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CONTENTS

OFFICIAL PUBLICATION OF THE UTAH DENTAL ASSOCIATION

CONTRIBUTING WRITERS

Help Wanted: Utah Dentist in Practice Less Than 10 Years to Serve as ADA Delegate 2022-2026

Matthew Mikkelsen, MA

Looking for a Few Good Dentists

Rachel Morrissey, MPA

What Has the ADA Done for You Lately?

Marcelo W.B. Araujo, DDS, MS, PhD Cameron G. Estrich, MPH, PhD

Dr Scott Theurer

Dr Bryan Trump

Brittany Harrison, MA

Dr Dan Poulson Jeff Hummel, MD, MPH

ASSOCIATION

Dr Mike Smuin

James H Bekker, DMD

Creator of My Own Insanity

Utah Gen X and Millennial Dentists' Stage Significant Takeover of Utah Dental Association

Mary Beth Versaci

Melissa Moore Sanchez, CIC

PRESIDENT'S MESSAGE

Dr Gregory Gatrell Dr Kay Christensen

Maria L. Geisinger, DDS, MS

PRACTICE

Communication is Key

Dental Kindness

Ouch! Are You Okay?

COVER PHOTO

Mobile Outreach

Writer Brett Prettyman and fly fishing guide Colby Crossland fish on the Green River in Utah, July 21, 2020. Jim Urquhart for Utah Office of Tourism

Oral Pathology Puzzler: Do You See What I See?

Screening for Prediabetes in Dental Offices

Are You Netflix or Blockbuster?

PUBLISHER: Mills Publishing, Inc.

A New Drug Target for Treating Toothaches

PRESIDENT Dan Miller

Understaffed and Ready to Hire, Dentists Face Applicant Shortages as They Emerge from COVID-19 Pandemic

COVID-19 Among Dentists in the United States

Judson Laipply

Effie Ioannidou, DDS, MDS Marko Vujicic, PhD

CDA

JADA

Dr Linda Edgar

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 2021.

PRESIDENT'S MESSAGE CREATOR OF MY OWN INSANITY Sometimes it seems like I bring on my own life challenges. This month I have a daughter getting married, I have a 2 week river trip and we decided to make our life more challenging and take advantage of the hot housing market and to quickly sell our house that we were not planning to sell. My front desk always reminds me “you pay to play” and my wife reminds me that I am the creator of my own insanity. I am very fortunate to be mostly in charge of my schedule. This is one of the advantages of being a self-employed general dentist. As many of you know there are some disadvantages too, but I feel that overall the advantages far outweigh the disadvantages. I was recently talking to a longtime neighbor who recently moved. He owns a private optometry practice. He said while at the gym recently he noticed his heart skipping beats and decided to go in and have the issue looked at. He walked away with triple bypass surgery. His surgeon told him how lucky he was to have sought help. Many healthy individuals die from an undiagnosed condition like his. My neighbor was out of his practice for 6 weeks. Some friends stepped up to help run the practice in his absence, but when he returned so did his patients. They were happy to reschedule during his time away from the practice and were happy to come back and see him. We talked about how patients came to see him as their optometrist not because of his building or location or even because he participated on their insurance plan, but because of how he treats them and the relationship they have

developed over the years. The same holds true in dentistry. Our patients come to see us for who we are and the way we treat them. Unfortunately most of us contribute to our own insanity also. We have failed to address the problem of insurance interference in our practices. We give too many “discounts” to patients and are willing to accept reimbursement rates that are far too low. We fail to recognize that our patients come to see us for who we are and how we treat them. I have always felt it was wrong in dentistry and medicine to charge different fees to different people for the same procedure. We should be charging the patients with insurance more for having to deal with their often frustrating insurance company and their methods. If we treat all of our patients with the same care shouldn’t we be reimbursed the same? Needless to say I have been very busy and most of the related stress is self-inflicted. This upcoming trip will be the longest time I have been out of the office in the nearly 15 years I have practiced in Salt Lake City. Of course I will miss the income while I am gone, but I’m not worried about patients going somewhere else in my short absence other than for emergency treatment. I can’t wait until I can get life under control again. Dr. Gregory Gatrell UDA President

Your patients rely on your expertise to evaluate and make recommendations to keep them healthy. Your local independent insurance agent can do the same for you when it comes to suggesting the right combination of coverage to protect the practice you’ve worked hard to build.

SPEND YOUR TIME EXAMINING YOUR CLIENT’S TEETH, NOT YOUR COVERAGE.

Find an independent agent representing The Cincinnati Insurance Company by visiting cinfin.com or by calling Mike Terrell, 800-769-0548.

July / August 2021

PRACTICE COMMUNICATION IS KEY A friend of mine recently had a very negative experience at a health care facility. In a discussion with her about her experience the root of the problem seemed to be communication. She felt the provider was uninterested in her concerns and did not have time to listen. In a recent conversation with a medical colleague, about the challenges we face as health care providers, communication again surfaced as a primary issue. His comment was that Medicine is 60-70% communication. It seems almost impossible that in the high-tech world we live in, with all the information literally at our fingertips, with all the modes of communication available, that communication would be a significant challenge in most relationships. A quick google search about communication produces a long list of material sources. Everything from types of communication, communications skills, communication training and the list goes on. Being able to communicate effectively is one of the most important life skills to learn. Having strong communication skills aids in all aspects of life; from professional life to personal life and everything that falls in between. In dentistry our communication with others is essential to our success. We communicate with a variety of entities: patients, parents, co-workers, dental laboratories, dental supply and equipment vendors, accountants, lawyers, financial planners, and bankers to name a few. Each of these entities have their own personalities, communication style, knowledge base, preconceived notions, and life’s distractions that we need to wade through to establish good communication. In all of these relationships, in my mind, there is one where it is imperative that we get it right; the Doctor-Patient relationship. At the end of the day, it is this relationship that will determine our success as dental professionals. Generally speaking, if we are able to communicate effectively with our patient’s; treatment decisions will be made by informed individuals, financial arrangements will be understood, missed appointments will decrease and we will have fewer unhappy and confused patients. Our practices will have more patients who promote us and fewer who pursue litigation.

Initially when thinking about being a better communicator we probably default to - I need to become a better presenter or talker. While it is true conveying one’s feelings, knowledge, and desires is very important most of us do ok with his skill. The part we are challenged by is listening. How often do you introduce yourself to someone and in return they tell you their name? If you do not actively listen to their name you will not remember it a few seconds later, you probably didn’t even hear it the first time. We automatically focus on what we are going to say rather than hearing what is said. This is just one simple example of the importance of listening. Most of us at some point have attended a class, lecture, workshop, or read a book on communication skills. My most formal training on communication came at a Boy Scouts of America leadership camp/course. I know many reading this article have attended a similar camp, for some it will bring fond memories, for others just hearing the word Wood Badge will make them cringe. One strong take away for this experience was instruction on “Listening to Learn”. The entire exercise was to help us develop better listening skills. I soon realized that this part of communication was undervalued and underrated and one I needed to work on. I will not try to convey all that is needed to be an effective listener in this article, but I will share the quote from Stephan R. Covey which sums up the value of listening “Seek first to understand, then to be understood.” I would suggest that communication would be a very valuable topic for an in-service meeting in our offices. There are many resources available to draw from in presenting this topic. There are also professional groups that you could use to teach these principles. Next time you seem to be having trouble communicating with someone slow down, listen to what they are saying and you may find the trouble was not them but you. Ouch! Dr Mike Smuin UDA Past President

In the google search mentioned above I found many articles with “steps for effective communication” some have 5 steps others 12. All of these steps are important and helpful in communicating, but it can get overwhelming trying to navigate through the various suggestions. In most of the programs teaching how to communicate better, at least in verbal communication, the most common #1 step is LISTENING. UDA Action

Registration Now Open

September 24, 2021 Salt Palace Convention Center 8:00 AM – 5:00 PM Rachel Wall, RDH, BS - Elevating Your Hygiene Service Bethany Valachi, PT, DPT, MS – Solving Work Related Pain in Dentistry Cory Glenn, DDS – Digital Dentistry in Practice Jason Chandler, DMD, MS – Sedation & Anesthesia Review Adam McCormick, DDS FACS - Med Emergencies & Provisional Implants Patrick Hall, DMD, MS – Bone Grafts & Neuromodulators Over 30 Vendors will be onsite. Lunch Included in registration fee.

PRACTICE DENTAL KINDNESS As a young child I learned a simple song with the following verse, “I ought to be kind to everyone, for that is right, you see; So I say to myself, ‘remember this – kindness begins with me.’” As I’ve pondered writing this article for my dental colleagues to read, I’ve questioned what I could say or share that would provide great personal and professional enlightenment. Should I share a message out of a responsibility to provide information to keep our dental community informed of relevant issues facing our profession and our local circumstances? Do I try to address the latest legislative updates that are affecting dentistry and the ways that we practice? Or should I campaign about the innumerable benefits of active participation in organized dentistry? Each of these important topics could be studied, researched, and addressed in great detail, and even with the approach of using and quoting scientific details and evidence, or intellectual proof and studies. But sometimes my intellect feels weary. I feel flooded with all the information I receive and attempt to digest about dental materials, dental technology, laws and regulations affecting dentistry, practice management methods, techniques and procedures, insurance issues for the practice, property insurance, health insurance, and the list goes on and on. And I have to admit that kindness is something that has been on my mind a lot lately. The world around us these days is often anything but kind. Is it a topic with too much “fluff” for a dental professional? I think not. At least for me, I think it may often times be the very heart of the matter. We have recently been seeing a patient with the disabled Medicaid program. He has very few teeth remaining. His desires are to try to keep and care for his remaining teeth and probably pursue removable prosthodontic therapy to restore function of missing teeth. We reviewed treatment plan options, prognosis, answered questions, and went to work. When we saw him the other day, he thanked us for being nice to him and treating him with dignity and respect, something he said he hadn’t received from other offices. It doesn’t need to be difficult to be nice, and treat someone as a friend or family, even if you seem to have little in common. They may even thank you someday, and that’s a good feeling. Kindness has been on my mind a lot lately. Last month we saw one of our regular patients, a 20 year old young woman, for her routine recall exam visit. As it usually happens, we caught up with how she had been doing the last few months, joked around and laughed a bit. She always takes a bouncy ball as a prize when we finish up, adding to her

collection she started when coming to our office as a young girl. I don’t think I’ve ever seen her not smiling, and she has a beautiful smile. When people are so nice and happy around us, it’s very easy to be kind. A couple of weeks later, we heard of a terrible accident on the freeway in which a young, newly engaged couple was killed. Such news always brings sadness, but especially when we found out the young woman in the accident who passed was our smiling, happy 20 year old patient we had seen since her childhood. How grateful we were that she had made it so easy to reciprocate her kindness while she was among us. Kindness has been on my mind a lot lately. But what about those patients, or others, who aren’t always so pleasant? How do we treat those who seem so different than who we are? The patient on the schedule who always tries our patience? The patient who, when we see them on the schedule for the day, we hope cancels, or even no-shows? The patient who looks, acts, speaks, or believes so differently than we do that we might think they are the very antithesis of our existence? Can we really be kind to someone like that? I remember when I graduated from dental school I took an oath that I would do no harm. Naturally, I mostly assumed and hoped that I wouldn’t do something wrong, make a mistake, or bite off more than I could chew and cause some sort of physical harm to a patient. I believe that oath to do no harm applies also to emotional, mental, or psychological harm. Over the years I have learned, and am still learning, that patients are more than teeth connected to the rest of a physical body. I am learning that patients require patience. They all have a heart and mind and beliefs and values that are very important to them. Many of those values may be common to me as well, and I may agree with many of them. But I may be unfamiliar with many others. This is when I remind myself, or am reminded by others, that I need to look to others with kindness. It makes me think of this quote from Edwin Markham, “He drew a circle that shut me out- Heretic, rebel, a thing to flout. But love and I had the will to win: We drew a circle and took him in!” Kindness has been on my mind a lot lately. Some people seem to be naturals at being kind and inclusive to those they deal with. But if we are totally honest, we all have weaknesses and can be a little more kind to others. More kind to our friends and family, more kind to our patients and staff, more kind to our colleagues, more kind to our adversaries or opposition. We live in a world with wonderful, endless opportunities. In a world where we can be anything, be kind. Dr Kay Christensen UDA President Elect

UDA Action

Utah Dental Association

News for Immediate Release to all UDA Members Salt Palace Convention Center April 1, 2022

Contact: Dr Scott Theurer sltheurer@gmail.com

Utah Gen X and Millennial Dentists’ Stage Significant Takeover of Utah Dental Association At the conclusion of today’s Utah Dental Associations’, House of Delegates; the Association announced the outcome of officer elections, which included two UDA member dentists who have been in practice less than 20 years. Citing the demographics of Utah dentists, the emboldened GenX and Millennial members of UDA House of Delegates elected Dr. Michael Millennial as the incoming Secretary of the Association and Dr Jessica Jenex to a 4 year term as a Delegate to the American Dental Associations’ House of Delegates, from Utah. Dr Millennial said in his short campaign speech, “With nearly two thirds of Utah dentists being in practice less than 20 years, as well as over half of all dentists in the United States; it was

time for what has traditionally been a quiet majority of dentists, to lead their State and National Associations.” Dr Jenex similarly, thanked the UDA House of Delegates for supporting her and helping to bolster the influence of Young Dentists at the highest levels of the American Dental Association. She said, “Representing the 15% of Utah dentists in practice less than 10 years, I am looking forward to networking with the Young Dentists from surrounding states to give our voice to the governance of the dental profession.” It was noted by outgoing UDA President Greg Gatrell that the majority of those attending the UDA House of Delegates were much younger dentists from around the state than has been the tradition of past years. This engagement was viewed with enthusiasm by UDA officers.

PRACTICE OUCH! ARE YOU OKAY? Your patient is sitting in the operatory chair, waiting for you to begin treatment. All of the sudden, the backing shears off the chair and the patient falls to the floor. Or, your patient’s sitting in the operatory chair and the operatory light breaks and falls, hitting your patient in the head. Or your drill head stops running water through the head and you burn the inside of your patient’s mouth. Maybe even more common, a drill burr breaks or comes out and your patient either swallows or aspirates it. All of these are examples of claims we’ve seen for patients that have been affected by faulty or failing equipment in their dentist’s office. Obviously, no one can predict if equipment is going to break, but there are a few things you should be doing before and after an incident. This is pretty elementary but maintain your equipment! Delivery systems come with the manufacturer’s recommendations for cleaning, maintenance, and storage. Follow those recommendations and keep good records of equipment maintenance and inspection. It you receive a recall notification or service bulletin, make sure you follow through and keep the notification as part of your maintenance records. Use equipment properly and for what it was designed to do. Some dentists have extended burrs too far when they didn’t have a set of extended burrs. Don’t do it! 8

If equipment fails and hurts the patient, stabilize the patient and get them to the Emergency room. Explain to the patient what happened and document the conversation. If you speak with a family member, also document it. Witnesses (chairside) should make a report of what they saw. Take photos of the equipment, isolate and store it somewhere safe. Don’t offer it to the patient as a souvenir. Contact your insurance carrier if the patient is injured. Notify your carrier if you’re planning to contact a technician to repair the equipment; your carrier may want you to preserve the evidence instead. Before throwing it out, also check with your carrier. Sometimes plaintiff attorneys will tell their clients to wait 2 or 3 years to file a claim, knowing the odds are greater that the dentist will have discarded the equipment by then. Do not speculate on why the equipment failed. All of your conversations moving forward, whether with the patient or the equipment manufacturer, supplier, distributor or repair technician, will be used as evidence. And finally, check on your patient. That compassionate gesture can make all the difference in the world between a lawsuit being filed and a lawsuit being avoided. Melissa Moore Sanchez, CIC TDIC

July / August 2021

Future meetings dates and locations will be soon announced by the ADA.

Help Wanted: Utah dentist in practice less than 10 years to serve as ADA Delegate 2022-2026. In 2014, the Utah Dental Association By-laws were amended to include the election of a dentist in practice less than 10 years, to a 4-year term as one of the 5 Utah Delegates to the ADA.

Several weeks prior to the ADA Annual Session is “Caucus I” a meeting of delegates and alternate delegates in the 14th ADA Trustee District which includes Arizona, Colorado, Hawaii, Nevada, New Mexico, Utah, and Wyoming. (UDA officers serve as alternate delegates and as delegation secretary). The Caucus I meeting is rotated among the 7 states. In 2022, the Wyoming Dental Association will host the meeting at a location yet to be determined. At Caucus 1, resolutions from member dentists in the U.S. and the ADA Leadership to be considered by the ADA HOD, are reviewed and discussed with opportunity for delegates to agree with, modify by amending, or oppose. These resolutions affect all ADA member dentists.

ADA Delegates are also voting members of the UDA Board. They serve as a resource on national and state issues and may be asked to serve in UDA workgroups. UDA Board meetings are alternately held at the UDA office in Woods Cross and via Zoom, 8-9 times a year. These are usually held from 6-8:30 pm on the second Thursday.

Expenses to attend 14th District Caucus and ADA meetings and distant UDA meetings are reimbursed as a travel allowance. The day-to-day responsibilities as a UDA board member and Delegate are minimal as they are handled by our Executive Director, Val Radmall and our UDA administrative team.

ADA Delegates have the responsibility to study resolutions and budgets being considered by the ADA House of Delegates (HOD) which is held as part of ADA Annual Meetings. The 2022 meeting is being held in Houston, October 14-17, 2022.

If you have been in practice less than 10 years and even remotely would consider this opportunity to serve in volunteer governance of our Association, please call the UDA office at 801-261-5315.

UDA Action

PRACTICE MOBILE OUTREACH

As a pediatric dentist having practiced in Utah for 30 years, I have a great love for our profession. In transitioning to an academic setting and traveling throughout the state, my eyes have been opened to the many populations in Utah that are challenged in their ability to access care. Because of this, I am very excited to highlight the continuation of a wonderful program that increases access to care for the underserved. The University of Utah School of Dentistry Mobile Outreach Program travels statewide and provides needed dental care. Our van carries portable equipment that can be set up in a community center, school, or any public building. The information about these opportunities goes out through local community organizations that connect with underserved populations and makes them aware of the dates the van will be in their area. This program is funded by state grants awarded to the U of U School of Dentistry. It is important to note that the Mobile Outreach Program does not to compete with local dental practices. When people come to the clinic that have the ability to pay for their care, we refer them to the local dentists and in many cases help them gain access to Medicaid benefits so that local dental offices will accept them as patients. In this way the Mobile Outreach Program serves as a referral source for local dentists- definitely a win-win. So far this year, mobile clinic sites have included Ephraim, Roosevelt, Blanding, Beaver, Logan, Tremonton and Fort Duchesne Utah. Our team of a dentist, dental assistant, and mobile outreach coordinator report a strong response from these communities, and it has been gratifying to see the positive effects of the dentistry rendered. During the pandemic, extra

care has been taken to test all patients before their procedures to ensure a safe environment. The COVID-19 testing is done at no cost to the patients. As professionals, we all have areas of dentistry that we are passionate about, and a vision for how we can achieve our goals. At the U of U School of Dentistry, we are honored to partner with dentists throughout the state in achieving one of our visions: “care for the underserved.” We look forward to this next year and opportunities to visit some of these sites again, and add new and needed sites to the schedule. We have long known that the smile is the first impression of a person, and too many good people suffer great challenges because their oral health is compromised. The old adage, “When you smile, the whole world smiles with you,” has never been more true! We love being a part of that vision and providing a pathway to progress. James H Bekker, DMD Associate Dean for Professional and Community Partnerships Associate Professor University of Utah School of Dentistry

LIKE US ON FACEBOOK! Utah Dental Association

July / August 2021

PRACTICE ORAL PATHOLOGY PUZZLER: DO YOU SEE WHAT I SEE?

Case History: An adult patient presents to the office with a pigmented lesion of the right retromolar pad area. Duration of lesion is unknown. Patient unaware of lesion. Which of the following represents the best diagnosis for the clinic findings: a. Oral Melanotic Macule A. b. Amalgam Tattoo B. c. Melanoma C. d. Blue Nevus (continued on next page) D.

Meet. Play. Learn. Oct. 11–13, 2021 With electric events, dynamic speakers, hotoff-the-press content, non-stop inspiration, and a community that is amazing, the ADA is proud to present a reimagined annual meeting that is sure to make you smile. Registration Now Open! SmileCon will be held in Las Vegas at the Mandalay Bay Resort and Casino.

We have practice in selling your practice. We have all of the experience, tools, and resources necessary to help you transition your practice into the right hands. With our help, you can avoid common pitfalls. We provide expertise on appraisals, practice sales, mergers, partnerships, and everything you might need for a fulfilling practice transition.

801.298.4242 | ctc-associates.com Randon Jensen | Larry Chatterley

UDA Action

Correct answer: (b) Amalgam Tattoo

The list above is the appropriate differential for a localized pigmented lesion in the oral cavity. The first step after recognizing the lesion is to take a radiograph. If small radiopaque “flecks” (as noted in the radiograph above) are noted, this is sufficient for the diagnosis of an amalgam tattoo and no further treatment is necessary. The lack of radiographic evidence of a foreign material (amalgam) would support the recommendation for a biopsy to confirm the diagnosis and rule out melanoma. An amalgam tattoo is due to the implantation of dental amalgam into oral soft or hard tissue. Clinically, the lesions are black, blue or grey in soft tissue tattoos. A blue nevus is most commonly on the hard palatal mucosa and is a

melanocytic tumor that usually exhibits slight surface elevation. They are typically less than 1 cm in diameter. An oral melanotic macule is a brown asymptomatic macule produced by focal increases in melanin deposition and are not dependent on sun exposure. The most common site is the vermilion zone of the lower lip (labial melanotic macule). Over 80% are solitary lesions that are less than 7mm is diameter and tend to be well demarcated. There is no malignant transformation potential but these lesions cannot be distinguished clinically from early melanoma. Mucosal melanoma presents at an advanced state and is more aggressive than skin melanomas, making an early diagnosis critical. To distinguish between melanoma and other pigmented lesions (like the benign melanocytic nevus), the ABCDE system has been developed to describe the clinical features of melanoma: A- Asymmetry B- Border irregularity C- Color variation D- Diameter is greater than 6mm (but they can be smaller) E- Evolving lesions (sudden increase in size) Works Cited Neville, Damm, Allen, Chi (2016). Oral and Maxillofacial Pathology, 4th Ed. St. Louis: Elsevier.

Bryan Trump, D.D.S, M.S. Associate Professor Oral & Maxillofacial Pathology University of Utah School of Dentistry

ASSOCIATION LOOKING FOR A FEW GOOD DENTISTS As part of the responsibilities of the State Board of Dental and Hygiene Licensure, includes the opportunity to help fellow professionals. From time to time, one of your colleagues has a challenge come into their life that compromises their dental licensure. When this occurs, the Utah State Dental Advisory Board (DOPL Board) works to help them regain their opportunity to bring their licensure back to a full privilege level. As part of this process, they need another dentist to supervise/ mentor them on their road to recovery. The DOPL Board is looking for Dentists in every part of the state (but mostly along the Wasatch Front) who would be available and interested in assisting a colleague in this journey. A supervisor’s responsibilities (many of which can be done online/remotely) are these: meet weekly with your assigned colleague, provide oversight of clinical services/patient treatment, their sobriety, boundaries, ethics, and professional relationships. They would also review monthly 20% of their assigned 12

colleague’s current patient charts (these charts to be chosen randomly by the supervisor). A supervisor would also make regular monthly or quarterly reports to the DOPL board regarding the progress of their supervisee. They would also review their colleague’s prescriptions and drug administration log weekly or monthly. Again, many of these responsibilities can be done online (remotely) so as to take a minimal amount of your time. The DOPL staff will also greatly assist throughout the process. If you would like to know more about this opportunity to serve your profession as well as your community at large, please contact the UDA office. Your help in this process would be invaluable to a fellow dentist, the State Dental Advisory Board, and your community. Please give the UDA a call at 801-261-5315 or email the UDA office at UDA@uda.org or dotty@uda.org . Dr Dan Poulson State Board of Dental and Hygiene Licensure (DOPL Board) July / August 2021

PRACTICE

Screening for Prediabetes in Dental Offices Jeff Hummel, MD, MPH Medical Director, Informatics Research and Innovation Comagine Health Although medicine and dentistry usually operate in silos, the human body is unaware of the lack of communication between the two professions. Many dental conditions have an impact on medical disease and vice versa. A common example of this whole person interconnectedness is the complex relationship between periodontal disease and diabetes. The details about the interaction between diabetes and periodontal disease continue to emerge, but one thing is clear: elevated blood sugar speeds the progression of periodontal disease and makes it harder to control. The same is true in prediabetes, a condition known in medical parlance as impaired glucose metabolism, in which a person’s blood sugar is elevated, not sufficiently to meet diagnostic criteria for type 2 diabetes but enough to accelerate periodontal disease. There is still uncertainty as to whether treating periodontal disease in people with prediabetes actually prevents or slows progression to diabetes, but once a person has diabetes, successful treatment of periodontal disease makes it easier to keep a person’s blood sugar in a safe range. What does all this mean for dentists? There are many of people with impaired glucose metabolism who are unaware they have prediabetes, and many of them see their dentist more frequently than they see a primary care physician. This means that dentists are in an ideal position to help identify people who may have prediabetes without realizing it. This is important because there are proven interventions to slow progression from prediabetes to type 2 diabetes or stop it altogether.

The most effective treatment for prediabetes is a major life-style change involving exercise and diet, so this is not something a dentist would be expected to manage. However, dental offices are a perfect place to identify people at high risk for prediabetes and refer them to a medical office or community resource where they can receive guidance in lifestyle changes that will keep them and their periodontium healthy in the long run. The National Diabetes Prevention Program (National DPP) is a public-private partnership comprised of federal and state agencies, employers and health care professionals, and works with a wide array of partners, including dental practices. The program supports participants in improving their nutrition and increasing physical activity. Participants have been shown to reduce their risk of developing type 2 diabetes by 58% — up to 71% for people 60 and older. In Utah, the partnership includes public health districts, private medical groups and community partners. If you would like to learn more or get involved, a list of Utah organizations offering the National DPP can be found here. Your partnership is appreciated. For additional information, contact: Trei Herd, Consumer Engagement Manager Comagine Health therd@comagine.org | 503-515-5359

Jeff Hummel, MD, MPH Jeff Hummel is a general internist with 35 years of medical experience and advanced training in health services. He is currently Comagine Health’s medical director for health care informatics, a position in which he provides leadership for practice coaches working in population health consulting, clinical outcomes reporting and integration of behavioral health and oral health into primary care. About Comagine Health Comagine Health is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system. This material was supported by the Grant or Cooperative Agreement Number, NU58DP006369-01, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

UDA Action

PRACTICE ARE YOU NETFLIX OR BLOCKBUSTER? There’s a city in Oregon called Bend. Known for craft breweries, natural scenery and the Deschutes River that runs through the heart of the city. Bend is a shining example of a Pacific Northwest city and the air is clean and crisp. Home to more than 130 dentists, Bend also is unique in that on a semibusy street sits the lone remaining Blockbuster Video store in the world. I’ve visited the store and there’s mostly just people taking selfies out front or walking the aisles wondering who still uses a VCR. Blockbuster Video at one time had more than 9,000 locations around the world and 60,000 employees. Renting movies and DVDs was a lucrative business with more than $5 billion in revenue at its peak. Blockbuster was the leader in its space. Yet in less than 10 years, Blockbuster went from the top of the mountain to laying in a crumbed heap at the bottom to eventually becoming a novelty with one remaining store on the planet (which is now also offering limited Air B&B rentals). This article is not about Blockbuster though, it’s about the inevitable aspect of all things that Blockbuster refused to embrace. Evolution.

What’s your practice worth?

Everything changes, but not everything evolves. Blockbuster, Nokia, Kodak – these are just some of the names of large companies that were at the top of their industries, done in by ignoring the world around them, being unprepared to evolve and falling prey to their own conceit. We all know things change. Trends emerge. Technology advances. Consumer expectations evolve. Are you ready to meet them? Is your practice embracing change? Or resisting it? Are you evolving to meeting your patients’ wants and needs? Or do you still require people to pay by mailing in a check? (Side note: I switched dentists solely based on the fact my previous one only took checks mailed in an envelope – in 2020!) While we never know for sure where the future will lead us or what unexpected events will affect your practice (like a complete shutdown!) we can be assured that teeth will need to be cleaned, fixed, built and more. Alignment will be wanted and reconstruction will be needed. The mission to help people have healthy, beautiful smiles will always remain. The methods, though, will evolve. You must be ready and willing to evolve. You should be giving a portion of your time to researching innovative technologies, techniques and products, attending conferences (virtual or in person), networking with peers, talking with vendors and suppliers about what’s happening in research and development and getting involved with the association to help you stay in the know. Blockbuster was at the top of its industry and even had a chance to buy the very company that would eventually be its demise. At one point, Netflix was in talks with Blockbuster to be acquired and Blockbuster executives laughed Netflix out of the boardroom. Blockbuster’s leaders said they didn’t’ think a DVD delivery system had longevity. What they didn’t know was that Netflix agreed and was already working on the next evolution: streaming. Netflix as a company has always looked to the future. While the company delivers for customers in the present, there’s also an eye toward the future. In its short life, Netflix evolved from a delivery service to a streaming service to a content creator/studio. Who knows what its next play will be?

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So, the question is: Are you more like Netflix or Blockbuster? Are you keeping an eye on the future to know what’s coming? Or are you resting on your past successes and fighting against evolution of any sort? If you’re the latter … be wary. Chances are, you’ll be left behind. Work hard not to become a practice where someone will caption their selfie with your sign and say, “remember when?” Judson Laipply Today’s FDA July / August 2021

PRACTICE A NEW DRUG TARGET FOR TREATING TOOTHACHES An international team of scientists has figured out how teeth sense the cold and has pinpointed the molecular and cellular players involved. The team led by David Clapham, MD, PhD, vice president and chief scientific officer of the Howard Hughes Medical Institute, reported that tooth cells called odontoblasts contain cold-sensitive proteins that detect temperature drops in both mice and humans. Signals from these cells can ultimately trigger a jolt of pain to the brain. The study was published in the journal Science Advances in March. The work offers an explanation for how one age-old home remedy eases toothaches. The main ingredient in clove oil, which has been used for centuries in dentistry, contains a chemical that blocks the “cold sensor” protein, said electrophysiologist Katharina Zimmermann, PhD, who led the work at FriedrichAlexander University Erlangen-Nürnberg in Germany. Developing drugs that target this sensor even more specifically could potentially eliminate tooth sensitivity to cold, Dr. Zimmermann said. “Once you have a molecule to target, there is a possibility of treatment.” About 15 years ago, the research team discovered that an ion channel called TRPC5 was highly sensitive to the cold. But the team didn’t know where in the body TRPC5’s cold-sensing ability came into play. It wasn’t the skin, they found. Mice that lacked the ion channel could still sense the cold, the team reported in 2011 in the journal Proceedings of the National Academy of Sciences. But TRPC5 does reside in teeth and more so in teeth with caries, as study co-author Jochen Lennerz, MD, PhD, a pathologist from Massachusetts General Hospital, discovered after examining specimens from human adults. A novel experimental set up in mice convinced the researchers that TRPC5 indeed functions as a cold sensor. Instead of cracking a tooth open and solely examining its cells in a dish,

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Dr. Zimmermann’s team looked at the whole system: jawbone, teeth and tooth nerves. The team recorded neural activity as an ice-cold solution touched the tooth. In normal mice, this frigid dip sparked nerve activity, indicating the tooth was sensing the cold. This was not so in mice lacking TRPC5 or in teeth treated with a chemical that blocked the ion channel. That was a key clue that the ion channel could detect cold. One other ion channel the team studied, TRPA1, also seemed to play a role. The team traced TRPC5’s location to a specific cell type, the odontoblast, that resides between the pulp and the dentin. When someone with a dentin-exposed tooth bites down on a frozen pop, for example, those TRPC5-packed cells pick up on the cold sensation and an “ow!” signal speeds to the brain. Read more of this study in Science Advances (2021); dx.doi. org/10.1126/ sciadv.abf5567. CDA June 2021

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ASSOCIATION WHAT HAS THE ADA DONE FOR YOU LATELY? Most non-members and even some members are not aware of the constant effort that your ADA makes to keep you and your patients safe and help the dental profession remain strong. I would ask dentists who are non-members: What would dentistry be like if you did not have the ADA? The following are just some of the ways ADA has worked for dentists in recent months.

INSURANCE RELATED LEGISLATION

Recently – after over 10 years of effort, emails and testimony from grassroots leaders and dentists - Congress passed the bill which will reform the McCarran-Ferguson Act of 1945. This will ensure that health insurance companies will be subject to the same federal antitrust laws that nearly all other industries must comply with in the US. What does that mean for you? This will allow for greater transparency and oversight into the health insurance industry and hopefully more competitive pricing. Increased innovation and choices for consumers and providers may create better levels of coverage for YOU in your practices.

STATE PUBLIC AFFAIRS (SPA)

The ADA provides local support for insurance reform. Every year, states across the country spend hundreds of thousands of State Public Affairs (SPA) dollars funded by the ADA to help pass insurance legislation which helps you get paid more fairly in your practice. SPA funds have been offered for general legislation for many years. A few years ago District XI brought a resolution to the ADA House of Delegates specially allocating money to help with insurance legislation which will help every dentist in their practices every day. Out of that effort by District XI and its vision a pilot project was initiated that showed states and dentists were overwhelmingly supportive of the need for this insurance legislation help. Every year now money is put into the budget for this cause. The number of states asking for these SPA dollars has increased from 30 last year to 50 this year.

COVID-19 RELIEF

The ADA lobbied lawmakers to pass additional pandemic legislation to continue providing help for businesses devastated by the pandemic. Important provisions of recent legislation include: ● Making expenses paid for with the Paycheck Protection Program (PPP) loan tax deductible. 16

● Eliminating the requirement that PPP loan forgiveness would be reduced by the amount of the Economic Injury Disaster Loan (EIDL) grant that was received by the business. ● Allowing PPP borrowers to utilize the Employee Retention Tax Credit (ERTC). The bill also increases the wage cap and percentage of eligible wages for that credit. ● Easing the forgiveness process for loan of $150,000 or less ● Allowing borrower to use PPP to purchase personal protective equipment (PPE) and make facility modifications for COVID-19 protection.

PRODUCT RESEARCH

The ADA Science and Research Institute (ADASRI) was developed last year as a stand-alone entity. ADASRI works to develop new products for use in practices and to test existing products for safely. Your dues dollars also help you keep your patients safe.

COVID-19 VACCINE

The ADA successfully advocated for dentists to be included in the definition of health care personnel making them eligible to be offered some of the first doses of vaccine. The ADA also urged the Centers for Medicare and Medicaid Services (CMS) to expand the scope of practice for dentists, particularly public health dentists, to administer vaccines in order to aid in the prevention and control of Covid-19. Visit www.ADA.org/virus and www.ADA.org/vaccine to access a wealth of material ADA has produced since March 2020.

ADA PRACTICE TRANSITIONS (ADAPT)

The ADA Practice Transitions (ADAPT) program helps young dentists buy a practice or find an associateship and will help older dentists, especially in rural areas, sell their practices for much less than you would pay to most transition firms. Go to www.ADA.org/ADAPT to see how to sign up get a match. It is free to create your profile on the platform.

THE ADA HAS YOUR BACK

Those of you who are responsible to your profession and pay your dues are helping the entire profession. Can you imagine how much more we could do for you if dentist who are currently non-members took responsibility, joined and helped fund all these efforts? Dr Linda Edgar WSDA News

July / August 2021

PRACTICE UNDERSTAFFED AND READY TO HIRE, DENTISTS FACE APPLICANT SHORTAGES AS THEY EMERGE FROM COVID-19 PANDEMIC HPI data show more than 80% of hiring dentists find hygienist, assistant recruitment extremely or very challenging

“The profession of dentistry, much like those of many other sectors of the economy, is facing severe workforce shortages in all facets of the team. And although these deficiencies can be found throughout the country, the challenges vary from state to state, with some complaining of a lack of available team members to others expressing concerns about exorbitant or unrealistic salaries for new hires,” said Duc “Duke” M. Ho, D.D.S., chair of the ADA Council on Dental Practice. “Many shortages, especially in dental hygiene and chairside assistant, existed prior to the COVID-19 virus. However, these shortages have been exacerbated by the pandemic, as more employees have left the workforce for a variety of reasons, including early retirement, concerns about safety at the time and a desire for more work-life balance.”

Before the COVID-19 pandemic, Rebecca De La Rosa, D.D.S., prided herself on having a tenured dental team. But after losing two hygienists and an expanded-function assistant at the height of the pandemic — all of whom had been working for her for nearly 20 years — she has seen a limited number of job applicants and a revolving door of hires who have not lasted at her practice. “Weeks pass without applicant submissions, and temporary staffing services have no availability,” said Dr. De La Rosa, vice chair of the American Dental Association Council on Communications and owner of a dental practice in Avon, Indiana. “I have experienced interview no-shows and poor attendance from new hires. This reduction in staff in combination with COVID-19-related patient screening and slower operatory setup and teardown requirements has resulted in fewer patients being scheduled.” Dr. De La Rosa is not alone in the challenges she is facing as she attempts to fill open positions on her dental team — challenges the ADA is working to address. A May poll from the ADA Health Policy Institute found 35.8% of owner dentists are recruiting dental assistants, 28.8% are seeking dental hygienists, 26.5% are looking to hire administrative staff and 13.1% are in search of associate dentists — all four percentages representing a rise in recruitment since October 2020. Compared with before the pandemic, more than 80% of owner dentists who are currently hiring are finding the recruitment of dental hygienists and assistants to be extremely or very challenging: • For dental hygienists, 66.3% of dentists said recruitment was extremely challenging and 19.7% reported it was very challenging. • For dental assistants, 59.2% of dentists found recruitment to be extremely challenging and 23.9% stated it was very challenging. Hiring of administrative staff and associate dentists has presented difficulties as well, with more than 70% of owner dentists saying recruitment of administrative staff was extremely or very challenging and more than 50% of owners reporting the same for recruiting associate dentists.

In an effort to help address some of these concerns, the ADA has resources available to support dentists who are facing staffing issues. The Council on Dental Practice developed two promotional flyers intended to help recruit qualified people into allied dental careers. These resources are being shared with ADA members seeking personnel, state dental society staff, and high school and community vocational and educational programs, Dr. Ho said. The flyers, available at ADA.org/AlliedCareerFlyers, can be personalized for individual practices. The ADA also has information and guidelines on managing the dental team, following a hiring process, leading a dental team during a pandemic and more at ADA.org/Staff. Like Dr. De La Rosa, Michelle Steinhubel, D.D.S., who owns a dental practice in Everett, Washington, lost staff during the pandemic, including dental assistants and a scheduling coordinator. “The response to ads placed online seems to be hit or miss; I have experienced a flood of applicants, and at other times, it is crickets — no response for days,” Dr. Steinhubel said. “The inconsistency in response is difficult depending on how urgently you need to fill the position.” The people who do apply are sometimes seeking part-time as opposed to full-time employment, and some are new to the profession, requiring more on-the-job training.

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“It is this sticky situation where we want to take in as many patients as we can to accommodate their needs, yet with working with fewer staff or training someone new, how can I as the employer take good care of both my patients and my team?” Dr. Steinhubel said. Allison House, D.M.D., chair of the Council on Dental Practice’s subcommittee on practice management, said the need for training can be difficult in the new normal created by the pandemic. “The complexity of dental practice in 2021 has made it difficult to do on-the-job training with dental assistants and front office staff,” she said. “While dentists are doing on-the-job training for these positions, it is not ideal.” Even before the pandemic, dental team members were in short supply, and the educational requirements for these positions could be part of the reason. “Hygienists have been in short supply for a number of years,” Dr. House said. “In most states, hygienists must have a license, and therefore it takes several years to graduate a qualified hygienist.” Dr. Steinhubel said there has been a shortage of both dental assistants and hygienists in her area for a few years. An assisting program closed, and a hygiene program was in danger of closing before finding a new facility, where it will be operating with a smaller number of students for at least the first year, she said. “There aren’t enough trained people to apply,” Dr. Steinhubel said. “We were beginning to feel the pinch of fewer applicants already.” Dr. De La Rosa’s employees have been approached by both headhunters and other dentists in the community with job offers. Headhunters reach out via social media and offer positions based on prior published work experience without personally meeting the candidates or checking references, she said. Her colleagues have reached out to her employees through word of mouth from their employees or others in the community. “When an employee has given me their resignation notice, they find solace in indicating that they were approached for the position, not actively seeking one. Unfortunately, I have not experienced solace in knowing they have not sought employment elsewhere,” said Dr. De La Rosa, who has been approached by a headhunter herself. “I have been left with the task of finding employees in a tight market during a pandemic.” Intense competition to fill openings has affected pay, which dentists say has been difficult as they recover from lower-than-normal patient volumes and rising overhead brought on by the pandemic. HPI data from May show the majority of hiring dentists have raised the pay rates for dental assistants, hygienists and administrative staff since the pandemic began, with 73.1%, 70.7% and 67.1% increasing pay for assistants, hygienists and administrative staff, respectively. Dr. Steinhubel has experienced the financial difficulties of increasing compensation rates while making additional purchases for her practice related to COVID-19, such as enhanced personal protective equipment, suction devices and air filters and purifiers. “I’m sure many other dentists are in a similar situation where we 18

feel the strain of catching up from our lost months of 2020 and managing quickly rising overhead costs on several different fronts while keeping our teams together and happy,” she said. It has been challenging to match the compensation requests of new applicants, who sometimes ask for pay outside the customary range for their experience and location, Dr. Steinhubel said. And she also has the paychecks of her current staff to support. “The low supply of applicants has caused several offices to advertise higher pay rates, which has led to several of my team members requesting raises — despite recent raises given post-pandemic — because they reported they see higher rates advertised in ads in cities nearby and will look there if not given one,” she said. Dr. De La Rosa has also increased pay in response to the pandemic. “I have always exercised and believed in a fair and competitive salary with generous benefits for my employees,” she said. “The pandemic has raised the expected compensation significantly. To keep my practice operational, I have increased salaries, added parttime employees, increased time allotted for patient appointment times and increased fees.” When positions are left open, it affects the way dentists and their remaining team members operate. “It creates much more pressure and stress on the entire office as each team member is asked to step outside their primary duties to help others, all with the aim of creating a smooth and seamless experience for the patient,” Dr. Steinhubel said. “As a business owner, it is my responsibility to provide for my employees, and right now, striking that balance of ensuring they have enough support to do their jobs and ensuring the business stays profitable despite sky-rocketing costs of overhead, so their salaries can be paid, is difficult to say the least.” With full-time applicants scarce, she has hired part-time employees just to get some help, but she worries about the impact on her staff’s work routine. “This makes for a daily change in work pace where we used to strive for a consistent, even flow,” Dr. Steinhubel said. “It’s another strain that we can adapt to, of course, but it just means some days are pretty crazy compared with others.” To address the concerns of dentists and their team members, the ADA is working alongside its affiliate organizations, such as the American Dental Assistants Association and American Dental Hygienists’ Association, to find outcomes that are mutually beneficial for the entire team, Dr. Ho said. In a statement, the American Dental Assistants Association said it is monitoring the dental assistant shortage and taking steps to address it. “The American Dental Assistants Association is aware and continually concerned with the shortage of dental assistants across the U.S.,” the association stated. “We continue to provide occupational services and education to advance dental assisting in America. Many factors have contributed to these shortages, such as July / August 2021

low wages and long hours with additional responsibilities and PPE. Dental assisting is a highly skilled profession requiring education and training. We will continue to monitor and address these concerns and look forward to working with the dental community to explore solutions that advance the profession.”

with adherence to the Centers for Disease Control and Prevention guidance, including proper PPE, dental hygienists can practice safely. Communication among the dental team is more important now than ever. As health care professionals, we need to support one another as we continue to navigate through this pandemic.”

The ADA and American Dental Hygienists’ Association are working together to research U.S. dental hygienists’ employment patterns during the COVID-19 pandemic, as well as their infection rates and infection control practices.

More dental hygienists returning to practice is a positive sign for dentists seeking to hire staff. But Dr. Ho said he knows addressing the staffing shortages and hiring challenges dentists are facing will take time.

As of late April, 3.8% of the surveyed dental hygienists who had been employed as of March 2020 were not currently working — the lowest unemployment rate since the start of the survey — with 66% of them leaving their positions voluntarily. According to survey data from March 1, 6.8% of dental hygienists had contracted COVID-19 since the start of the pandemic, lower than estimates for other health care workers and the general population.

“This is a big problem that will not be solved overnight,” he said. “The Council on Dental Practice, as well as the ADA, is open to all suggestions, especially those outside the box, to tackle these workforce shortages.”

“The health and safety of the entire dental team, their patients and families has been first and foremost,” said Ann Battrell, CEO of the American Dental Hygienists’ Association. “Many dental hygienists had questions and concerns about COVID-19 and rightly so. Some dental hygienists were faced with the very personal decision about returning to work in the face of the pandemic. Our most recent data indicate that for dental hygienists who have voluntarily left their positions, 42.9% reported, ‘I do not want to work as a dental hygienist until after the COVID-19 pandemic is under control.’ Another 38.1% stated, ‘I have concerns about my employer’s adherence to workplace/safety standards.’ We are pleased that

Dr. De La Rosa said she is heartened by the efforts of the ADA and her local and state dental associations to address the COVID-19 pandemic and its effects on the dental profession, including staffing issues. When facing professional challenges in the past, she has found that being open to change, keeping a positive outlook and leaning on available resources have helped her make sound decisions, develop tangible solutions and maintain her practice and patient-centered values. She is confident she can do that again. “I am certain that the future will be bright,” Dr. De La Rosa said. Mary Beth Versaci ADA News

PRACTICE COVID-19 AMONG DENTISTS IN THE UNITED STATES A 6 MONTH LONGITUDINAL REPORT OF ACCUMULATIVE PREVALENCE AND INCIDENCE ABSTRACT

Background - In 2020, the Centers for Disease Control and Prevention and the American Dental Association released COVID-19 infection control interim guidance for US dentists, advising the use of optimal personal protection equipment during aerosol-generating procedures. The aim of this longitudinal study was to determine the cumulative prevalence and incidence rates of COVID-19 among dentists and to assess their level of engagement in specific infection control practices. Methods - US dentists were invited to participate in a monthly web-based survey from June through November 2020. Approximately one-third of initial respondents (n ¼ 785) participated in all 6 surveys, and they were asked about COVID-19 testing received, symptoms experienced, and infection prevention procedures followed in their primary practice. Results - Over a 6-month period, the cumulative COVID-19 infection prevalence rate was 2.6%, representing 57 dentists who ever received a diagnosis of COVID-19. The incidence rates ranged

from 0.2% through 1.1% each month. The proportion of dentists tested for COVID-19 increased over time, as did the rate of dentists performing aerosol-generating procedures. Enhanced infection prevention and control strategies in the dental practice were reported by nearly every participant monthly, and rates of personal protection equipment optimization, such as changing masks after each patient, dropped over time. Conclusions - US dentists continue to show a high level of adherence to enhanced infection control procedures in response to the ongoing pandemic, resulting in low rates of cumulative prevalence of COVID-19. Dentists are showing adherence to a strict protocol for enhanced infection control, which should help protect their patients, their dental team members, and themselves. Practical Implications - COVID-19 infections among practicing dentists will likely remain low if dentists continue to adhere to guidance.

BACKGROUND

As of February 2021, severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2) has infected tens of millions worldwide with severe cases resulting in hospitalization and death.

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SARS-CoV-2, the virus that causes COVID-19, is transmitted primarily through personto-person contact, as well as via viruscontaining droplets (5-12 mm) and aerosols (5 mm). Susceptible people may become infected if virus-containing respiratory droplets or aerosols settle on their mucosa or are inhaled. The scientific community has established that transmission of COVID-19 is linked to aerosol-generating procedures (AGPs) and that the total viral load to which the health care providers (HCPs) are exposed is the main risk factor for infection. Therefore, both the Centers for Disease Control and Prevention (CDC) and World Health Organization have issued statements specific to AGPs and the need for the use of enhanced personal protective equipment (PPE). In 2020, a cross-sectional study published by our group reported that the prevalence of COVID-19 among US dentists was low, with a weighted estimated rate of 0.9% (95% CI, 0.5% to 1.5%). The study’s results showed that dentists following interim safety guidance were well prepared to resume their practice. In addition to our study, there have been limited reports on rates of COVID-19 among dentists. One report evaluated safety practices in 3 specialty dental clinics in the New York, New York, area and observed 0 cases of COVID-19 among 2,810 patients, 2 dentists, and 3 registered dental hygienists during a 6-month period. The practices indicated enhanced use of PPE, increased measures to screen and protect patients seeking care, and assessment of infection risk factors.6 Considering the infection rate in New York, New York, at the time, the authors concluded that oral health care can be safely provided as long as appropriate safety measures are followed. Another report surveyed 454 members of the American Academy of Endodontics, finding a high rate of adherence to enhanced infection control measures, including the use of N95 respirator (also called an “N95 mask”) by 83.1% of the participants. In the time after our initial study was deployed, the interim guidance for dental professionals from the American Dental Association (ADA) and CDC were revised on the basis of emerging scientific data. Most revisions addressed types of PPE for various procedure types, management of aerosols in the operatory area, and quarantine periods for dental HCPs exposed to COVID-19. As of December 2020, the revised CDC interim recommendations mandated that dental HCPs wear N95 masks or those that offer an equivalent or higher level of protection, gowns or protective clothing, and gloves and eye protection (goggles or full face shields) during AGPs and in areas with moderate to substantial community transmission of COVID-19 during AGPs. Although cross-sectional studies offer a snapshot of infection rates in a given population, there is a paucity of widespread longitudinal evidence of the safety levels and rates of infection among dentists and other HCP. Our 6-month longitudinal study aimed to ● determine the cumulative prevalence rate of COVID-19 among dentists; ● calculate the monthly incidence rate for the same population over the course of the study; ● assess the level of engagement in specific infection control practices among dentists over a 6- month period.

METHODS

We administered a novel web-based cross-sectional survey using Qualtrics from June 8 through November 13, 2020. Dentists were 20

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eligible to participate if they held a license to practice dentistry in the United States, were in private practice or public health, and indicated a willingness to participate in the previous ADAgenerated survey related to COVID-19. The protocol and survey were approved by the ADA Institutional Review Board and registered at ClinicalTrials.gov (NCT04423770). Details of the study population and questionnaire are described in our previous publication.5 We made several changes to the questionnaire after the first survey on June 8, 2020, which are detailed in the Supplemental File. All participants signed an electronic informed consent before starting the survey. We ascertained COVID-19 infection via self-reported date, type, and result of COVID-19 test (confirmed case) or, if not tested, the date an HCP told the respondent he or she had a probable COVID-19 infection (probable case). Each month, we considered those who reported a COVID-19 positive test or diagnosis who had not previously received a diagnosis of COVID-19 as newly infected. We calculated monthly incidence as the number of new confirmed or probable cases that month divided by the total number of dentists responding to the survey that month. The date a respondent was tested or received a diagnosis was missing for 22.0% of cases, so we used self-reported dates only to verify in which month a case should be counted. In no instance did the reported date not match the month in which it was counted. We also calculated the positivity rate as the number of confirmed cases over the total number of those tested that month. Respondents reported which PPE they used and how often when treating patients in the prior month as never, sometimes, or always. We used the CDC interim guidance document to categorize PPE use. We conducted all statistical analysis in Stata Version 13.0 (StataCorp). For COVID-19 testing results, we performed statistical weighting using linearization variance estimation so that the sample appropriately represented licensed US dentists in private practice or public health by age group and US Census Bureau division. We used single and multivariable multilevel regression models (logistic for binary outcomes, ordered logistic for ordinal outcomes), with survey results nested within each respondent to account for the same respondents answering surveys over time. We weighted COVID-19 incidence and used linearization variance so that the estimated incidence more accurately represented licensed US dentists in private practice or public health by age group and US Census Bureau division. We determined the weights on the basis of the ADA master file of all US dentists, as previously described. July / August 2021

RESULTS

A total of 2,196 US dentists participated in our 6-month longitudinal study from June 8 through November 13, 2020. The initial response rate was 40.1% in the first month. A decreasing number of the initial respondents continued to participate in the survey, such that 1,291 (58.8% of those who participated in the first month) participated in the final month, and a total of 785 (35.7% of initial respondents) participated in all 6 surveys. One participant who completed the initial survey 3 days after the study period ended had been excluded from the previously reported crosssectional results5 but was included in this analysis. The median age of responding dentists was 52.6 years, and most (1,300 [59.2%]) were male (Table). Overall, most respondents were non-Hispanic White (1,673 [76.1%]), in private practice (2,081 [94.8%]), and general dentists (1,802 [82.1%]). Participants with missing demographic and practice information in the first survey were asked again the following month, allowing for lower proportions of missing data in this study than our initial report. When exploring factors potentially related to participation rates, we observed that age, sex, race and ethnicity, region, and dental practice type were not associated with continued participation (P > .3). Among the respondents, 536 (an estimated 24.4%) had at least 1 medical condition associated with higher risk of developing severe illness from COVID-19, most commonly asthma (160 [7.3%]) and obesity (166 [7.6%]). To identify potential sources of infection, we asked dentists about their activities outside of their clinical practices. In the first month, 103 (4.7%) dentists reported no in-person contact (that is, interaction) with anyone outside their household in the month before answering the survey. This rate was significantly lower (P < .01) in all subsequent months. In-person contact in health care practice or social setting outside the household in the prior month were not significantly associated with participant age group or sex (P > .6) but was significantly associated with location. Specifically, over the course of the study, dentists in the Pacific region and Puerto Rico had the lowest overall rates of in-person contact (P < .01) compared with other regions of the nation. Rates of in-person contact with people outside of the household in the prior month did not significantly change in most regions over time (P > .05) but increased significantly over the study period in the Middle Atlantic region and Puerto Rico (P < .05). Throughout the study period, a minority of participants reported contact with someone with a suspected or confirmed COVID-19 infection in the past month. The percentage reporting contact with someone with COVID-19 significantly increased over time, from 4.6% (n ¼ 100) in the first survey to 16.1% (n ¼ 208) in the final survey (P < .01). In total, contact with someone with a suspected or confirmed COVID-19 infection was reported 875 times among the 2,196 participants over the course of 6 months; 430 (49.1%) of those reports were because of contact with dental patients. Another 310 (35.4%) stated that within the past month a coworker had COVID-19. In the study period, the likely source of COVID-19 was identified via contact tracing by a health agency or clinic in only 23 cases among dentists; in 2 instances, the dental practice was identified as the likely infection source.

Each month, most participants indicated that they provided oral health care in the prior month, increasing significantly over time from 2,043 (93.0%) in the first survey to 1,266 (98.1%) in the sixth (P < .01). The rate of dentists performing AGPs increased from 92.8% (n ¼ 1,893) in the first survey to 97.3% (n ¼ 1,502) in the second survey and continued to rise over time to 98.4% (n ¼ 1,246) by the end of the study period (P < .01). Over the period of our longitudinal study, the use of at least a surgical mask and eye protection while performing non-AGPs remained statistically stable, and similar results were observed for always wearing a N95 mask or equivalent and eye protection in the same month they performed AGPs (P > .5). We saw a statistically significant decline in dentists reporting sometimes or always wearing N95 or equivalent masks and eye protection during AGPs over time from 92.4% in the first survey to 88.0% in the final survey (P < .01) (Figure 2). During the course of our study, the CDC encouraged PPE optimization strategies in instances of limited PPE supplies. In the first month, only 355 (17.6%) dentists reported changing their masks or respirators between patients, and 407 (20.2%) changed them only if soiled or damaged. Over time, there was a decrease in PPE optimization, as significantly more dentists changed their masks with every patient (P < .01). Since June 2020, the rate never fell below 25.5%, and fewer dentists reported changing their masks only if soiled (by November, only 99 [8.2%] did so). Enhanced infection prevention and control strategies in the dental practice were reported by at least 99.7% of all dentists each month (no significant change over time; P ¼ .2). Throughout the study period, high and statistically unchanged numbers of dental practices reported screening patients and staff members for COVID-19, disinfecting between patients, and encouraging social distancing between patients (P > .05) (Figure 3). Although in the initial survey most dental practices already reported providing face masks to staff members and patients and had physical protections such as barriers, open windows, or air filters or scrubbers, an increasing proportion of practices instituted these strategies over time (P < .01). We added a question about teledentistry to the survey the second month, and the results showed that this was used at the highest rate in July (418 [26.1%]) and declined to 265 (20.5%) by November (P < .01). The proportion of dentists who had been tested for COVID-19 increased over time, from 355 (16.6%) in the initial survey to 566 (43.9%) in the final survey. Testing for COVID-19 using saliva samples was relatively rare (47 [2.1%]) compared with testing with nasal or pharyngeal swabs (703 [32.0%]). A minority (317 [14.4%]) were tested for COVID-19 antibodies via blood samples. As of the first survey, 20 (0.9%) dentists reported having ever been told they had COVID-19 by a medical HCP. New cases identified in each subsequent month were tallied to calculate monthly incidence and cumulative prevalence rates (Figure 4). In total, our 6-month analysis showed a cumulative prevalence rate of 2.6%, representing 57 dentists ever with confirmed or probable COVID-19 infection. The weighted incidence rates varied month by month, ranging from 0.2% through 1.1%.

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DISCUSSION

Owing to the aerosol-generating nature of many dental procedures, it was originally hypothesized that dentistry presented a high risk of transmitting SARS-CoV-210; however, no confirmed cases of COVID-19 transmission related to patients’ receiving oral health care have been reported to date. Furthermore, the results of our earlier cross-sectional study and the results of this study show that prevalence and incidence rates among dentists continue to be very low in comparison with the population as a whole and with other HCPs. At the conclusion of our study, robust data among front-line HCPs in the United States and the United Kingdom (2,035,395 HCPs) showed a higher rate of COVID-19 infection11 compared with findings from our study. A prevalence of COVID-19 was found among 2,727 cases per 100,000 HCPs compared with 242 cases per 100,000 people in the general population. The high number of cases mostly were associated with direct contact with infected patients and lack of appropriate PPE, with the highest rates reported in large metropolitan areas such as New York, New York, and London, United Kingdom. In addition, the same study showed that in the United States, 4.1% of medical HCPs were tested during the period of the study compared with 1.1% of the general population. In another report, results of a cross-sectional survey of front-line HCPs in the United States (n ¼ 3,083) showed a reported prevalence rate of 29%, which is much higher than the 2.6% rate among dentists reported in our study. In August 2020, 24% of employees of a large oncology hospital in New York, New York, were quarantined because of COVID-19. Another cross-sectional study examined levels of antibodies among HCPs and indicated that 265 of the 500 HCPs tested showed presence of SARS-CoV-2 antibodies, possibly resulting from a previous infection with the virus. Compared with these reports of nondental HCPs, our longitudinal data show lower rates for US dentists over the June through November 2020 time frame. Although the near universal adoption of enhanced PPE per the interim CDC guidance may have minimized the risk of getting an infection in the dental office, we also observed a higher rate of testing among dentists (up to 43.9%) than front-line HCPs. Despite this high testing rate, the cumulative prevalence among dentists in our survey was 2.6% by November 13, 2020. Furthermore, dentists have shown continued low monthly incidence of disease despite several regional and national COVID-19 rate spikes during the study period. This may indicate that dentists are able to mitigate much of their own exposure in clinical environments through consistent use of enhanced PPE and interim guidance adherence. The results of our study show high rates of pre-appointment screening of patients and appropriate infection control measures throughout the study period. The risk of getting SARS-CoV-2 infection decreases substantially with appropriate PPE use. An important distinction between dentists and other HCPs is that many medical procedures that do not involve intubation for anesthesia can be performed while a patient is wearing a mask. However, dental procedures universally require patients to be seen unmasked. This highlights the importance of continued use of enhanced PPE, in particular N95 masks, and the need for continued availability and prioritization of such protections for dental HCPs. We observed a minor shift in 22

the use of PPE during the 6-month period of our study, most likely owing to access to the equipment, clinical judgment, schedule planning, and other resources that dentists implemented since practice reopening. In mid-November 2020, 59.8% of dental practices in the United States reported having at least a 2-week supply of N95 or KN95 masks.16 Expanded use of N95 masks may be limited by supply shortages and the number of hours each HCP may be exposed to potentially infected patients. To our knowledge, this is the first large-scale longitudinal report of incidence rates of COVID-19 among dentists in the United States. The results of our report may show a decreased response rate over time but still present a sample that is nationally representative of US dentists. Our surveys also used the strictest definitions for infection prevention and control. These findings are selfreported and, therefore, subject to recall and social desirability biases. Unfortunately, the survey was limited to dentists’ PPE use and whether they performed AGPs that month and thus did not entirely match CDC interim guidelines for PPE use; it did not ask about dentists’ PPE use during AGPs compared with non-AGPs. Conceivably, dentists could answer the survey as sometimes wearing the correct PPE during a month they performed AGPs and be in compliance with CDC recommendations. Furthermore, not all dentists were tested for COVID-19 during the study; asymptomatic cases for which dentists did not seek testing or care were likely missed. We also could not survey participants who were hospitalized or died during our survey time frame. These people would not have been captured in this study. However, data on hospitalizations and deaths from March through May 2020 by health care occupation indicate both dental professionals and physicians had hospitalization rates below some occupations not expected to have patient contact, such as administrators. Therefore, we expect our estimation of the monthly incidence and cumulative prevalence to be affected less by hospitalization or death than survey research in professions with higher rates of severe COVID-19 cases.

CONCLUSIONS

The level of adherence to enhanced infection control procedures in response to the COVID-19 pandemic continues to be high among US dentists. The low rates of cumulative prevalence (2.6%) and monthly incidence ranging from 0.2% through 1.1% reflect the high level of self-care among dentists. Oral health care is being delivered safely because dentists are showing adherence to a strict protocol for enhanced infection control, which should help protect their patients, their dental team members, and themselves. Marcelo W.B. Araujo, DDS, MS, PhD Cameron G. Estrich, MPH, PhD Matthew Mikkelsen, MA Rachel Morrissey, MPA Brittany Harrison, MA Maria L. Geisinger, DDS, MS Effie Ioannidou, DDS, MDS Marko Vujicic, PhD JADA June 2021 July / August 2021

Mask off! Mask off! HOW WILL YOU HELP PATIENTS PREPARE FOR THE POST-MASK SEASON? OO U LHUENLTP EPEAR TI N I EGN TAST PSRAE LP T A RLEA FKO S TD- M N ?E S $ S L D D S % . OTWA W Y O U A NH S R TI L LYY V E RD TOHNEAPTO ED E NATSAKL SSEEARSVOI YOU AN START Y VOLUNTEERING AT SALT LAKE DONATED DENTAL SERVI ES $SLDDS%. SLDDS' mission proves to be more critical than ever as we deal with the effects of the COVID-19 pandemic. SLDDS' mission proves to be more critical than ever as we deal with the effects of the COVID-19 pandemic. Thousands of Utahns have experienced disruptions of income, which in turn has caused the loss of dental Thousands of Utahns have experienced disruptions of income, which in turn has caused the loss of dental insurance coverage. High out-of-pocket costs of dental care are jeopardizing the average family’s ability to insurance coverage. High out-of-pocket costs of dental care are jeopardizing the average family’s ability to afford basic care. nd delaying regular dental check-ups can result in progressing caries, periodontitis, and other afford basic care. nd delaying regular dental check-ups can result in progressing caries, periodontitis, and other preventable diseases that are costly to treat. The access to dental care has been further limited for families living preventable diseases that are costly to treat. The access to dental care has been further limited for families living in poverty as Utah experienced safety-net clinics' closures and shortages of volunteers and regular workforce. The in poverty as Utah experienced safety-net clinics' closures and shortages of volunteers and regular workforce. The average wait time for dental care in the community clinics is 5 1 weeks! average wait time for dental care in the community clinics is 5 1 weeks!

SLDDS knows that by providing our underserved neighbors with free comprehensive oral health care better equips SLDDS knows that by providing our underserved neighbors with free comprehensive oral health care better equips you help them to But we we cannot cannotdo doititwithout withoutour our community's support. Will you help us us them tosucceed succeedin inall all aspects aspects of of life. life. But community's support. Will improve in need

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Volunteering at SLDDS is easy! Our clinic has 5 operating rooms with modern equipment

Volunteering at SLDDS is easy! Our clinic has 5 operating rooms with modern equipment and materials. Dentist work with the experienced dental assistants we have on staff or and materials. Dentist work with theearning experienced dental assistants we have on staff or volunteer with their teams while 1 CE credit for every 4 hours volunteered. volunteer with their teams while earning 1 CE credit for every 4 hours volunteered.

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