2015 16 fall issue final

sfdda Volume 57, No. 2 www.sfdda.org Fall 2015

We are different, and together we create a powerful picture

President’s Message

Elaine deRoode, D.D.S.

Importance of Belonging to Organized Dentistry - “Are You With Us?” I became an ADA (ASDA) member at UCLA because it was the “correct” thing to do. At that time, the common thought in the academic environment was, “If you aren’t with us, you’re against us.” Since becoming a member, I have realized how crucial my tripartite membership is.

Every ADA member has their own reason for belonging whether it is the political lobbying, the active support of science and research, or the abundance of practice resources the ADA provides. My personal reason for maintaining membership is to ensure that the advocacy the ADA and FDA provide for us in Washington, D.C. and Tallahassee remains the strongest and most powerful, enabling us to practice in a manner that is mutually beneficial to dentists and our patients.

After serving for several years as a delegate for the FDA House of Delegates, I have become aware of the crucial role of our FDA lobbyists. On a daily basis, they work intimately with our politicians in order to maintain the validity and quality of our dental license, the autonomy of our dental practice, and the safety of the public.

Inside this Issue: Part 2, Ethics in Dentistry, pg 4 Email Responses on Ethics, pg 9 Mid-Level Providers-Why ADA Membership Matters, pg 10 The Lighter Side of C.E., pg 13 Editorial Response to DHAT Issues, pg 14

Of recent, the topics of utmost relevance to our practice include maintaining our current practice model, with an appropriately trained and licensed dentist as the leader of the dental team, ensuring foreign trained dentists who practice here are held to similar standards as US graduates, and working closely with the Board of Dentistry on the issue of record keeping.

At the national level, some of the issues the ADA is currently involved with include health care reform, student debt, and medical device tax repeal. Through the ADA Engage Action Center, contacting your state legislator is a only few clicks away. If you have not done so already, use to the link below to urge your representative to support the ADA on current issues: http://cqrcengage.com/dental/home The ADA is our profession of dentistry’s leading (and sometimes only) advocate with regard to how we practice, whether as a general dentist or specialist. No other organization is as encompassing as the ADA, nor as effective in lobbying for the dentist in the political, professional, and personal realms. The voice of our organization will only be as strong as our numbers. Thus, the question remains, “Are you with us?”

The Truth Behind the PAC, pg 15 Important: A New Member Benefit , Pg 16 Classifieds, pg 19

Celebrating Diversity, pg 20 3

Ethical Considerations In the Practice of Dentistry - Beginning the Conversation The second of a multi-part series: Richard A. Mufson, D.D.S., Editor

The beginning of this conversation took place in our last issue, Volume 51, No. 1 Summer, 2015.

The initial premise referenced the many changes occurring within dentistry over the past decade or more, some very positive, paving the way for improved care of our patients, but others, perhaps not so positive – or at best, resulting in many questioning the nature of what is taking place within our profession.

A central common theme, in the case of the latter negative concerns, often appears to bear some relation – whether directly or indirectly - to issues involving ethics, or ethical decision-making.

Several questions were posed as examples, which among others, included, “Are economic forces, such as student debt, insurance plans and/or varying dental practice models possibly influencing our choice of care or procedures we may perform?” Or, “Are the myriad hands-on techniques and courses marketed to us resulting in our feeling increasingly empowered to perform an ever-widening scope of procedures which may exceed our training and expertise?” “Are the ever-increasing numbers of specialists (or those who claim to be specialists) traveling to ever-increasing numbers of dental offices in a given region of the state, or even the entire state, able to adequately care for - including post-operative follow-up care - their respective patients?” Does every single extraction site truly require a ‘bone graft’?” There are no doubt many other related questions one could imagine or ask.

Following the initial article, I received an unexpected, but welcomed, influx of responses from others, from both the South Florida area and elsewhere, agreeing with varying aspects raised, while also adding new related comments, and some of which I wanted to share with you (please see page 9).

Sharing A Chapter Written For an Ethics Textbook As I related in the opening article, I had been asked several years ago to contribute a chapter for a textbook on the subject of ethics in dentistry. The chapter assigned to me was entitled, “Ethical Aspects of Referrals Within Dentistry.” And, my stated goal was to share the chapter with you in the form of a “multi-part series.”

I also wanted to repeat the disclaimer that I do not by any means 4

consider myself an “expert” in the field of ethics. However, after almost backing away when asked to write and submit such a chapter, I reflected on my 28 years of practice as a specialist,and having seen and lived through a vast array of experiences and scenarios involving “referrals” and the complex ethical issues inherent to this important part of dentistry, I felt I could envision contributing a number of important thoughts to others.

In the last issue, following other introductory comments, I chose to begin the discussion by first sharing the “preface” of the chapter, which essentially sets the stage with my own view of the meaning of, or how I personally define, “ethics.”

“Part 2” of the chapter is next, and… here it is. (Another brief disclaimer: If some information within the chapter appears far too elementary or basic for one’s “dental” intelligence level, such as identifying all the ADA specialties – please keep in mind the target audience for the text was intended to be undergraduate and graduate dental students.)

Chapter on “Ethical Aspects of Patient Referrals Within Dentistry” – Part 2 Patient Referrals in Dentistry The majority of referrals in dentistry are initiated within the office of a general dentist seeking the services a specialist in one of nine disciplines or specialties recognized by the American Dental Association (ADA). These include endodontics, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, prosthodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, and dental public health.

Referrals to the first six of those listed take place on a more frequent basis than the latter three, although no less important, specialties of dentistry. The indications for referral, which are covered in more detail within the next section, generally consist of situations in which a patient’s perceived needs, whether diagnostic or therapeutic, are different or fall outside the scope of what the referring dentist is trained or accustomed to providing.

There are several other “specialty areas,” which have not been granted official specialty status, nor recognized as such, by the

ADA. Considerable debate has taken place over the years as to whether such disciplines represent legitimate or true “specialties” within dentistry, or whether a dentist may legally or ethically purport to be a “specialist” when conversing with patients or in advertisements. Some of these include dentists who have devoted significant time, interest, a greater portion of their practice, or even limitation of their practice, to performing such treatment as nonsurgical TMJ/facial pain therapy, implantology, dental anesthesia, holistic dentistry, and others. Despite one’s viewpoint on this issue, many dentists practicing within one of these ancillary areas - by virtue of additional time, interest, and experience in performing a particular procedure or treatment modality - are also the recipients of referrals from other dentists seeking the additional expertise they may offer.

Referrals also take place on a frequent basis between specialists.

This most often occurs in situations in which a given specialist may learn that his or her patient has developed a condition or requires a procedure which may fall outside the scope of his or her own training or specialty, and feels the patient may require treatment by a dentist within a different specialty area from their own.

As one example of many, it is not uncommon for a patient to appoint with an oral surgeon for an extraction, only to learn that the tooth in question is able to be treated and preserved, if so desired, by referral to an endodontist, or perhaps a periodontist, depending on the underlying cause of the problem. The reverse situation is also a common occurrence, in which an endodontist or periodontist discovers that a given tooth is not amenable to therapy other than extraction by an oral surgeon. Pediatric dentists frequently refer to orthodontists depending on a patient’s age or status of dental and occlusal development. Surgical specialists send biopsy specimens to oral pathologists on a frequent basis, and of lesser frequency, patients requiring complex imaging or interpretation thereof may be referred to oral and maxillofacial radiologists.

Physicians and medical specialists are also the frequent recipients of referrals when the condition or needs of individual patients fall beyond the limits of a dentist’s scope of practice. Among numerous examples, patients suffering from facial pain, headaches, or those with perceived ear, nasal or sinus problems are often referred to neurologists or otolaryngologists respectively. Patients with complex medical problems are frequently referred back to their family physician, internist, cardiologist, or depending on the specific medical condition of a patient, perhaps to a pulmonologist, nephrologist, or even rheumatologist (or others) for “medical clearance” prior to our initiation of dental treatment. Medical professionals also refer to dentists in situations in which dental pathology is a suspected source of a patient’s underlying symptoms or problem.

Physical and occupational therapists, speech pathologists and host of other ancillary health care professionals also receive referrals of patients from practicing dentists.

Although the majority, but not all, referrals in dentistry are initiated within the office of a general dentist seeking the services of a dental specialist, a myriad of variations of referral patterns exist

among a multitude of differing dental and, as mentioned, other health care providers. However, for the purpose of this chapter, the term “referring dentist,” when used, should usually be taken to mean the patient’s general dentist or primary dental provider, and the term “specialist” or “consulting dentist” should be usually taken to mean the health care practitioner to whom a patient in being referred.

Indications For Referral: When To Refer?

Health care providers share a common responsibility, both from a clinical and patient care point of view, as well as from a legal and ethical one, of having a knowledge and appreciation for “when to refer” a patient.

According to Section 2.B. of the ADA Principles of Ethics and Professional Conduct, “Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge and experience.”1,2 By virtue of one’s dental school education and training, combined with one’s license to practice dentistry within a given state or jurisdiction, and the respective laws, rules, and definition of dentistry therein, dentists are afforded the tools and opportunity to perform a wide array of procedures and services ranging from restorative therapy to periodontal, endodontic, oral surgery, orthodontic and others. Many of today’s postgraduate continuing education seminars and hands-on courses, some with significant length and intensity, may also widen the base of knowledge and skills in performing more advanced or complex procedures which, in many cases, may even be the same or similar to procedures generally performed by specialists.

However, all health care professionals, regardless of education, training and experience, are expected to have a general awareness and appreciation for their own individual respective “limitations” and the clinical judgment to know when certain procedures or clinical circumstances may require a level of expertise beyond that which they are capable of effectively or safely providing.

Perhaps the single most ubiquitous common thread and recurring ethical theme applicable to the process of patients referrals in dentistry is the very duty and obligation of a dentist to (a) know his or her own limitations in training and expertise relative to performing a given evaluation or procedure, and in turn, (b) possess the knowledge and awareness of when to refer a patient to a provider with a different, or more advanced, level of knowledge, skill and expertise – all in the name of properly safeguarding the health and well being of the patient.

The majority of practicing dentists are familiar with, or through a process of learning and experience, are expected to become familiar with, their respective limitations. For example, when faced with performing a given procedure, whether it be an extraction of a tooth, an endodontic procedure, a large prosthetic reconstruction, or any of a number of other procedures performed on a daily basis - an assessment is typically made prior to initiating treatment as to whether the procedure in question is “routine” and/or continued on pg. 7

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Ethics, continued from pg. 5

expected to fall within the dentist’s scope of experience and training, or whether it may be potentially more complex or outside the realm of what the dentist feels competent to perform. If falling into the latter category, a prudent and ethical dentist would be expected to refer the patient for such a procedure to a specialist or other practitioner capable of performing the treatment in a more skilled and competent manner.

However, the line separating routine and complex procedures is far from always being obvious and clear, may often be clouded by a multitude of given factors and/or individual patient or clinical situations, and to a large extent, depends on adequate forethought, experience and careful judgment on the part of the evaluating dentist.

There are also some dental procedures, which may appear “routine,” even to the most experienced and trained of eyes, but once performed, may surprisingly turn out to be more complicated than expected, and may even require referral to a specialist in the middle of a procedure. This situation has the potential to be quite unsettling for the dentist and patient, and may also at times result in patient harm.

In any case, it is our clinical and ethical responsibility to refer a patient – not only when the need for a more experienced and competent practitioner appears clear and obvious – but also when a procedure has a reasonable possibility of turning out to be more complex than anticipated. Erring on side of patient safety and knowing “when to refer” is considered an integral part of being a prudent and ethical dental practitioner.

Regretfully, situations exist in which patients may knowingly be subjected to care above and beyond the boundaries of a given dentist’s training, experience or clinical competence, potentially resulting in inferior, incomplete, or incorrect care, or in more extreme cases, care which is injurious or inhumane. This type of care – when a practitioner knows, or should very well have known, that treatment attempted or provided clearly falls outside of the boundaries of his or her own ability and/or level of training, and especially when resulting in patient harm - is clearly regarded as unethical.

Should such treatment result in harm to a patient, it may also be regarded as a breach of the prevailing standard of care from a medico-legal standpoint, and potentially result in a lawsuit or action against one’s license.

Finally, there are situations in which a patients may present to a dentist with legitimate oral health care needs, but in which it may be readily apparent or obvious – whether due to factors related to age, behavioral or emotional status, ability to cooperate, certain medical conditions, or other “special needs” – that he or she may not feel capable nor be in a position to offer treatment. However, dentists have both a clinical and ethical responsibility to recognize the fact that patients in need of such treatment may suffer unfavorable consequences if proper care were ignored or delayed, and therefore an ethical obligation to refer such patients in a timely manner for that which they themselves are not able to pro-

vide.1-3,5,7 Misrepresentation of Specialty Status or Training Situations occur in which dental practitioners, whether intentionally or unintentionally, may imply, infer, or otherwise communicate to patients or the lay public that they are a “specialist” in one or more disciplines of dentistry, when in fact, the practitioner may not limit their practice to that purported specialty nor have earned a certificate of training from an accredited postgraduate specialty training program. Some may erroneously communicate specialty status in some cases simply as a result of having completed one or more abbreviated courses of additional training, or based on the misguided logic that they may possess a higher level of interest or experience in a given procedure or discipline than other similar general practitioners.

Similar to the issue of failure to refer a patient, when appropriate or necessary – a failure in being truthful and/or the misrepresentation of one’s specialty training or status, especially if it were to result in patient harm, is not only unethical, but for reasons of fraud and deception, may also be subject to violations of law, the prevailing standards of care, and may place one at an increased risk for potential civil litigation.5 When “Not to Refer” Ethical, and even legal, violations may also occur in situations involving referrals for improper or inappropriate reasons. Similar to the expectation that dentists have an awareness of “when to refer,” there are also situations in which an appreciation must exist for the concept of “whether to refer,” “when not to refer,” or when a logical, genuine or forthright rationale for referral, in the name of the best interest of the patient, is lacking.

In such instances, the decision to refer may be questionable if not based on the typical reasons of one’s limitation of training or skills, or when the expertise of others is not truly required, but rather when other hidden motives may be involved in the decision making process which may not be in the best interest of the patient.

Notable examples involving the questions of “whether to refer” or “when not to refer” would include referrals based on a patient’s race, religion, sexual orientation, or whether a patient may have an infectious disease, such as HIV/AIDS.1-4 Referral of, or refusing to treat, a patient, when confined to such reasons is not only unethical, but is also, in many or most cases, and depending on individual circumstances, a violation of state and federal antidiscrimination laws.

Other situations involving the decision to refer a patient for disingenuous or self-serving reasons, rather than for those of patient benefit, may include those in which a dentist may discover a patient who may have an objectionable personality or personal hygiene, a substance abuse or pain management problem, a lack of finances, a history of litigation against a health care provider, or any of a number of other personal circumstances one may simply “not like.” Referral to other providers in such cases, under the guise of the patient requiring more advanced care, such as to ancontinued on pg.8

Ethics, continued from pg. 7

SFDDA 2015-2016 Officers and Executive Council President ELAINE DEROODE, D.D.S. (305) 373-7799 Vice President Mark A. Limosani, D.M.D., Msc (954) 800-3453 Secretary Joseph Pechter, D.M.D. (954) 981-0012 Treasurer RODRIGO ROMANO, D.D.S., M.S. (305) 667-8766 Immediate Past President MARCOS DIAZ, D.D.S. (954) 659-9990 Young Member ENRIQUE MULLER, D.M.D. (305) 931 0607 Trustees & FDA Line Officer Michael D. Eggnatz, D.D.S., FDA 2nd Vice President (954) 217-8888 Jorge Centurion, D.M.D., Trustee 305-662-22167 Beatriz Terry, D.D.S., Trustee (305) 279-2828 Alternate Trustees Jeannette Peña Hall, D.M.D. Rodrigo Romano, D.D.S., M.S. Delegates to the Executive Council from the Affiliates Societies

other specialist, to a local academic center, or even more inappropriate, to a hospital emergency room, is known to occur within dentistry as a convenient method of having the patient leave the office and go elsewhere.

Many specialists within medicine and dentistry have come to know this practice of referring such “difficult patients” as “dumping.” It is important to point out that such scenarios may have many gray areas in which one’s intent or other circumstances are not always clear or obvious. However, referrals clearly motivated by such self-serving reasons rather than patient benefit may be subject to question from an ethical standpoint.

Yet another category of patient “dumping” involves after-hours emergency care. It is considered both a legal and ethical responsibility of every practicing dentist to ensure that he or she may be contacted and available for patients of record in the event an emergency need arises after office hours (or alternatively, to arrange for a similar provider to cover the practice, when out of town), and especially for those in the middle of ongoing care.1,3,4 However, some practitioners do not heed this well known clinical and ethical responsibility.

Such a problem may become apparent in the course of daily practice when a specialist receives an occasional call on an evening or weekend from a patient complaining of a postoperative problem following recent treatment by their dentist, but with whom the specialist is completely unfamiliar, and in the absence of any previous communication or arrangement having been made in advance for covering the practice of the treating dentist. Rather than the treating dentist address the problem directly by providing advice, or offering to see their patient at the next available opportunity, the patient may relate that they were instead told by their dentist (or answering service) to contact a given specialist, or even a more random and inappropriate message, such as, “go to the hospital.” Aside from being subject to laws governing dental practice or increased exposure to potential civil litigation, dentists who may choose to make themselves unavailable for the after-hours emergency needs of their patients are engaging in behavior which is unethical.

Future Chapter Sections Include:

Carlos Sanchez D.M.D. (MDDS) Esteban Leon, D.M.D. (MDDS) Richard Mufson D.D.S (ND/MBDS) Isaac Garazi, D.M.D. (ND/MBDS) Ross Schwartz, D.M.D. (SBDS) Affiliate Society Presidents Alexandra Castillo, D.M.D. (MDDS) Chandy Samuel, D.D.S.(ND/MBDS) Mark Limosani, D.M.D. (SBDS) Richard A. Mufson, D.D.S., Editor Yolanda Marrero, Managing Editor Jackie Quintero, Advertising Manager SFDDA NEWSLETTER Copyright: © SFDDA 1996 Published by the South Florida District Dental Association 420 S. Dixie Highway, Suite 2E Coral Gables, FL 33146 Send announcements and correspondence to the Editor: 420 S. Dixie Hwy, 2-E Coral Gables, FL, 33146-2271 Phone: (305) 667-3647 FAX: (305) 665-7059 or email to: sfdda@sfdda.org Disclaimer: Opinions stated in the SFDDA Newsletter are not necessarily endorsed by the South Florida District Dental Association, its Executive Council or Committees. Advertisements printed should not be construed as an endorsement by the Association of the company, product or service.

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continued on next page

- Referral Decisions Based on Financial Considerations - Decisions Affecting Our Choice of Specialist or Consulting Doctor - Proper Communication in the Referral Process - Ethical Considerations From the Specialist/Consulting Dentist’s Perspective - Respect for the Referring Dentist-Patient Relationship - Justifiable Criticism - Choosing Words Carefully When Speaking About Others _____________________________________________ References: 1. Principles of Ethics and Code of Professional Conduct, with official advisory opinions, American Dental Association, revised to 2011.

2. General Guidelines for Referring Dental Patients, American Dental Association Council on Dental Practice, revised 2007.

3. American Association of Oral and Maxillofacial

Surgeons Code of Professional Conduct, September, 2011.

4. Principles of Ethics and Code of Professional Conduct, American Association of Orthodontists, adopted May, 1994, amended through May, 2009.

5. Ethics Handbook for Dentists: An Introduction to Ethics, Professionalism, and Ethical Decision Making, American College of Dentists, Gaithersburg, MD, 2008.

6. Mufson, RA, Dentists Talking Negatively About Dentists, East Coast District Dental Society Newsletter, Volume 40: No 1, pg 4-5, September/October, 1998.

This article is the second in a series on the topic of ethical considerations in the practice of dentistry. Dr. Mufson is the editor of the SFDDA Newsletter, and may be contacted at (305) 935-7501 or MufsonOralSurg@aol.com

Email Responses to Ethics in Dentistry Article - SFDDA Summer, 2015 Issue Note from the Editor: In response to the article appearing in our last newsletter (Summer, 2015), “Ethical Considerations In the Practice of Dentistry - Beginning the Conversation,” I received a number of responses from members/readers, and felt that I would like to share those responses. The respondents were also asked for permission to print the responses, including the name of the author, as opposed to whether anonymity was preferred. In cases in which the author was not identified by name, a response back was not received in time for printing of this newsletter (no respondents otherwise expressed a preference to remain anonymous).

Although some of our readers may not universally agree with some the words or opinions expressed, please keep in mind the following are “opinions,” and do not necessarily reflect those of SFDDA, officers and/or staff. We would also welcome your own opinion, if you so choose to send an email or “Letter to the Editor.”

Great article. One of the greatest challenges facing our profession, in my opinion.

- John Joffre, General Dentist, South Miami As a dentist who has always done what I thought was best for that particular patient, I want to say that overall, there is a tremendous loss of ethics in dentistry. I don't think there is one simple reason but numerous ones that all have allowed this occur. A major factor is the over abundance of dentists in Florida. A local famous trial attorney once said that it is much easier to be ethical when you are busy.

-Ray Kimsey, General Dentist, Coral Gables Your article was “right on the money.” What about “rent-a-docs” and their complications? You have no idea how many of these patients I see on a weekly basis in ER’s at local hospitals. Some have transfusions, anesthesia complications, fractured jaws, etc.

Whey can’t we shut these people down? Just a thought.

- Dr. F, Oral and Maxillofacial Surgeon, South Florida Awesome article! I can’t agree with your more. It is unfortunate that “I” have been practicing 22 years, I have seen a significant decline in morals and ethics when it comes to patients. Whether it be changing all amalgams to composites, to the use of the CT for diagnoses that can be made with a standard radiograph, there is a lot to ethically consider. When you consider the rest of the world, why would we be any more ethical than what we see, hear and learn each day about corporations, governments and people in general. It is people like yourself that produce constant droplets of ethics that may one day create a puddle or an ocean.

Time will tell.

-Ed Kirsh, Endodontist, Pembroke Pines I appreciate the chance to read your article. Indeed, I believe that you will start a "conversation." In summary, and it bothers me to write this, I feel our profession is transitioning into a trade.

The driving force - money. We can discuss student debt and corporate health care, both of which, in my opinion, are preeminent as causative factors. Others include, as you stated, technical advancements with materials and techniques, a replacement of collegiality by competition, an increase in itinerant practitioners (who have no roots in the community - carpetbaggers, so to speak), a disregard for appropriate treatments (one local general dentist I know places Arestin in each tooth socket at $43.00 a pop), treatment alternatives are not discussed, and likely a myriad of others.

I cannot recall when a new dentist came to town and introduced him/herself at my office. The attitude seems to be, at least among the newer breed is, "here I am, and I can do it all." Corporate health care further add its "cans and cannots" to the problem. As you know, referrals go to the closest doc on the same insurance plan, and quality is not even a consideration. continued on pg. 17

Mid-Level Providers: Why membership in the ADA Matters - Cesar R. Sabates, DDS, FACD, FPFA

“Access to dental care” has been a growing concern for many years. Foundations and many other individuals have frequently used the same catch phrase to propose a new provider be introduced within the dental team to meet the challenge. “Mid-level providers” (aka “dental therapists”) are being touted as the solution to this nation’s access to care problem. The W. K. Kellogg Foundation has committed millions of dollars to advocate and promote this “solution.”

2.6% by 2033.

However, such arguments are simply not valid. Consider an article from the ADA Health Policy Resource Center, written by authors, Thomas Wall, MBA, Kamyar Nasseh, PhD and Marko Vujicic, PhD, “U.S. Dental Spending Remains Flat Through 2012.” The article contains invaluable results of extensive research and is very effective in countering such inaccurate claims made by others.

Many who advocate for mid-level providers use the argument that, “There is a shortage of dentists.”

The American Dental Association (ADA) remains steadfast in opposition to the mid-level provider. ADA Policy on the Mid-Level Provider (Trans. 2008:439) states: “Resolved, that the ADA’s position on any proposed new member of the dental team shall be an individual supervised by a dentist and be based upon a determination of need, sufficient education and training and of scope of practice that ensures the protection of the public’s oral health.”

The highly acclaimed ADA Resource Center, in doing expansive research and sharing of such important information, is yet another membership value and benefit of belonging to organized dentistry.

In spite of the ADA’s opposition to the Mid-level provider, the Commission on Dental Accreditation (CODA), an independent entity recognized by the U.S. Department of Education as the national accrediting agency for dental, allied dental and advanced educational Many who advocate for mid-level providers use the ar- programs, adopted standards by which programs that edgument that, “There is a shortage of dentists.” A recent ucate mid-level providers can apply for accreditation. report by the ADA Health Policy Institute demonstrates that the number of dentists practicing per 100,000 people To give you an idea of what the scope of practice of a today has climbed more than 4% from 2003 to 2013, is mid-level “dental therapist” would be, I ask you to read projected to increase by 1.5% from 2013 to 2018, and the following, taken directly from a document entitled

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“CODA Accreditation Standards For Dental Therapy Ed- remember one of my oral surgery professors telling me, ucational Programs” “Son, you can only say it’s a simple extraction once you have that tooth sitting on the bracket table.”

“At a minimum, graduates must be competent in providing oral health care within the scope of dental therapy It is time that we all wake up! Those of you who are practice with supervision as defined by the state practice members of the ADA, I applaud you for your investment acts, including: in your future. Those of you who are non-members I sima. identification of oral and systemic conditions requiring ply ask you: “What are you waiting for?! Your profession evaluation and/or treatment by dentists, physicians or needs you! Don’t wait until it’s too late.” other healthcare providers, and managing referrals b. comprehensive charting of the oral cavity In a recent commentary published in Dental Abstract, c. oral health instruction and disease prevention educa volume 60, issue 1, 2015, Dr. Frank Catalanotto, states tion, including nutritional counseling and dietary that, “Organized dentistry at the state and national level analysis has opposed virtually all efforts to expand access to care d. exposing radiographic images to underserved individuals. And, in many cases, the Fede. dental prophylaxis including sub-gingival scaling eral Trade Commission [FTC] has stepped in to help preand/or polishing procedures vent this restraint of trade. Great examples of FTC f. dispensing and administering via the oral and/or top- intervention in the past decade or so can be found in ical route non-narcotic analgesics, anti-inflammatory, Alaska, Alabama, Minnesota, South Carolina, Louisiana and antibiotic medications as prescribed by a licensed and Florida. Dentistry PAC’s are in full battle mode. Just healthcare provider get a copy of ‘The Dental Workforce Cook Book,’ if you g. applying topical preventive or prophylactic agents (i.e. can. I have only heard about it, but have not seen it.” fluoride) , including fluoride varnish, antimicrobial agents, and pit and fissure sealants With all due respect to Dr. Catalanotto, I would disagree h. pulp vitality testing with his statement that: “Organized dentistry…has opi. applying desensitizing medication or resin Those of you who are non-members I simply j. fabricating athletic mouth guards k. changing periodontal dressings ask you: “What are you waiting for?!” l. administering local anesthetic Your profession needs you! m. simple extraction of erupted primary teeth Don’t wait until it’s too late. n. emergency palliative treatment of dental pain limited to the procedures in this section posed virtually all efforts to expand access to care to uno. preparation and placement of direct restorations in pri- derserved individuals.” As a past president of the Florida mary and permanent teeth Dental Association, president of Florida’s Donated Denp. fabrication and placement of single-tooth temporary tal Services, vice-chair of the ADA’s Council on Access crowns Prevention and Interprofessional Relations, and a general q. preparation and placement of preformed crowns on practitioner in private practice who has devoted most of primary teeth his professional life advocating for access to the underr. indirect and direct pulp capping on permanent teeth served, I could not be prouder of the ADA’s leadership s. indirect pulp capping on primary teeth role when it comes to advocating for “access to care.” t. suture removal u. minor adjustments and repairs on removable prosthe- Please take time to look at the following publications by ses the ADA and the FDA Action for Dental Health Initiav. removal of space maintainers” tive: “Breaking Down Barriers to Oral Health for All Americans: The Community Dental Health CoordinaAll of this can be accomplished by an individual with tor,” “Breaking Down Barriers to Oral Health for All just three years of post-secondary education! A bit alarm- Mid-Level Providers continued. from pg. 9 ing wouldn’t you say? How about “m. simple extractions”? Who can define the term, “simple?” I can Americans: The Role of Finance;” Breaking Down Barcontinued on pg. 14 11

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The Lighter Side of C.E. South Florida District Dental Association Affiliate Society Dinner Meetings & More At the SFDDA, we offer many opportunities for you to receive continuing education, participate in personal enrichment and meet and mingle with your colleagues.

There are three affiliate societies under our umbrella including North Dade /Miami Beach, South Broward and Miami Dade Dental Society.

Each society meets in an area near your practice or your South Broward Dental Society All Meetings Held at Tropical Acres, Davie September 9, 2015 Dr. Irwin Becker Occlusion November 11, 2015 Dr. Inez Velez Oral Pathology January 13, 2016 Dr. Juan Carlos Quintero Airway and Ortho March 9, 2016 Dr. Ozwaldo Mayoral Microscope Based Dentistry

South Florida District Dental Association Events Held in Various Locations October 21, 2105 “Medical Errors & Domestic Violence” Dr. Richard Mufson Tropical Acres December 2, 2015 Dr. Sanjiv Chopra Kovens Conference Ctr North Miami February 2, 2016 Adrian Wilkins Solé Hotel Sunny Isles

home, making it easy for you to attend a continuing education dinner meetings through out the year.

Enjoy a very nice meal while receiving C.E.credit at the many interesting lectures being presented.

From information on the latest science, technology and practice management to programs designed to inspire, the SFDDA and its affiliate societies are always thinking of ways to help you succeed.

North Dade / Miami Beach Dental Society All Meetings Held at Bonefish Grill, Aventura September 2, 2015 “Cone Beam CT and Airway Centered Treatment Planning” Dr. Juan Carlos Quintero November 3, 2015 North Dade / Miami Beach Social December 8, 2015 “Digital Workflow & CAD Prosthetics” Dr. Ethan Pansick

Miami Dade Dental Society All Meetings Held at Graziano’s, Coral Gables Sept 8, 2015 “Dental Office Lease Negotiation Strategies: Identifying $100,000 Traps inYour Dental Office Lease” Justin Ditkofsky Manager of Cirrus Lease Consulting October 13, 2015 “Diagnostic Benefits of Variable Field of View 3D Imaging” Jordan Reiss

January 12, 2016 “Periodontics” Dr. Saynur Vardar

November 10, 2015 “Solutions For Immediate Full Arch Rehabilitation “In One Day” Wayne Szara, CDT - Emerging Technology Specialist

March 1, 2016 Members Night Presentations by Fellow Members

January 12, 2016 “Microscope use in the Dental Practice” Dr. Ozwaldo Mayoral

2015-16 SFDDA & Affiliate Society Presidents South Florida District Dental Association Dr. Elaine deRoode Miami Dade Dental Society Dr. Alexandra Castillo

February 10, 2106 Reese Harper Tropical Acres, Davie

North Dade / Miami Beach Dental Society Dr. Chandy Samuel

April 20, 2016 Annual Business Meeting Location TBD

South Broward Dental Society Dr. Mark Limosani

March 8, 2016 “Regeneration” Dr. Rodrigo Romano April 5, 2016 “Current Approaches to the Assessment, Diagnosis and Treatment of Halitosis” Dr. Irene Marron

Joining an affiliate society is as simple as calling us at 305.667.3647or visit sfdda.org and click on “affiliates”

Editorial RESPONSE TO ADVOCATES OF DHAT/MID-LEVEL PROVIDERS – by Carlos A. Sanchez, DDS There is a growing movement in our nation, whose proponents have had little or no experience with dental care, but still lecture those of us who do, on how to solve the “access to dental care” problem. They believe we don’t have enough dentists to treat the poor, so these patients live with chronic dental disease, pain and even life threatening infections, in some cases. The purported two-fold solution is to “open more dental schools” with progressive “self instructive” models, wherein faculty are few and far between, especially the all important specialty instructors. Never mind the fact that the best dentistry taught and practiced in the world is in the U.S. or other nations that apply our dental educational format.

The second part of their “solution” is to create a separate tier of mid-level dental therapists who would be more highly trained than a dental auxiliary, but less trained than a dentist. So far, this modality has not been shown to increase access or reduce the incidence of dental disease, where it has been implemented. That is because such implementation takes place in areas where the model can sustain itself economically, but yet does not emphasize prevention, and more tends to focus on invasive treatments after the damage is done.

party, with no such restrictions. However, the only way to get dentists into areas where the poor live, and need access to dental services, is to provide loan relief in exchange for agreeing to practice in these areas for a set number of years.

In the past, there were few new dental graduates willing to do this because they saw better prospects in private practices in more affluent areas. They also had much lower loan debt to deal with. Neither of those factors exists today. New dentists graduate with very high, and often staggering, loan debt. No bank will touch them, especially when they have no demonstrable business experience and constitute a bad loan risk.

Many of these new dentists may never own their own practice and often end up in corporate practices. This accomplishes little in resolving their loan debt problem.

In states where the legislatures have applied the loan relief model, the results have been good. In some cases, the dentist does not move on after their contract ends, preferring to remain in that community and even buying the practice outright.

The problem inherent in this movement – it that it ignores the fact we have a have more than enough dentists, but that there is a serious maldistribution of dentists.

Unlike medicine, dentistry is comprised of 80% general practitioners who can deliver most of the services patients need. We don’t need to create a second tier to do these procedures, as the medical profession did, with physician assistants and nurse practitioners.

No dentist or DHAT (dental health aid therapist, aka mid-level provider, dental therapist) can work in an area where they will go bankrupt. And thus, they need to be subsidized by a third

Let’s not dismantle healthcare that works, but rather, let us place it where it is needed most in a mutually beneficial process.

Mid-Level Providers, cont. from pg 11

riers to Oral Health for All Americans: The Role of Workforce,” “Breaking Down Barriers to Oral Health for All Americans: Repairing the Tattered Safety Net,” and “Action for Dental Health: Bringing Disease Prevention into Communities,” just to name a few.

I am almost certain that Dr. Catalanatto meant to say that the ADA has opposed all efforts to bring in mid-level providers/dental therapists. And if that is the case, I would agree with him!

and irreversible procedures. Through Action for Dental Health, the ADA and its member dentists are implementing solutions that have been proven to help address the multiple barriers that prevent many Americans from attaining better oral health.”

The issue of access to care is a complex one. I applaud and respect the efforts of anyone and everyone attempting to eliminate the barriers that prevent all Americans from suffering needlessly from a totally preventable disease. I hope and dream that, as a profession, we can continue to To quote the ADA president, Dr. Maxine Feinberg: “The work to bring about the changes needed to provide the ADA believes it is in the best interest of the public that necessary education and care to those who need it. only dentists diagnose dental disease and perform surgical 14

The Truth Behind FDAPAC An investment in the Florida Dental Association Political Action Committee (FDAPAC) is an investment in your profession. Along with the American Dental Association PAC we become One Voice United against harmful industry regulations at both the state and federal levels.

Contributing to either PAC is not about choosing sides it’s ensuring we have boots on the ground fighting for us in the state capital and in Washington, D.C.

Overall, the FDAPAC:

--Dr. Gerald Bird, FDAPAC Chair

* Provides non-partisan financial support to candidates and legislators who support the interests of Florida’s dentists and the dental profession. * Serves as a resource for the FDA, giving members and officeholders opportunities for political engagement. * Allows FDA members to have a voice in policy discussions that could impact the continued success of our industry and gives us a seat at the table with our peers.

Questions? Contact FDA Director of Governmental Affairs Joe Anne Hart at jahart@floridadental.org or 850.224.1089.

Disclosure: FDAPAC is a state-registered political committee that makes contributions to state candidates and committees. Contributions to FDAPAC and ADPAC are voluntary and any member has the right to refuse to contribute without reprisal. The contribution guidelines are merely suggestions and a member may contribute more or less or not at all without concern of favor or disadvantage by the association. Corporate donations to ADPAC will be used exclusively to pay for the administrative and operating expenses of ADPAC. Contributions are not deductible as charitable contributions for federal tax purposes

Capital Report is the FDA’s legislative newsletter that provides up-to-date information on legislative issues happening in Tallahassee, as well as around the state that impact dentistry.

CAPITAL REPORT

During the annual legislative session, Capital Report is available on a weekly basis, typically on Fridays, to provide you with real-time news updates on dental-specific issues that are being addressed before the Legislature. During the interim months, Capital Report is available every other month and is posted on the FDA’s website at www. floridadental.org.

Email Responses continued from pg.9

Money continues to be the root of all evil and it has become what I consider the greatest factor in the decline of a profession. It pervades every aspect of our profession beginning with the education of each of us. Corporate health care (i.e., greed) adds its ugly head. These are compounded by marketing, lack of communication skills (greatly influenced by electronics), a diminution of mutual respect for the attributes of the generalist and specialist, the decline of mentorship, and others.

A paradigm shift is taking place, and I am not sure what, if anything, can be done about it. Getting back to the basics - the Golden Rule - could be a start. However, how can you sell that to a 25-26 year old dental graduate with a wife and child, who cannot find a bank who will make a loan for a house and a practice?? Hence - corporate dentistry. A sad, sad commentary.

Thanks for addressing a perplexing problem.

-John Yurosko, Oral and Maxillofacial Surgeon , Venice, FL Thank you for sharing that great article. As part of a generation of recent graduates in our field with astronomical student loans to repay (just about half a million dollars in my case), I often feel the pressure created by Sallie May, in addition to OMSNIC, Guardian, Standard, Northwestern Mutual and all other profes-

sional expenses. I often hear the little “devil on my shoulder’ saying I should drop some xenograft into a socket or extract that full bony impacted third molar that hasn’t caused a problem in 50 years. So far (and by that I mean in just one year of private practice) I have been able to resist such temptation and cannot recall a time I have performed a procedure that those whom I admire would not have approved of. However, I do hear quite often of other practitioners who do such questionable things that it makes it very difficult to do the right thing for the patient without “throwing someone under the bus.” Being on staff at 8 local hospitals, I unfortunately see this as much on the medical side as the dental side of our specialty. As a recent grad, I question my judgment quite often and at times wonder if those who are doing things like grafting every third molar socket or doing a closed reduction on every uninsured mandible fracture are right and I am just young and naive. Reading about your reflections on 28 years of practice is very refreshing and motivating. I think that the introduction takes the reader back to basics, something we all should probably do from time to time. I look forward to reading the other sections of your chapter. Thanks again!

-Dr. B, Oral and Maxillofacial Surgeon, South Florida I thoroughly enjoyed your article as it ties common basics tenets that we were raised with, and that we raised our kids with, to the "higher bar" that the medical/dental professionals must ascribe to. In particular, your comparison to the business community and the "buyer beware" approach that some businesses follow draws the stark difference between a profession and a business. Although we have a business side of our practice, we must not let that interfere with our decisions that pertain to patient care.

-Brian Hogan, Oral and Maxillofacial Surgeon, Newport, RI

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ORTHODONTIST WANTED: We are a growing dental group looking for an Orthodontist to join our dental team. Excellent compensation. English/Spanish required. Call Manuel 305.915.2953

Want to buy, sell, hire, or announce?

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GENERAL / SPECIALIST: Ft/Pt Great opportunity for General Dentist / Specialist. Excellent compensation, bonus and partnership positions. Multiple locations in South Florida.

Please fax resume to (305) 770-1232 or call Kathy (954) 430-2188 or email to haroldhui@aol.com GENERAL DENTIST WANTED: Hialeah, Pembroke Pines or Kendall area, excellent compensation and bonus with guarantee income. Eng/Spanish required. Call Manuel 305.915.2953 BUSY DENTAL PRACTICE: Looking for PT associate dentist in Fort Lauderdale and Delrey Beach. Competitive % compensation based upon experience. Ask Dr. Martin 786525-9946

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MISCELLANEOUS MISC. OFFICE EQUIPMENT FOR SALE: Alabama Cabinets (Mobile Carts), Mica-Dent Air Abrasion Units, Nitrous Oxide Carts. Waiting room furniture, etc. Please call (305) 567-1992

Call Ms. Jackie Quintero at (305) 667-3647 ext. 13.

Or visit us on-line at www.sfdda.org 19

Celebrating our Diversity.

We are different...and together we create a powerful picture.

The South Florida District Dental Association The SFDDA leadership reflects this diversity, boasts one of the most diverse communities and that is “powerful stuff.” To have a great understanding of the community and to be in Florida - and we love it. able to forge a strong bond between the pubOne need only to travel US 1 from the South- lic and the association is a benefit of having ernmost Point in Key West to South Broward embraced our diversity. to experience the various foods, music and entertainment that make up our district. The Each day, we are eager to welcome a popucuisine includes an amazing mix of lation of dentists who have not yet experiFloribbean and Latin Fusion from the islands enced the value of this wonderful organization of the Caribbean, including Cuba, Puerto and while knowing we can learn a thing or two Rico, Jamaica, Trinidad and Haiti, to name a from each other. few, and foods ranging from South and Central American to French, Italian, Asian, Middle We have many events and dinner lectures Eastern Greek and Jewish fare. And our lan- where you and your colleagues can experiguages, religions and pastimes are as varied ence the diversity of our district. We invite you to attend and experience what membership as the foods above. in the American Dental Association through Consequentially, the SFDDA membership is the South Florida District is like. There are comprised of several cultures, ethnicities, re- truly many benefits for everyone. ligions and is almost equally divided in gender and age. It is rich and wonderful and has pro- Visit our website for a complete listing of vided us with opportunities to become aware events and meetings: www.sfdda.org of each other, giving us a sense of pride for the diversity in which we thrive and an understanding of how important it is in our personal and professional growth.

SFDDA Members recieve $200 off any purchase made at the show!

Haven’t Completed Your CPR Renewal for the Biennium?

These are our next available dates: January 20, 2016 February 24, 2016 March 30, 2016* Download a CPR Registration Form at www.sfdda.org or call (305) 667-3647 *after biennium ends

Finally…a place to send those difficult patients!

January 27, 2016 5:30 - 11:00pm Hilton Miami Airport Hotel 5101 Blue Lagoon Drive Miami, FL 33126 Admission: Free

Dr. Harold Menchel limits his private practice to treatment of TMD and orofacial pain in Coral Springs.

TMD Headache Neuropathic pain Sleep disordered breathing (OSA) Dr. Menchel coordinates treatment with restorative dentists, orthodontists, endodontists, and oral surgeons for these complex patients.

Dr. Menchel has been in practice in S. Florida since 1981. He received the majority of his training at the University of Florida Parker Mahan Facial Pain Center under the tutelage of Drs. Mahan and Gremillion from 1992Ǧ 1999. He achieved the prestigious Diplomate of the American Board of Orofacial Pain in 2000.

Treatment includes: (partial list) Splint therapy, medical management, physical therapy, joint mobilization, diagnostic and therapeutic injections.

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