utah Dental Association. During the beginning of the COVID-19 pandemic, the UDA sent out multiple emails regarding current status and updates on PPE loans, and anything to help with the crisis that was happening in your lives and in the world. The UDA received many phone calls from Dr Smith stating his colleague Dr Miller is receiving these updates from the UDA, but Dr Smith is not receiving them, after investigating why, Dr Smith had not updated his email address and was still using the
Utah’s leader in in-office Dental Anesthesia HOSPITAL QUALITY ANESTHESIA IN THE COMFORT OF YOUR OFFICE
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As a dentist you recognize and understand the importance of keeping accurate records. It has been said, if it isn’t written down, it did not happen. This emphasis on accurate records goes beyond just the clinical aspect of dentistry. It continues into the front office or business aspect of your office.
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UDA Action
5
PRACTICE NOW WHAT DO I DO? You have just finished a very busy week in your dental practice and it is approaching 5:00p.m. on Thursday afternoon (or Friday afternoon?) And you are looking forward to a relaxing weekend. The phone rings and your receptionist informs you that Mrs. Smith, a long-standing patient, needs to be seen on an emergency basis complaining of severe pain and swelling that started several months ago, but has become severe in the last 24 hours. She is then scheduled to be the last appointment of the afternoon. When Mrs. Smith arrives, a problem-focused evaluation demonstrates severe carious lesion associated with tooth number 14 with acute periapical pathology causing a vestibular space infection and abscess. The tooth is non restorable and in need of immediate extraction. Further evaluation demonstrates notable ecchymosis of both arms and dorsal surfaces of the hands. Upon further evaluation and questioning Mrs. Smith states that she was recently diagnosed with non-valvular atrial fibrillation and is now taking Eliquis. Lots of questions now need answers. Can I refer the patient to the oral surgeon today? Is the treating physician available for consultation regarding the use of the anticoagulant medication? Can the anticoagulant medication be stopped? Is it necessary to stop the medication prior to the extraction and what are the risks to the patient? The old adage that an “ounce of prevention is worth a pound of cure” quickly comes to your mind and you’re wondering if you have that “ounce of prevention” currently in your office. This article is not intended to be an extensive treatise on the types of medications currently used, indications, contraindications, effects, or complications of the use of anticoagulant therapies, however, there are some basic treatment protocols and supplies that need to be in every dental office that engages in minor oral surgical procedures, especially, extractions, as more and more patients are on anticoagulation therapy. Briefly, indications for anticoagulation therapy include nonvalvular atrial fibrillation, deep vein thrombosis, recent hip or knee replacement surgery, ischemic stroke, myocardial infarction, pulmonary embolism, and unstable angina. All of these have their own challenges adding to the now complicated extraction, with possible incision and drainage. Categories for anticoagulants are basically divided into four groups. The first group is Coumadin or Warfarin. This is a vitamin K antagonist, and it works by limiting the availability of Vitamin K to produce clotting factors 2, 7, 9, and 10. 6
Coumadin requires a significant amount of monitoring and follow-up of the patient at least once monthly. There are also a significant number of medications and foods that can interfere with the effect of Coumadin, significantly a number of antibiotics that are commonly used in dental practice. These include Bactrim/Septra, Diflucan, Ciprofloxacin, and Biaxin. We have all seen patients on coumadin therapy. While this continues to be a common anticoagulant the newer medications that are now available are safer, have a faster onset and shorter half-life, and require less monitoring. The second category of anticoagulants are factor 10a inhibitors. These include many of the newer anticoagulants likely to be used by patients seen in the dental office including Eliquis, Savaysa, Arixtra, and Xarelto. The third category is direct thrombin inhibitors. The only one likely to be seen in the office from this category is Pradaxa as most of the medications in this category need to be given parenterally. The last group of anticoagulants fall into the Heparin category and this group is rarely if ever seen in the dental office. Multiple Studies have supported no change in anticoagulation therapy is necessary prior to minor oral surgical procedures if the patient is in therapeutic range. The risk of altering the anticoagulation therapy far outweighs the risk of minor bleeding which generally can be managed with local measures. What are those local measures and how can we be prepared in our office to manage this scenario? The first step of management is consultation with the patients cardiologist or prescribing physician if at all possible. If the patient is on coumadin a recent INR value is mandatory. Current studies support minor oral surgical procedures on patients if their INR value is below 3.5. Most physicians try to maintain the INR range somewhere between 3.0 and 3.5. INR monitoring is not necessary with the newer anticoagulant medications. What supplies do we need to have in our office for extraction of teeth for patients on anticoagulation therapy? These may include any and all of the following and all are readily available from any of the major dental suppliers. 1. Gel foam. This can be placed in the extraction site directly and may be saturated with saline and an antibiotic if desired prior to application. 2. Collagen. There are multiple forms and brand names of collagen (generally bovine in origin) available, either in the form of plugs, sponges or tape, that can be placed directly into the extraction site as well. Microfibrillar collagen (Avitene) is a superb product that enables hemostasis, but it is also quite expensive. July / August 2022
3. Surgicel is another commonly used resorbable product.
gauze in the Tranexamic acid mouthwash and apply it over the wound with direct pressure rather than using it as a mouthwash.
4. During the extraction if there are any obvious bleeding areas chemical or electrical cautery may be used but bear in mind that most of the time these patients simply generally “ooze” from the surgical sites and cautery is not the management of choice.
8. The last thing to remember is that Mrs. Smith will have less bleeding in your office then later that night once the local anesthetic with its vasoconstrictor has dissipated and has been metabolized. Take a good hard look at the area prior to discharge because things will be worse later on!
5. Topical thrombin. This can be reconstituted and collagen sponges, plugs, tape, gel foam or Surgicel can be saturated in the topical thrombin and applied directly into the surgical wound.
9. If indicated, ask for the help of the hematologist or physician. I have had several patients that required additional hematological workup to control the bleeding.
6. Mechanical pressure also plays a significant role in hemostasis for these patients. This includes placement of slowly resorbable or non-resorbable sutures over the hemostatic agent of choice approximating the wound margins or at least applying pressure to the wound margins.
Much more information is available on the ADA website and in professional journals on how to manage these patients that are on anticoagulant therapy. These are some of the items needed to have the “ounce of prevention” in your office and send your patient home well cared for and happy and hopefully you have avoided a 1:00 a.m. rendezvous with Mrs. Smith in your office!
7. Postoperatively Tranexamic acid mouthwash should also be prescribed. Patients need to be aware that this prescription will only be available at a hospital pharmacy or compounding pharmacy. They should also be told that they can saturate their
Dr Ken Baldwin ADA Delegate
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7
ASSOCIATION A NEW DAY AT THE ADA: PRINCIPLES AND PRIORITIES FOR SHAPING OUR FUTURE Last November when I began my tenure as the ADA’s executive director, I recognized that my experience as a clinician, volunteer leader, educator, and dental school dean had culminated in this new opportunity to give back to our profession. Although my new role brings a different set of responsibilities, I am grateful for how our Association empowered me to be my best in every phase of my journey. Ultimately, I want to build a next-level ADA where the members of today and tomorrow can say the same. I am charged with creating an organization that serves its members so they can provide optimal care to their patients and thrive as professionals. But just as the practice of dentistry has evolved over time, so have the needs and expectations of those we support. We are living in a time when technology grants us greater authority on how and when we engage with content, whether we’re searching for information online, watching a new-release movie at home, or reading (perhaps listening to a podcast about) the news on our phones. Technology has also changed everything about how dentists work – from treatment modalities to practice management to how patients find and communicate with their clinicians. In the era of all things accessible and on-demand, the user is at the center. The ADA membership experience should be no different. Over the last 163 years, the ADA has built a trusted reputation as the leading voice for the dental profession. We’ve provided tremendous value to generations of dentists, and we stand on a solid foundation. Our future relevance hinges on some key principles: • • •
Sustainability, both in our membership and financial position Global presence that ensures that our Association and its offerings remain top-of-mind for the dental community around the world A sharp focus on our members, their expectations and their needs
For the ADA, meeting the needs of the 21st century dentist requires us to assess our current ability to do so and to change if we need to – even if it means letting go of what has worked in the past. It also requires us to take risks – not those that jeopardize our organization, but that instead empower us to play to our strengths. 8
This approach reminds me of what former Disney CEO Bob Iger writes in his 2020 memoir: “Companies must innovate or die.” When so much is shifting, limiting ourselves to the way we’ve always done things could mean limiting what’s possible for the future. For the sake of our relevance, also fulfilling the key principle of innovation is not solely as aspiration; it is a necessity. You may have heard me state in other editorials and presentations, is that Iger’s experience exemplifies what can happen when a respected brand takes a gamble to meet a paradigm shift. He was aware that in an ever-changing world, even a company of Disney’s stature risked failure if it stayed the same. The term “strategic incumbency” comes to mind in this exact situation for our own ADA. It means as established firms’ ability to dynamically convert age, size, and tradition into the key advantages of market power, trusted relationships, and deep insights. Companies that encompass this value are the ones that reinvent themselves, their strategies and how their business models, to create new opportunities. Akin to Disney, can our ADA possess this ability? I guess the real question is not whether we can possess this ability but more along the lines that if we don’t, what will the ADA be, or more critically, what the ADA may not be. Disney took a bold step and created avenues of their own to deliver their content. This is testament that they removed their content from the usual streaming services and place it all on their new Disney+ streaming service. This change directly meant a loss of immediate revenue from these streaming services, in order to create their own and greater future. This was a bold move, but they recognized their customers were no longer the customer of yesterday and the customers of today uses their own personal devices, such as cell phones, tablets, and other personal devices to receive the content they want it, how they want it and when they want it. That is the consumer of today. The ADA is not in the entertainment business, but Disney is an example of a company that created strategic incumbency and how focusing on the customer through innovation, will drive the future. I believe the ADA has the ability to do just that and create its own strategic incumbency.
July / August 2022
Thus, the ultimate question is do we have a membership problem or do we just have an operation that is using methods and processes that are no longer effective in today’s changing market and consumer demands? Using a thought process of strategic incumbency, I believe that membership engagement and support can grow.
As we discussed prior, the five key values to a future of any business success is customer focus, global presence, sustainability, innovation and nimbleness. We know that we can achieve customer focus, global presence. However, sustainability, is driven by innovation, which cannot be limited due to a lack of nimbleness.
While I am looking and evaluating all aspects of the ADA, I have three immediate priorities as follows: • • •
Re-establishing a more effective and agile, membercentered ethos within the Association’s governance Expanding capacity throughout the tripartite and in dental education to enhance member services at all levels Developing a robust digital experience that puts the vast array of ADA resources, products, and services at members’ fingertips
This may lead us to a new though process learned by so many progressive companies; if innovation requires changes that a system cannot make efficiently, if at all, the answer is to change the system altogether.
Nimbleness, after all, is the key principle upon which all others are predicated. Relevance is the most at stake if any entity – even more for our association – is not agile enough to strategically adapt to evolving realities. Successful business entities are critical on their innovation, sustainability and are tightly focused on their mission. And for our ADA, the mission is always to help our members succeed. Welcome to what will be the new ADA. Dr Raymond A. Cohlmia Executive Director American Dental Association
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UDA Action
9
PRACTICE DENTAL INSURANCE CONFUSION AND INEQUITY Self-insured vs. fully insured The issue of self-insured versus fully insured leads to another frustration. Can a patient assign benefits to the dentist and if so, how will that benefit be paid? Fortunately, almost half of the states have provisions in the law that allow for assignment of benefits regardless of the dentist’s network affiliation, thanks to the efforts of political action and government affairs at the state associations. However, that may not be the case for self-funded plans, which are how most large employers manage their benefits.
Photo: Image licensed by Ingram Image
Most dentists agree that dental insurance has created better access to care during the last 40 years. They might also agree that dental insurance is one of their largest sources of frustration in managing their practices and patients. With close to 40 years of experience as a private practicing dentist and having spent many of those years in leadership positions in organized dentistry, I admit that the confusion and inequity perpetrated by the insurance industry has occupied more of my time and energy than I’d ever thought possible. The confusion begins with the misunderstanding that dental insurance is needed to achieve good oral health, when in reality consumers are buying insurance products that are nothing more than reimbursement plans. These plans have maximum amounts they’ll pay for care that hasn’t changed in more than 35 years, and for this reason the plans don’t reimburse enough to offset the current cost of dental care. Lack of transparency The array of dental plans available with varying designs, degrees of plan provisions, and restrictions, coupled with the lack of transparency, adds to the frustration. Why should so much of a dentist’s time and energy focus on educating patients about their dental insurance rather than on their oral health-care needs? As the American Dental Association looks at dental insurance reform, addressing this lack of transparency is crucial to enhancing the doctor-patient relationship. The lack of transparency is best demonstrated in the bifurcated insurance system that exists. Is a plan self-insured or fully insured? Do the plan provisions follow state guidelines or federal guidelines? Patients certainly don’t know, and my experience in dental benefits and government affairs has demonstrated that most dentists don’t know either.
10
Assuming state law allows for assignment of benefits, is the benefit paid with a check, electronic fund transfer, or a credit card? Accepting so called “virtual” credit card payments from a carrier results in a fee to the dentist and savings to the carrier. Once again, through the efforts of effective government affairs advocacy, some states have prevented carriers from limiting claim payments to only virtual credit cards. Dentists now have options on payment methods. Nonduplication of benefits When we talk about inequity and lack of fairness, I think of the nonduplication of benefits clause found in many dental plans. There are many confusing aspects of dental insurance. For many, coordination of benefits (COB) is at the top of that list. When I was chairperson of the New Jersey Dental Association’s Council on Dental Benefits, I gave a one-hour lecture on COB. By the time I was done, even I was still confused. Patients are led to believe that by paying two premiums and having two dental plans they’re entitled to the full benefits of each plan. Sometimes they are, but in most cases they are not. This one-plan provision has led to more confusion and misunderstanding with patients than probably any other provision. Patients should be made aware of plan provisions prior to purchasing a plan and should be entitled to their full benefit following reasonable and fair coordination of benefits. Carriers claim that nonduplication clauses prevent the insured from being enriched by the plan when in reality this provision adds to the carrier’s cost saving and profitability. Leasing of networks A recent challenge that dentists who participate with dental plans have faced in the past few years is dental insurers selling or leasing their networks. More than 35 years ago, I became a participating provider for a discount insurance plan that after two years yielded very few patients. Due to lack of activity, I assumed the plan had ceased to exist. Two years ago, I was informed by patients who work for the New Jersey state government that I was now in their network, despite my office never being involved with the state plan or any of the carriers they had contracted with. July / August 2022
To my dismay, after investigating, I found that the carrier that had the New Jersey state contract had purchased the network from the company that I assumed no longer existed. Subsequently, it took me three months and thousands of dollars to get out of a contract that I didn’t know even remained in effect. It interfered with my patients’ relationship, which took months to repair. I had to initiate a marketing campaign to correct the miscommunication and misunderstanding that the insurer had created for my patients. Since leased network legislation passed in New Jersey, this won’t happen again. Carriers are required to provide adequate notice and provide the dentist with the ability to opt out of the network lease offer and do so without impacting the original contractual relationship.
practices by the dental payer industry whose goal appears to be reduced claims cost rather than optimal patient outcome. The business financial goals set forth by the insurance carriers interfere with the patient’s access to appropriate and necessary care, and it’s unfair to the beneficiary and the benefit purchaser. We could argue that it borders on unethical business practice.
Dental insurance reform As chairperson of the ADA Council on Government Affairs, I realize how many dentists are working at the state and federal level to effect dental insurance reform. Each of the successes has led to a decrease in confusion and inequity in dental insurance. A prime example is noncovered services.
The dental insurance maze can be daunting for patients, dentists, and dental team members. The best way to minimize confusion and inequity is for dentists to educate themselves so they can educate team members and patients. Dentists taking an active role in organized dentistry and advocating for insurance reform is key to reducing confusion and inequity.
The current dental insurance landscape is unfair to both providers and patients. Dentists, their patients, and the public at large are at a disadvantage from the negative impact noncovered service provisions have on competition among entities in the health insurance industry. Imposing discounts on providers for services an insurance company doesn’t cover is a marketing ploy designed to gain a competitive advantage over small carriers. It also acts to hinder the doctor-patient relationship and may shift costs to the uninsured.
The ADA has a program called the Third-Party Concierge that helps dentists with their concerns regarding dental insurance companies. ADA members can call or email a designated expert for insurance-related questions and concerns. Check out the ADA online hub for the latest dental insurance information to help you understand the nuances of doing business with dental insurance companies.
One way to minimize confusion and inequity in a dental practice is to implement an in-office membership and loyalty plan for patients. This has been especially appreciated by those patients who assumed they need insurance to visit the dentist. These plans also offer an effective way to assist patients who want to stay with a practice despite financial hardships.
Dr Mark A. Vitale
At the federal level, the ADA has been advocating for the Dentist and Optometric Care Access Act. This will prevent insurers from holding dentists to fees for services they don’t cover, and from providing unreasonably minimal compensation for services rendered. The ADA has been lobbying this bill for more than two years. While this legislation would affect selfinsured plans, the state’s dental associations have been working on legislation to affect fully insured plans. To date more than 40 states have enacted legislation that prevents carriers from dictating fees for noncovered services. If the noncovered services campaign was a constitutional amendment, it would have been ratified by now. Confusion from coding Speaking of confusion and inequity, one cannot forget about downcoding, bundling, and disallowed services. Downcoding and bundling create tremendous confusion for patients and may create lack of trust in their dentist. When a carrier downcodes (substitutes a fee for a lower cost service) or bundles (combines services with separate fees into one fee), patients perceive that the dentist or office staff did something wrong. “Disallowing” dental treatments is questionable because the plans do not use diagnostic and patient preference information the doctor used to make the treatment recommendation to conclude their disallowance/denial. These are unfair business
UDA Action
Future UDA E
UDA Spring Seminar February 10, 2023 St. George, Utah
September 6 – Box Elde September 8 – Uintah B September 13 – Weber September 20 – South D September 22 – Cedar B September 27 – North D October 4 – Wasatch Ba October 6 – Provo CQI October 20 – Canyonlan October 27 – Salt Lake N Salt Lake South,
UDA Annual Convention March 30-31, 2023 Salt Lake City, Utah
11
HEALTH Oral Health Changes Reported BY by 70% of OF Utahn Long-COVID Patients ORAL HEALTH CHANGES REPORTED 70% UTAHN LONG-COVID PATIENTS 1 in 5 individuals infected with SARS-CoV-2 will develop lasting post-infection complications(1). These complications, referred to as Long COVID, may impact multiple organ systems throughout the body, including the central nervous system (CNS), respiratory, and cardiovascular systems among others (Figure 1). Recent studies have reported oral health changes in Long COVID patients. We anticipate more patients developing Long COVID as the COVID-19 pandemic continues and more patients experience primary infections and reinfection(s). The underlying mechanisms of Long COVID are not well defined and no curative therapies are currently available. The aim of this article to educate the local dental community about oral health changes associated with Long COVID and outline local resources for patients.
Post-COVID Oral Disease (PCoV-OD) In Utah
Fig 2. Oral health changes in Utahn Long COVID 70% of Utahn Long COVID patients surveyed report changes in their oral health. An active survey of Long COVID-19 patients is being conducted by the University of Utah Health. Initial analysis has identified 81 out of 114 (70%) Long COVID patients report changes in their oral health. As detailed in Figure 2, patients are experiencing Dry mouth or change in saliva (68%), Receding, swollen or bleeding gums (63%), Grinding or clenching teeth (51%), Oral or jaw joint pain (44%), Discoloring, chipped, cracked or broken teeth (21%), or Tooth loss or loosening (20%), among other symptoms. Average age of respondents with oral health changes is 52 ± 11 years. There is a strong female predominance in the Long COVID patient population with 9:1 female to male ratio. Multiple studies have characterized the impact of the SARS-CoV-2 infection on oral health. SARSCoV-2 has been shown to actively infect and replicate within salivary gland tissue(2). Deterioration of oral health in PCoV-OD patients can start occurring months after a SARS-CoV-2 infection(3). Similar to the symptoms reported by the Utahn Long COVID patients, Brandini, et al noted dry mouth, tooth pain, chipped or cracked teeth, gingival recession, oral ulcers, and tooth loss, among other symptoms in a review of oral health issues reported post-SARS-CoV2 infection (4). Early publications of PCoV-OD oral symptoms have additionally described ectasia of the salivary ducts and sialadenitis (5,6). Larger studies are 12
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now required to further characterize Long COVID oral disease and to decipher the underlying mechanisms of PCoV-OD. One of the challenges will be to differentiate between PCoV-OD and oral health changes due to limited access to dental care during the COVID-19 pandemic. What is Causing Long COVID and PCoV-OD? Research into the underlying cause(s) of Long COVID is the focus of numerous research studies in the United States and around the world. Currently there are multiple hypotheses of what may be causing Long COVID, including(7):
As of yet, the underlying mechanisms of Long COVID and PCoV-OD are not well understood. The National Institutes of Health (NIH) recently started the Recover initiative to support basic and clinical research to define the mechanisms of Long COVID and to support the development of targeted therapies (https://recovercovid.org). Potential Similarities with Sjogren’s Syndrome We can learn from other similar viral-mediated diseases that impact oral health, namely Sjogren’s Syndrome (SjS). Sjogren’s syndrome (SjS) is a chronic autoimmune disease diagnosed by xerostomia or xerophthalmia, autoantibody profiles (anti-SSA/Ro, anti-SSB/La) and focal inflammation within labial minor salivary gland tissue. With a strong female bias, SjS is most often diagnosed in women in of peri- or post-menopausal ages (40-50s) but is also diagnosed in male and female patients ranging in age from pediatric to geriatric. Similar to Long COVID, SjS patients often report dry mouth, increased caries and inflammation within the oral cavity. The underlying etiology of SjS is attributed to a chronic pathogen exposure in genetically susceptible individuals. The Weller Lab at the University of Utah School of Dentistry studies the salivary gland microbiome and differential profiles present in SjS salivary gland tissue, including Hepatitis Delta Virus (HDV). Chronic presence of viruses in salivary gland tissue can significantly alter the cellular metabolic profile and may contribute to altered saliva flow and/or saliva buffering capacity. The similarities between SjS and PCoV-OD are striking, including oral and systemic symptoms and patient demographics. UDA Action
The one primary difference is the timeline for onset of disease: Sjogren’s syndrome can take years to develop and meet criteria for diagnosis. Long COVID and PCoV-OD appear to have a rapid onset of months post infection. This rapid onset of oral health changes in patients post-SARS-CoV-2 infection warrant increased surveillance in the dental community. Information on Resources and Clinical Studies If you know of dental patients that are experiencing Long COVID or PCoV-OD symptoms, please share the local resources below: COVID-19 Long-Hauler Clinic at the University of Utah Health: https://healthcare.utah.edu/locations/covid-19-clinic/ The Long-term COVID19 Symptom Survey: https://redcap.link/Utah.Long.COVID Melodie Weller, PhD Virologist, Assistant Professor School of Dentistry, University of Utah Melodie.Weller@hsc.utah.edu, 801-213-2078 References: 1. Bull-Otterson L, et al. Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years - United States, March 2020– November 2021. MMWR 2022;71:713–717 2. Huang N, et al. SARS-CoV-2 infection of the oral cavity and saliva. Nat Med. 2021 May;27(5):892– 903. 3. Lambert N, et al. COVID-19 Survivors’ Reports of the Timing, Duration, and Health Impacts of PostAcute Sequelae of SARS-CoV-2 (PASC) Infection. medRxiv (non-peer reviewed preprint) 4. Brandini DA, et al. Covid-19 and Oral Diseases: Crosstalk, Synergy or Association? Rev Med Virol. 2021 Nov;31(6):e2226 5. Gherlone EF, et al. Frequent and Persistent Salivary Gland Ectasia and Oral Disease After COVID-19. J Dent Res. 2021 Mar 3 6. Chern A, et al. Sialadenitis: A Possible Early Manifestation of COVID-19. Laryngoscope. 2020 Nov;130(11):2595–7. 7. Ortona E, et al. Long COVID: To Investigate Immunological Mechanisms and Sex/Gender Related Aspects as Fundamental Steps for Tailored Therapy. Eur Respir J. 2022;59(2):2102245. 13
ASSOCIATION QUALITY CONTROLS IN DENTISTRY A few years after I started my practice I was asked to serve on the Medical Executive Committee of our local hospital. I think it was just because I drew the short straw during a Dental Department meeting. At that time, the hospital was implementing quality checks and measures to be in compliance with new standards that Medicare was implementing. I saw the headache that it was causing the administration and the toll that it took on clinicians who had to jump through additional hoops in order to get a good evaluation. The quality assurance measures were put in place as a way to improve patient outcomes and identify and rate physicians based on their “quality of care.” The debate continues whether these burdensome evaluations are effective. Dentistry is currently facing a similar dilemma. The Dental Quality Alliance (DQA) is an organization whose goal is “improving oral health through measurement.” They want to accomplish this objective through the evaluation of the quality of dental care provided by dentists. Here is their stated purpose… “The mission of the DQA is to advance performance measurement as a means to improve oral health, patient care, and safety through a consensus-building process. Objectives 1. To identify and develop evidence-based oral health care performance measures and measurement resources. 2. To advance the effectiveness and scientific basis of clinical performance measurement and improvement. 3. To foster and support professional accountability, transparency, and value in oral health care through the development, implementation and evaluation of performance measurement. Quality of Care: The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The ADA is trying to get ahead of the game by utilizing the DQA as a way to dictate what quality assurance measures will be used to evaluate dentists in the future. If the ADA sets the standards for these performance measures, the thought is that the federal government or other outside entities (ie. dental insurances) cannot dictate how dentists should be evaluated. The Council of Government Affairs (CGA), along with other ADA councils, were recently asked to evaluate some of these metrics proposed by a DentaQual whitepaper. The evaluation was composed of a list of 40+ performance measures, including… ● Percentage of restored teeth developing subsequent caries ● Percentage of treated teeth subsequently extracted ● Percentage of fillings requiring replacement [within 36 months] of initial placement ● Percentage of Total Crowns requiring extraction of the tooth subsequent to placement 14
● Percentage of high risk patients ages 6 to 9 that received sealants on a first permanent molar tooth ● Percentage of patients that leave and go to another provider of the same specialty Along with several other ways to evaluate Endodontists, General Dentists, Oral and Maxillofacial Surgeons, Pediatric Dentists, and Prosthodontists. After reading the DQA whitepaper and evaluating the quality measures, the CGA was in agreement with the other councils that there are several factors that could influence the outcomes of dental work performed by providers. Some of the concerns of the CGA with this method of evaluation include… “A number of social factors may influence treatment outcomes and cannot be controlled by the treating dentist. Examples may include patient education and assumed patient responsibility for proper oral health care, medical and environmental factors, financial ability, and perception of the need for dental insurance or the assistance afforded by dental insurance. The risk stratification of a patient can also be used to measure quality and can factor into a quality metric if defined and analyzed properly to showcase provider skillsets through treatment outcomes.” Another concern of the CGA is how this data will be used and publicized… “What is the purpose of this data? If these metrics and rating systems are made public, we could see a backlash in the dental world. If this data is to be used for social safety net programs such as Medicaid, CHIP, and possibly future Medicare programs it could deter dentists from accepting government subsidized programs, thus further limiting access to care for populations who desperately need increased access to dental services. If dentists know that they will be scrutinized by the quality of their care to certain populations, they may avoid treating those populations. This could be detrimental to elderly, special needs, and other patients with untoward medical conditions.” These delicate issues are at the forefront of the ADA today. I personally hope that the ADA stays engaged in this arena and will somehow find a solution to this problem that could cause a huge dilemma to the future of dentistry. The insurance industry is already using these metrics to evaluate dentists on their panels; the ADA should be making every effort to make sure this data isn’t published and made public. Without the ADA’s help on this matter, dentistry could be burdened by quality measures that are meant to improve the quality of care to the public. For more information on the Dental Quality Alliance visit: http://ada.org/dqa Darren Chamberlain, DDS ADA Council on Government Affairs July / August 2022
2022 CQI Seminars Box Elder District & Cache District September 6, 2022 @ 6:30 PM Riverwoods Conference Center 615 Riverwoods Parkway Logan
Central District September 20, 2022 @ 6:30 PM Steve’s Steakhouse 1170 South College Avenue Richfield
Uintah Basin District September 8, 2022 @ 6:30 PM Seven Eleven Restaurant 77 N Main Vernal
Cedar Breaks District September 22, 2022 @ Noon Rusty’s Ranch House 2275 E Highway 14 Cedar City
Weber District September 13, 2022 @ 6:30 PM Timbermine 1701 Park Boulevard Ogden
Dixie District September 22, 2022 @ 6:30 PM Dixie Hygiene Auditorium 1526 S Medical Center Drive St. George
South Davis District September 20, 2022 @ Noon Joy Luck Restaurant 566 W 1350 S Bountiful
North Davis District September 27, 2022 @ 6:30 PM Annie’s Diner 286 N 400 W Kaysville
Provo District October 6, 2022 @ 6:30 PM Thanksgiving Point Grand Ballroom 3003 N Thanksgiving Way Lehi Canyonlands District October 20, 2022 @ 6:30 PM Carbon Country Club 3055 N Hwy 50-6 Helper Salt Lake North District, Salt Lake South District & Tooele District October 27, 2022 @ 6:30 Utah State Fair Grounds Pioneer Building 155 N 1000 W Salt Lake City
Wasatch Back District October 4, 2022 @ 6:30 PM Jordanelle State Park Hailstone Events Center Heber City
PRACTICE KIDS AND EARLY DENTAL VISITS The American Academy of Pediatrics (AAP), the American Dental Association (ADA) and the Centers for Disease Control and Prevention (CDC), recommend a child visit a dentist within 6 months of the time the first tooth appears in the mouth, but no later than the child’s first birthday.1 An established dental home is an important piece for any early intervention and prevention plan. Children who have dental homes are more likely to receive appropriate preventive and routine oral health care. The first visit is a perfect time for families and providers to work together to establish positive oral health habits, provide guidance about the importance of primary teeth, good eating and snacking habits, reviewing medical history, and providing fluoride varnish. All families should be told why age one visits are so crucial. Brush, Book, Bed is a fantastic evidence-based tool from the AAP, that can be used in these early visits.2 It helps parents
create new bedtime structures and links oral health with early literacy and development of a regular bedtime routine. AAP’s user-friendly website includes: book marks, posters, and additional resources and suggestions to help implement this in the homes of young children. Information is available in Spanish and English. As healthcare providers, we help all families establish a dental home. We need to make sure that all children establish a dental home by age one. Lauren Neufeld RDH, BSDH Oral Health Educator Oral Health Program, Office of Primary Care and Rural Health Utah Department of Health and Human Services
Sources 1 https://www.cdc.gov/chronicdisease/resources/infographic/oral-health-kids.htm https://www.healthychildren.org/English/ages-stages/prenatal/Pages/Protect-Tiny-Teeth.aspx 2 https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Brush-Book-Bed.aspx
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PRACTICE NEW ADA GUIDE CREATED FOR ENSURING ACCURACY OF CLAIMS MADE ON BEHALF OF TREATING DENTISTS Editor’s note: Dental Insurance Hub is a series aimed to help dentists and their dental teams overcome dental insurance obstacles so they can focus on patient care. A new ADA resource guide developed in May details the responsibilities of treating dentists in ensuring the accuracy of their claim submissions. In an aim to help employee dentists safeguard themselves, the guide provides information about how to minimize the risk of inaccurate or even fraudulent claims being submitted under their name. The ADA Council on Dental Benefit Programs created the new guide in response to Resolution 93H, which was passed by the House of Delegates in 2021. “The resolution came out of the realization that in some occurrences, billing claims made to third-party payers have been done under the employee dentist’s NPI number and signature on file but without the employee dentist’s approval,” said Mark M. Johnston, D.D.S., chair of the council’s Dental Benefit Information Subcommittee. “There is growing evidence that this is becoming a greater concern for employee dentists.” Resolution 93H stipulated that the appropriate ADA agency — CDBP in this case —study the feasibility of creating guidance and education on best practices on procedures that would ensure the accuracy of claims submitted by the office or a third party on behalf of the treating dentist. The council took the initiative to move forward with creating the new educational resource for dentists.
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Dr. Johnston said office staff should be sure the treating dentist reviews all claims before anything is submitted under that dentist’s name and license. If the practice is using another agency to perform billing services on behalf of the dental office, the dentist is still responsible for ensuring the accuracy of the submitted claims of services rendered, he added. When such claims are inaccurately or inappropriately submitted without the employee dentist’s approval, it may expose the employee dentist to allegations of fraud, Dr. Johnston said. “Remember, the treating dentist is responsible for ensuring the accuracy of claims and should always conduct claim form reviews before claims are submitted,” he said. “The state dental boards and courts of law will look at the license of the providing dentist — and not a dental team member — when examining a case of [a potentially] fraudulent dental benefit claim. Keeping your head in the sand will not allow this problem to disappear.” Although the ADA currently has a policy regarding employment of a dentist which states that employers should make certain that proper business practices, including billing, are followed, no guidance or resources previously existed that assisted employee dentists in either avoiding these pitfalls or addressing them with their employer should they occur. Additional information on other educational ready-to-use resources on dental insurance solutions for dentists can be found at ADA.org/dentalinsurance. ADA News
July / August 2022
ASSOCIATION AMERICAN DENTAL ASSOCIATION – POLITICAL ADVOCACY Every dentist’s voice holds the power to make meaningful changes for the profession of dentistry. I did not realize how impactful this statement would be when I first began advocating for the profession within my state many years ago. Since then, I have had the opportunity to lead dedicated advocacy efforts for the entire profession at the national level in Washington DC, and it has better positioned me to find successful methods for collaboration within the different levels of our tripartite membership that I would like to share with you. The need to mobilize all dentists, especially the newer dentists, has never been greater. The ability for us to reach new advocates who can help us offer even more education to legislators and become more involved in the political process has never been more vital. We saw early on during the pandemic the significant impact dentists had on reaching every member of Congress to discuss critical issues dentists faced as the reason for the numerous legislative accomplishments helping dentists. Let’s keep that momentum for supporting the profession going. This past year, we saw a number of steps in the right direction in Congress as the ADA continued to educate lawmakers on many bills aimed to help patients and the profession. We saw the successful introduction of numerous bipartisan bills. The federal legislative and regulatory accomplishments from 2021 are now on the ADA’s advocacy website, ADA.org/advocacy. This year’s priorities will build on the successes of the past year. For example, we will continue to work to push dental insurance reforms like the Dental and Optometric Care Access Act (DOC Access Act), the Ensuring Lasting Smiles Act, and the Medicaid Dental Benefits Act. All three of those bills impact different challenges patients and dentists face, particularly the dental insurer’s interference with the doctor-patient relationship and the dental coverage options in public and private plans. The level of education debt that new dentists face after graduating from dental school is astronomical. Fixing this has been a priority, and we have been advocating for numerous federal student loan repayment bills in Congress. Recently, the U.S. Senate introduced a bipartisan bill called the Resident Education Deferred Interest Act (REDI), which would allow dental students to defer interest accrual on federal loans during their residency. We’re going to need your advocacy to help pass this legislation and many other important student loan reforms that will be necessary to help the newer generation of dentists. In March we re-invigorated dentists and dental students’ lobbying efforts and abilities in Washington D.C., with the first in-person lobby day in two years due to the pandemic. We learned during the pandemic how grassroots advocacy is essential to achieving the ADA’s legislative goals, and we are going to use this in-person opportunity to find ways of engaging dentists and dental students on important issues. It was exciting to encourage
dentists to become more involved and feel like they are part of a group that is making a difference and creating changes. We’re now looking at improvements to the grassroots and advocacy programs to engage all relevant and necessary conversations that will be required to move the needle to help the profession and patients. How we mobilize our membership will have to change to mirror the ways that all generations of dentist wish to participate. This mean connecting with everybody so that all voices are heard, not just those who shout the loudest or who have participated in organized dentistry the longest. These experiences like my own example are important, please don’t misunderstand, but let’s not overlook those newer and younger dentists who have not yet become a part of the process or who might have become disillusioned that their voices don’t matter – they do. Let’s include everybody in this important advocacy experience. We know that a big part of your mission is focused on fixing some of the dental insurance issues that frustrate patients and dentists and seeking solutions to student debt issues for recent dental school graduates. Insurers can disrupt practice operations and patient relationships, especially when they lease networks. I learned this firsthand when a plan, without any notice, leased a network I had joined many years prior, requiring me to have tough conversations and make hard choices. States are steadily enacting transparency solutions in their legislatures to prevent this disruption. Using past successes to bolster future wins is what the ADAs State Public Affairs (SPA) Program is all about. SPA was created to help address issues like the ones Oregon is pursing. In 2021, we saw 28 new laws enacted in 18 states that positively reform dental insurance operations, may of these enacted with a collaborative effort between ADA and state dental societies. We’re ready to help initiate a proactive predentistry agenda this legislative session. Participating in the ADA SPA Oversight Workgroup with my fellow dentist leaders has provided me with a greater perspective on regulatory challenges and opportunities in the states and how each state requires a different tack to achieve effective public policy results. I see the state’s societies efforts to protect dentists from regulatory burdens that can interfere with patient care and am pleased with the collaborative nature between the state and national organizations that brings about positive changes to the profession. Working together with state dental societies, we develop and share resources that amplify the work of addressing the most urgent issues dentists face. I’m proud of the enhanced influence brought by combining the energy of state dental societies and ADA in a very focused and intentional way through the SPA program. I hope you see value in our shared commitment, too. Dr Mark Vitale
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PRACTICE A PATIENT REFUSED TO PAY FOR WHAT HIS INSURANCE REFUSED TO COVER. WHAT CAN I DO? In this case, your basic options are (a) to sue, or (b) to forgo your right to collect the payment due. However, there are things you can do to make your future collections efforts more successful. Dentists often presume that patients will remit co-pays, pay for any portion of the bill that is not covered by insurance, and remit full payment even if their insurance refuses to pay the claim. But when a patient refuses to pay, the dentist has to make a judgment call weighing the risks and rewards of pursing a collection action. The collection process is not without cost, in both time and money, and it is not a sure bet. In a lawsuit, the patient will be given the opportunity to explain his or her position, which is likely to be the dentist agreed to do the work in question without holding the patient financially accountable for the disputed amount (such as, “Dr. Smith told me not to worry about insurance, and that he would collect whatever he could from my insurance company.”). In such a case, the court may wind up believing the patient, or at least some doubt as to who owes what to whom. Knowing the risks in filing a collection suit, many dentists in such situations have decided to forgo their right to sue. In addition to the value of your time and the expense involved in the collection process, there are also reputational risks, such as an aggrieved patient posting negative comments on social media, or yellow journalism.
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One way to bolster the dentist’s legal position in future cases, and potentially make collections efforts more successful and less costly, is to have patients sign a clean agreement up front, before dental work is commence, acknowledging their responsibility for the total amount due, regardless of what the insurance carrier ultimately pays. A signed document to this effect can be a stark reminder to a patient who later refuses to pay, and send a clear message to the patient early in the collection process that this agreement will be used against the patient in court if payment is not forthcoming. In addition, you may wish to follow the lead of the many dental offices that post and publish their financial policies. These policies can be displayed on a plaque at the receptionist’s desk and can be published in the practice’s brochure, website, or in a special mailing. While likely not as helpful to the dentist’s collection case as having the patient’s signature on an agreement accepting financial responsibility, evidence that the patient was on notice in this manner would likely be a positive in a legal action for collection purposes. Finally, there are certain things that you may not do, such as withholding the records of non-paying patients, both for ethical and legal reasons. A Dentist’s Guide to the Law Page 167-168
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PRACTICE IMPROVE PATIENT SAFETY WITH A TIMEOUT POLICY Patient safety is always a top priority; however, in a fast-paced working environment, countless distractions can impede best practices. Shortcuts often come at a high cost. Making the time to check the procedure details protects your patients and your practice. A timeout is an immediate pause by the entire surgical team to confirm the correct patient, procedure and site. It’s the last in a series of steps established by the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Joint Commission requires accredited dental practices to implement a timeout before all surgical procedures. Even when not required, all practices should strongly consider implementing a timeout policy to mitigate mishaps. Calls to the Dentists Insurance Company’s Risk Management Advice Line illustrate the need for consistent timeouts. In one case, the dentist had referred a patient to an endodontist for an evaluation on teeth #14 and 15. After diagnostic radiographs and further testing, the endodontist identified tooth #14 as the source of the complaint and recommended root canal therapy. The patient returned the following day for treatment. Halfway through the procedure, the endodontist realized he had accessed the wrong tooth and was working on tooth #15 instead of #14. He immediately completed a root canal on #15 to repair his mistake and then began the root canal on the correct tooth. After completing the procedure, the endodontist informed the patient of the incident and offered to waive the fee for both teeth. He also promised to take care of tooth #15 should it require treatment in the future. A few days later, the office received a demand letter from the patient regarding the “mistake of drilling” the wrong tooth, seeking restitution. The endodontist contacted TDIC for assistance, and a claims representative and the insured were able to reach a settlement with the patient in exchange for a release of liability. Conducting a Timeout with the Dental Team Prior to invasive or irreversible treatment, a timeout is a vital step. Dentists, dental assistants and front desk staff all play significant roles. The timeout is initiated by a designated member of the treatment team, usually the dentist, and begins with a pre-procedure verification of the patient, the procedure, and the site. It involves interactive verbal communication with the patient, if possible, and all team members. Any team member is able to express concerns about the procedure verification.
The timeout is conducted in a fail-safe mode, meaning that the procedure is not initiated until all questions or concerns have been resolved. It includes a process for reconciling differences in responses among team members. The completed component of the timeout should be clearly documented in the patient’s records. The Joint Commission does not require providers to individually document each step. One checkbox or a brief note regarding the successful completion of the timeout, located in a consistent area of the patient record, is adequate documentation as long as the full content of the timeout is specified elsewhere, such as a policy handbook. The Joint omission recommends dentists and oral specialists follow these steps: • Review the dental record including the medical history, laboratory findings, appropriate charts, and radiographs. Indicate the tooth numbers or mark the tooth site or surgical site on the odontogram or radiograph to be included as part of the patient record. • Ensure that radiographs are properly oriented and visually confirm that the correct teeth or tissues have been charted. • Verify completion of the informed consent process, ensuring any questions or concerns from the patient are addressed. • Conduct a timeout to verify patient, tooth, and procedure with an assistant present at the time of the extraction. • For patients referred to a specialist review the referral slip to verify the tooth for which the patient was referred. Employer Liability for Employee Negligence Verification processes should be conducted any time the responsibility of care is transferred to another dentist within the practice or when the patient is being referred to another provider. In many cases, the practice owner could be held vicariously liable for the negligence of their employees. In another case reported to TDIC, a patient arrived at the dental office for an extraction that had previously been diagnosed by the practice owner. The extraction was performed by an associate dentist who was not involved in the initial consultation. The patient returned to the office a few days later for fillings on a different quadrant with a different associate dentist. After reviewing the patient’s treatment plan, the dentist noticed that the other associate had extracted the wrong tooth.
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The dentist informed the patient and recommended a consultation with the owner, who then reassured the patient he would do whatever it took to fix the problem. A short time later, the dental office received an intent to commence litigation notice from the patient’s attorney. This case underscores how easily a wrong site procedure can occur and how quickly these incidents can escalate. Had the associate dentist verified the details of the procedure prior to beginning treatment, it could have been easily avoided. Even when the owner is not the one who performs the procedure, they could still be held liable. Employers may be
responsible for their employees’ actions while they are on the job and are considered to be able to prevent and/or limit any negligence by the employees. It is in an owner’s best interest to prevent negligent behavior. A timeout policy promotes a safe environment with team members who are all empowered to work on behalf of the patient. Open the lines of communication among all team members and create the space to speak up before, during, or after a procedure. TDIC Risk Management
ASSOCIATION ASSOCIATION TACKLES MENTAL HEALTH WITH SENSE OF URGENCY “WE WANT PEOPLE TO KNOW THAT THIS WHOLE STIGMA OF NEEDING TO HIDE FROM MENTAL HEALTH ISSUES MUST BE ADDRESSED NOW” You are sweating, feeling restless, tense, irritable and notice that your heartbeat has sped up. You are stressed out, on the precipice of your breaking point. But you are not alone. With May being Mental Health Awareness Month, the ADA is ramping up its efforts to show its member dentists that the Association and the profession is committed not only to helping dentists facing overwhelming stress and anxiety but also supporting members’ wellness so that patient care is never compromised. “As dentists, taking care of our mental health allows us to take care of others. Now, more than ever, our profession must prioritize the mental health of all dentists so that they can provide the very best oral health care to their communities,” said ADA President Cesar R. Sabates, D.D.S. “Mental health is a vital part of the health, happiness, and overall well-being of our members.” Illuminating survey The 2021 Dentist Well-Being Survey Report revealed that the percentage of dentists diagnosed with anxiety more than tripled in 2021 compared with 2003. Results from the 2021 survey indicated that dentists continue to be plagued with mental and emotional health concerns. Many were less likely to feel in control of their work environment, reported a higher level of stress at work and scored high on a depression scale. According to the survey, many dental professionals are dealing 20
with burnout and other conditions related to stress that in worst-case scenarios could impair their abilities to practice competent dentistry. The survey’s results demand immediate attention and action, said the ADA Council on Dental Practice, which commissioned the poll, since many dentists practice in solo practices and are unable to easily and readily find counsel and compassion. Dentists from across the ADA agreed with Dr. Sabates’ message that there is a sense of urgency in the message that mental health is an ongoing process deserving of sustenance. “We want people to know that this whole stigma of needing to hide from mental health issues must be addressed now,” said Seth Walbridge, D.M.D., chair of the ADA New Dentist Committee. Prioritizing mental health The magnitude of mental health’s importance was reemphasized at the Las Vegas convening of the 2021 ADA House of Delegates. The House passed Res. 95H-2021, Prioritizing the Mental Health of Dentists, which stipulated that the ADA, in conjunction with mental health consultants, analyze the availability of resources to support the mental health of dentists and collect information regarding existing health and wellness programs from across the tripartite and other professional organizations including, but not limited to, the American Student Dental Association and the ADA New Dentist Committee. It further resolved that the ADA use the collected information to: Explore partnering with third-party mental health providers for member dentists. Analyze the existing ADA well-being conference for potential enhancement. The next conference is scheduled for 2023. July / August 2022
It all starts with a conversation..... Create a toolkit to help prevent dentist suicide, including a guide for responding to a suicide or unexpected death, and recommendations for practice coverage for short-term and longterm absences due to mental illness and permanent absence due to suicide or unexpected death. Identify best practices, then consider the creation of an effective mental health and wellness campaign for members. The resolution also instructed the ADA to explore safeguarding dentists from punitive action by state dental boards with regard to mental health issues and report back to the 2022 House of Delegates with an actionable plan. Dentistry ‘relatively stressful career’ Amir Karzim, D.D.S., a Long Beach general dentist, attested to the demands of delivering care amid the pandemic. “COVID-19 had compounded the stresses in my own life but the lives of those around me as well,” he said. “From adapting my sleep schedule in the early onset of the pandemic to allowing more time to put on and take off PPE, to having to placate frustrated patients dealing with the additional stringent regulations to seek care for their oral health. COVID has made dentistry in the 2020s an emotionally taxing journey.” Jessica Cohen, D.M.D., an Illinois-based orthodontist, said that she thinks the events over the past two years have definitely changed dentistry stress levels, and enumerated the reasons. “Office air filtration systems are more complex in some offices, which is added overhead,” she said. “[Other reasons include] N95 mask wearing, a smaller potential employee population which can lead to staffing issues, dentists retiring earlier than anticipated, small practices merging with larger practices, etcetera.” Shane Ricci, D.D.S., a member of the ADA Council on Dental Practice, agreed. “I think, in general, being a dentist has always been a relatively stressful career,” Dr. Ricci said. “The nature of working in a person’s mouth, often while they are in pain and have anxiety, and then asking them to pay a sometimes large balance that isn’t covered by their insurance, among many other challenges, can be stressful in the best of scenarios.” Dr. Ricci added: “Add to these stresses the effects during and post pandemic, increasing costs of PPE, inflation, insurance companies cutting fee schedules and other evolving complications to dentistry. I think all of these factors weigh heavily on dentists, especially as many of us have large student loans, families to support and retirements to consider. I know for me, personally, the last couple of years has increased my own anxiety and stress levels.” Robert Trager, D.D.S., a New York-based dentist, said he sees many people every day who are stressed out, and those stresses can carry over to dentists like him who treat them. “It’s been very stressful,” he added, saying that many of his dental colleagues are bemoaning the fact that they can’t find hygienists and assistants due to the nationwide staff shortage. UDA Action
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The ongoing COVID-19 pandemic has added stressors to dentists’ lives, said Jim Hoddick, D.D.S., ADA Council on Dental Practice chair, along with other factors. “I don’t think that increased stress is unique to the dental profession,” Dr. Hoddick added. “It is my sincere hope that we can all help support each other as we come out of this pandemic.” Dr. Hoddick’s comments about stress affecting all is backed by a 2021 survey of 1,500 U.S. workers that reported that more than half were feeling burned out as a result of their job demands. About 4.3 million Americans quit their jobs in December 2021 in what has come to be known as the Great Resignation. Dr. Walbridge said that the “pandemic has crushed many dentists with added stressors.” He continued: “Obviously, the financial aspect of the pandemic is a stressor, but now we have a major shortage of staff and team members to help provide for patients. This is currently what I feel is one of the major concerns seen across the country and related to the pandemic.” Psychology of stress Sheela Raja, Ph.D., a clinical psychologist and associate professor at the Colleges of Medicine and Dentistry at University of Illinois Chicago, leads the college’s Resilience Center. “The pandemic has been particularly stressful for dentists,” said Dr. Raja. She added that — rightly so — there was a lot of focus on frontline health care providers such as emergency department physicians, but there also needs to be a focus on dentists and mental health. Dr. Raja said that dentists are human beings, understandably affected by what is happening in the world at large. “Many people are struggling with anxiety and depression right now,” she said. “There have been so many prolonged stressors in recent years that we must find ways to support the well-being of our health care workforce — including dentists.” Dr. Raja talked about the need for trauma stewardship — the idea that that people need to take care of themselves if they are going to be able to care for others. If that doesn’t happen, she said, what could result in what is called compassion fatigue, where dentists are in danger of losing empathy for patients because the providers are feeling so overwhelmed. There is also another type of trauma that could happen to dentists, she said. “Vicarious trauma is when we might be taking on the stressors of the patients we serve,” Dr. Raja said. “If we are serious about wellness in health care and health care providers, it is going to take individual and policy change to make it work,” she said. Advocacy success The ADA has also been active in advocating for help for dentists struggling with mental health issues. 22
In March, a coalition that included the ADA praised Congress for passing the Dr. Lorna Breen Health Care Provider Protection Act, legislation that will give health care workers better access to education and training in order to manage stress. Lorna Breen, M.D., was an emergency room physician in New York who died by suicide in 2020 after treating COVID-19 patients. In a March 8 letter to leaders in the House and Senate, the coalition, led by the American College of Emergency Physicians, thanked the lawmakers for sponsoring the bill. The coalition said the COVID-19 pandemic has magnified longstanding issues faced by front line health care providers and stressed there “has never been a more critical time” to address mental health. “By passing this bipartisan and bicameral legislation, lives will be saved,” they wrote. “For decades, health care professionals have faced greater rates of mental and behavioral health conditions, suicide and burnout than other professions, while fearing the stigma and potential career repercussions of seeking care,” the letter continued. “When we take care of our health workforce, we ensure that patients have optimal care and support and that our health care systems can thrive,” the letter concluded. “As a profession, we should all be aware that our colleagues, staff, patients are all under stress. If we are concerned about them the ADA offers many ways to help.” —Jim Hoddick, D.D.S. ADA resources to help “As for me, I plan to share a smile and give an unexpected act of kindness,” said Dr. Hoddick. “As a profession, we should all be aware that our colleagues, staff, patients are all under stress. If we are concerned about them the ADA offers many ways to help.” The New Dentist Committee, in collaboration with other divisions in the ADA, is working with Chicago-based nonprofit Hope for the Day to add to the resources the ADA has to let dentists know that help is out there. Hope For The Day, empowering the conversation on proactive suicide prevention and mental health education, was created in 2011 by its founders to honor friends and family who had died by suicide. Since then, the nonprofit has evolved and grown by creating educational resources and programming called Proactive Prevention, and its work is already represented in all 50 states, 26 countries and 17 different languages. There is also the ADA’s Dentist Health and Wellness Program, composed of dentists and dental team members who are concerned about the health and well-being of their peers. “Given all the recent events that have affected members of our profession, I think now is as important a time as ever to help raise awareness while also facilitating acceptance of those who may be affected by mental health issues,” said Princy Rekhi, July / August 2022
D.D.S., chair of the ADA Dental Wellness Advisory Committee.
dentist well-being programs.
The ADA website itself houses many resources on mental health at ADA.org/Wellness, including The Ultimate Workplace Mental Health Kit, co-developed by the National Alliance on Mental Illness Chicago, part of one of the nation’s largest grassroots mental health organizations. In 2021, NAMI Chicago entered into a formal agreement with the ADA to develop a series of mental wellness tools and resources that can be used easily and effectively in the dental practice setting.
For those unaware and in need, the ADA Catalog features a freefor-members offering, the Dentist Well-Being Program Directory, which contains the contact information for the well-being programs offered in the 50 states and the District of Columbia.
In addition, the ADA’s Beyond the Mouth podcast series explores a range of non-clinical issues affecting dentists and their teams. Several of these podcasts include discussions with experts on how dentists can increase self-care and staff -care during COVID-19 and beyond. The ADA Accelerator Series is an online hub for wellness, leadership and work/life balance tools that Manny Chopra, D.M.D., a member of the Council on Dental Practice, recommends. “One concern that has arisen in the past few years, which has been exacerbated with the COVID-19 pandemic, is the mental wellness and general health of our practitioners,” he said. “The financial stress of running a business, the higher cost of PPE and the lower reimbursement rates from dental benefit providers has resulted in poorer sleeping and dietary pattens for many dentists. At the ADA, we are studying these stress patterns and through the Accelerator Series, we are providing education and guidance to practitioners with any assistance that they may need.” Keeping active can burn off stress. Dr. Traeger said that he goes to the gym every day of the workweek to keep his worries at bay and believes that talking about them openly can be helpful. “You have to keep active,” he said. “The more you avoid it, the worse it is.” In 2021, ADA Member Advantage endorsed ClassPass, which allows Association members free access to over 4,000 hours of on-demand audio and video workouts. ClassPass, a monthly subscription service that provides access to tens of thousands of different studios, gyms and wellness offerings in over 2,500 cities worldwide, allows ADA members to receive 10% off on in-person class packages. Kayla Yip, D.M.D., is a resident at the University of Illinois Chicago College of Dentistry and ClassPass member. She said that stress is a part of life, but she has found ways to not sacrifice what she calls “wellness time.” “You have to listen to your body,” she said. “We have to take care of ourselves.” ADA members can visit ADA.org/ClassPass and sign up for discounts using the company code ADA2021. State well-being programs According to the 2021 Dentist Well-Being Survey Report, less than half (46%) of dentists were aware of available of state
Barry Taylor, D.M.D., is the executive director of the Oregon Dental Association, which has a wellness committee as well as a Peer to Peer Ambassador Program developed in partnership with a psychologist. Dr. Taylor is open about talking about his own experience batting depression, so supporting the mental wellness of dentists is a priority of his. “Dentistry has always been stressful,” said Dr. Taylor, whose past includes stints as a practitioner and in academia. “It’s particularly stressful now.” The ODA’s Peer to Peer Ambassador Program offers a network of colleagues armed with resources to help support dentists and dental students who are dealing with wellness issues, including, but not limited to, stress management, practice issues, debt, fraud, family obligations, illness, isolation, injury, depression, loss, grief and addiction. In addition, in 2021 the ODA partnered with Permanente Dental Associates and the Oregon Wellness Program to offer free access to well-being resources for all licensed Oregon dentists. The expansion of the program to include Oregon dentists means ODA members can now receive up to eight free confidential, anonymous counseling sessions with one of the Oregon Wellness Program’s mental health clinicians. As an association — by definition a connection or cooperative link between people — the ODA believes that associations’ roles are crucial, Dr. Taylor said. “We’re in a unique position to help,” he said. “We should be taking care of one another.” “This is why we are at a pivotal point in our society,” Dr. Kazim said. “We are now having open frank discussions about mental health. With the advent of technology, we even have the options for mental health discussions at our fingertips in the form of mobile apps. This allows those who need help to seek it without having to deal with stigmas placed by differing societies or expectations.” He continued: “If you are not well, how can you be expected to help others seek wellness in their own right? We must be at our best — physically, spiritually and mentally — so that we can be prepared to help our patients seek the best care possible. This is why self-care is so integral for optimal performance. Wellness, in all respects, is important to manage a healthy life.” If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).. David Burger ADA News
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