April 2022 Texas Dental Journal

April 2022

TEXAS DENTAL

INSIDE: Operating Room Access Issues for General and Pediatric Dentists in the Medicaid/Medicare Population Due to Current Reimbursement Policy Working Better Together— How Men and Women Create Dynamic Leadership in Dentistry The Emergence of Artificial Intelligence in Dental Care Delivery

www.tda.org | April 2022

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Texas Dental Journal | Vol 139 | No. 4

Insurance & Dental Benefits (Dental Systems, Inc.)

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Contents April 2022 Established February 1883 n Vol 139, No. 4

FEATURES 170 | Working Better Together— How Men and Women Create Dynamic Leadership in Dentistry Stephanie R. Ganter DDS, MS Reprinted, with permission, from the Dallas County Dental Society Connection newsletter.

178 | Operating Room Access Issues for General and Pediatric Dentists in the Medicaid/Medicare Population Due to Current Reimbursement Policy Lianna Pulliam, DDS Nina Ray, DDS

188 | The Emergence of Artificial Intelligence in Dental Care Delivery

176 | Calendar of Events

Robert A. Faiella, DMD, MMSc, MBA

Profession: Let’s

Shaju Puthussery, MS

203 | Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management 206 | Value for Your Debunk Some Common

Reprinted, with permission, from

Misconceptions

the Journal of the Michigan Dental

About Starting a Dental

Association, April 2021 issue.

Practice

DEPARTMENTS

186 | In Memoriam

168 | President’s Message

210 | Advertising Briefs

174 | Oral and Maxillofacial

218 | Index to Advertisers

Katherine Miller-Nimmons, MPH, MSc Carolyn Kerins, DDS, PhD Dan Burch, DDS, MPH, MA

TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.

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Pathology Case of the Month

Texas Dental Journal | Vol 139 | No. 4

Editorial Staff Daniel L. Jones, DDS, PhD, Editor Paras B. Patel, DDS, Associate Editor Nicole Scott, Managing Editor Barbara Donovan, Art Director Lee Ann Johnson, CAE, Director of Member Services

Editorial Advisory Board Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS, MS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication.

Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 787043698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2022 Texas Dental Association. All rights reserved.

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association.

Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.

Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of Association of the quality of value of Dental Editors and such product or of the claims made of Journalists. it by its manufacturer.

Board of Directors PRESIDENT Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net PRESIDENT-ELECT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net PAST PRESIDENT Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com VICE PRESIDENT, NORTHEAST Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com VICE PRESIDENT, SOUTHEAST Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com VICE PRESIDENT, SOUTHWEST J. Ted Thompson, DDS 361-242-3151, tedito@aol.com 817-238-6450, pdalw@yahoo.com VICE PRESIDENT, NORTHWEST E. Dale Martin, DDS SENIOR DIRECTOR, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com SENIOR DIRECTOR, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, dr.owen@owendds.com SENIOR DIRECTOR, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com SENIOR DIRECTOR, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org DIRECTOR, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com SECRETARY-TREASURER* Cody C. Graves, DDS 325-648-2251, drc@centex.net SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN** Glen D. Hall, DDS 325-698-7560, abdent78@gmail.com EDITOR** Daniel L. Jones, DDS, PhD 214-828-8350, editor@tda.org LEGAL COUNSEL Carl R. Galant William H. Bingham, Advisor *Non-voting member **Non-voting attendee

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CELEBRATING 30 YEARS

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| April 2022

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Chewon this

N A T I O N A L VOLUNTEER M O N T H

D

id you know in the United States April is National Volunteer Month? April is dedicated to recognizing the importance of volunteering and honoring the significant contributions volunteers make by donating their time, resources and talents to worthy causes.

Our communities, churches, schools, and our dental societies would cease to operate if not for the efforts of volunteers! In fact, most of you can probably list a few volunteer roles in which you currently serve.

There are many mental and physical benefits related to volunteering. Studies show that volunteering • provides a sense of community, • helps counteract the effects of stress, anger, and anxiety, • combats depression, • increases selfconfidence, and • provides a sense of purpose.

With all the benefits associated with being a volunteer, one might think

people would be standing in line to sign up for the next dental society committee, council or leadership role, but that isn’t always the case. Many times our newer and younger members are intimidated by the more experienced members who’ve been involved in organized dentistry for years or, in some cases, they simply aren’t asked to get involved beyond attending a general meeting.

Staying engaged through service-oriented volunteer roles is ranked as one of the top priorities for Generations Y (otherwise known as Millennials) and Z. They are anxious to impact the world in a positive way.

While it’s important to keep proven and knowledgeable leaders active in our societies, it’s even more important to give our younger colleagues a chance to become involved.

We are counting on the next generation to carry the torch!

Allowing the newer dentists to step into leadership

168 Texas TexasDental DentalJournal Journal || Vol Vol139 139 || No. No.44

TDA President Debrah J. Worsham, DDS

positions also creates a built-in mentor program.

They need the expertise of the proven leaders to help them as they navigate presiding over a local meeting, hosting an event, running a membership campaign, representing their society at the Capitol, or developing the society’s annual budget.

Does your local component have a plan for engaging and recruiting new members into vital volunteer roles? If not, you need to get one and fast!

The future of our profession depends on it. Please contact Lee Ann Johnson CAE, Director of Member Services at ljohnson@ tda.org for member recruitment and retention information. Ms Johnson and the TDA Member Services team is ready and willing to assist!

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Editor’s Note: Changes to the face of dentistry are being reflected in representation on the TDA Board of Directors. For the first time, female members of the Board outnumber their male counterparts.

Accordingly, we present this article by Dr Stephanie Ganter of Dallas, first published in the Dallas County Dental Society Connection newsletter.

— D. Jones, Editor

Working Better Together— How Men and Women Create Dynamic Leadership in Dentistry Stephanie R. Ganter DDS, MS

A

s a new practitioner, I have quickly realized the need for more focused guidance as I begin to build a practice, interact with colleagues, and focus on what matters most to my patients and staff.

You may be wondering why someone who is new to practice is writing about leadership at all.

Realistically, every one of us is a leader: maybe as a business owner, as an associate with your clinical team, or as a leader in your family. My original intention for this article was to highlight some of the key challenges women face in leadership and make this female focused. However, my interactions with several leaders, new and experienced, male and female, changed that direction. I started to appreciate that leadership doesn’t have a gender as much as a season in one’s life. What does that mean? Let’s dive in.

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The pessimist complains about the wind.

The optimist expects it to change.

The leader adjusts the sails.

— John C. Maxwell

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T

here are numerous articles denoting leadership challenges that men and women separately face. According to the Harvard Business Review, male leaders exude assertiveness, boldness, and confidence—traits that are thought to enhance one’s ability to lead. However, there isn’t necessarily a strong correlation between ‘leaning in’ and being good at something. This gives a false sense of ability to some male leaders, setting them up for early failure. One theory on female barriers to leadership is the theory of “gender congruity”. This is where men and women are expected to exhibit leadership traits aligning with their gender.

In a recent Wall Street Journal article, for example, female leaders are expected to be compassionate, gossipy, multitaskers and male leaders are expected to be strong, arrogant, and direct. The incongruity happens when leaders cross over and exhibit the opposite traits. A male leader that portrays feminine traits or more commonly, a female leader that portrays masculine traits. When leaders knowingly or unknowingly go against these gender perceptions, they tend to decrease their effectiveness. It’s important for leaders to recognize their impact in their position and recognize that certain gender perceptions may create a barrier to maximizing your impact at work, home or within an organization. Okay, but what do our current leaders have to say about this?

Dr Lynne Gerlach is a fantastic example of a leader in dentistry. Of her many leadership roles, she currently serves on the Texas DENPAC board and is a long time delegate to the Texas Dental Association. In a recent interview,

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Dr Gerlach discussed the nuances of not just female leadership, but leadership overall. She advocates that leadership knows no gender, but it does have a season in one’s life that simultaneously requires a great deal of support from colleagues, friends, and family. This leadership season highlights the timing of becoming a leader as much more important compared to one’s gender. Dr Gerlach emphasized timing and patience makes the aspiring leader, man or woman, an asset to a team.

Dentistry is a profession with several areas for leadership opportunity at the local, regional and national levels. Within your office, there are leadership/managerial opportunities from office managers to part-time and full-time associates. Not to mention business ownership, which takes on an entirely new importance for sharp leadership and guidance. We train several years as general dentists and specialists to begin our journey providing dental care in our communities. However, do we offer enough guidance on something equally as critical to the success of your private practice and/or organizational goals?

Perhaps a higher focus in self awareness, leadership training, and business management.

When it comes to competency, aspiring leaders have seen growing opportunities for leadership training in the past 10 years. As a young female dentist, I’ve faced challenges myself as a leader for my clinical team. Several programs exist to increase leadership competency.

These opportunities can include flexible online courses through highly acclaimed programs such as Case Western

University, Cornell, and Harvard. Other opportunities that are more femalefocused are offered through seminars such as the Wall Street Journal’s Women In Series, which was created to highlight the challenges and successes of all women.

There are also non-profit organizations such as How Women Lead or the Malala fund that specialize in women’s education and leadership. Several local dental societies offer mentor/mentee opportunities such as the Dallas County Dental Society. I personally can attest to the benefits of such a program for young leaders as a current student at Cornell University, enrolled in one of their highly ranked leadership training and communication courses.

Dr Robert G. McNeill, another example of an accomplished leader, is a TSBDE Board Member who is taking a Healthcare Management and Leadership MBA. Dr McNeill states “One of the best parts of this MBA is the leadership training.”

He continues, “Leadership isn’t a destination, it is a life long journey that takes continual improvement in self awareness and effectiveness.” One of the recommendations from the MBA is to read at least one book on leadership or communication skills every month.

There has been a growing rate of female leadership in several corporate and private healthcare and organizational settings, including dentistry. In 2019, an American Dental Association article referenced “13 women serving as presidents in their state dental association—the most in the ADA’s 160-year history.” In Texas, we have had innovative leadership from women such as Dr Jacqueline Plemons, the immediate

(Dr Gerlach) advocates that leadership knows no gender, but it does have a season in one’s life that simultaneously requires a great deal of support from colleagues, friends, and family. past president of the TDA and currently, Dr Debrah Worsham as president of the TDA. Not to mention our diversified leaders locally with the Dallas County Dental Society, including our current president, Dr Elizabeth “Missy” Jaynes along with several of our board members, staffers, and notably our executive director, Ms Jane Evans. Jane has been the executive director of DCDS for over 20 years and is an exemplary role model for female leadership.

The notion of what makes an effective leader is changing and you may find both masculine and feminine components.

More and more we are seeing women with masculine styles or vice versa. I would encourage each of us to look for both male and female mentors and appreciate the balance that different types of leadership styles can provide.

Stephanie R. Ganter DDS, MS Dr Ganter is a periodontist and current partner in private practice at The Dental Specialists— Surgical Specialists. She is currently enrolled in leadership courses at Cornell University and has taken a 2 year fellowship in Integrative Medicine from The University of Arizona School of Medicine. Dr Ganter graduated dental school from Texas A&M University College of Dentistry and completed her Periodontics residency and Masters of Science Programs from TAMUCOD.

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ORAL

and maxillofacial pathology case of the month

Clinical History

A 49-year-old man visited a new dentist after moving from another city. During his first oral examination, the dentist noticed that there were bilateral masses on his retromolar pads. The one on the left was only a sessile, slightly elevated mass, but the one on the right was a “finger-like” tubular projection 5 mm high (Figure 1).

When asked if any previous dentist had mentioned it, he said, “yes, they all did.”

He said the masses had been present since his grade school days. The lesions were moderately soft to palpation and were asymptomatic, with no other oral masses present. The underlying bone was unremarkable on periapical radiographs.

His dentist elected to biopsy the right side “column” because the patient had complained about occasional food debris getting caught between the tissue column and the adjacent tooth.

1A

AUTHORS Safia Durab, DDS, MS Chief Resident in Oral & Maxillofacial Pathology, Department of Diagnostic & Biomedical Sciences, School of Dentistry, University of Texas, Houston, Texas

Carolyn Huynh, DDS, MEd, EdD Associate Professor, School of Dentistry, Department of Diagnostic & Biomedical Sciences, University of Texas, Houston, Texas

Jerry E. Bouquot, DDS, MSD, DABOMP, DABOM (hon), FAAOMP, FICD, FACD, FRCM (UK) Emeritus Professor & Past Chair, Department of Diagnostic & Biomedical Sciences, School of Dentistry, University of Texas, Houston, Texas

1B

Figure 1. Right retromolar pad area. A) Soft tissue “column” (arrow) just distal to the carious third molar was uniformly circular, soft and 5 mm. high; B) Close up of the column.

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Microscopic Appearance The columnar mass consisted entirely of dense, mature collagenous tissue with few blood vessels, although some of the vessels were dilated (Figure 2). The surface stratified squamous epithelium was unremarkable, except for a slightly thickened layer of orthokeratin. It showed no elongated, thin rete processes and there were no papillary or verruciform surface projections. A few lymphocytes were found within the stroma directly beneath the epithelium, along with occasional fibroblast-like cells which were much larger than normal, were angular (even some nuclei) and showed cytoplasm that was faintly purple. The giant cells were positive for vimentin (indicating mesenchymal origin) and Factor VIIIa (indicating a dendrocyte origin) by immunohistochemical staining.

2A Figure 2. Histopathology of the columnar mass. A) The mass consisted almost entirely of dense, somewhat avascular fibrous stroma covered by unremarkable stratified squamous epithelium, with a few scattered lymphocytes beneath the epithelium; B) The fibrous stroma contained several large, faintly stained, angular fibroblasts (arrows).

2B

What is your diagnosis?

See page 203 for the answer and discussion.

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Calendar of events

TMOM 2022 SCHEDULE Texarkana—June 17-18, 2022 Luling—September 9-10, 2022 Dallas—November 4-5, 2022

SMILECON

Houston—October 13-15, 2022 House of Delegates, October 15-18 Due to COVID-19, please check each meeting’s website for up-to-date information related to cancellations or rescheduling.

THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

LAW OFFICES OF MARK J. HANNA EXPERIENCED LEGAL REPRESENTATION FOR TEXAS DENTISTS •

Representation Before the Texas State Board of Dental Examiners

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Medicaid Audits and Administrative Hearings

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Employment Issues—Texas Workforce Commission Hearings

Mark J. Hanna JD Former General Counsel, Texas Dental Association

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Administrative (SOAH) Hearings and Counsel

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Professional Recovery Network (PRN) Compliance

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Employment/Associateship Contract Reviews

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Practice Acquisition and Sales

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Business Organizations, PAs, PCs, and PLLCs

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Civil Litigation

2414 Exposition Blvd., Suite A1 • Austin, Texas 78703 • Phone: 512-477-6200 • Fax: 512-477-1188 • Email: mhanna@markjhanna.com Not Board Certified by the Texas Board of Legal Specialization

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Operating Room Access Issues for

General and Pediatric Dentists in the Medicaid/Medicare Population Due to Current Reimbursement Policy Lianna Pulliam, DDS Nina Ray, DDS Katherine Miller-Nimmons, MPH, MSc Carolyn Kerins, DDS, PhD Dan Burch, DDS, MPH, MA

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Abstract Tooth decay remains one of the most prominent chronic diseases for children and adults, yet millions do not receive adequate care. This communication discusses the growing challenges many hospital dentists face around the country while treating tooth decay for children, geriatric, medically complex, and special needs patients under general anesthesia.

Hospitals and surgery centers across the country deny access to dentists due to the low reimbursements rates associated with full mouth dental rehabilitation in operating rooms. With fewer centers credentialing or allowing dentists to utilize operating rooms, adequate access to care has become a looming issue in maintaining the oral health of marginalized populations.

Keywords Full mouth dental rehabilitation, hospital dentistry, Medicaid, Medicare www.tda.org | April 2022

179

Executive

the quality of oral health

systems. The need to

Summary

care. Delayed treatment

maintain financial solvency

allows oral disease and

has pushed hospital

pain to proliferate, often

and ambulatory surgical

Denial of operating room

resulting in emergency

centers to prioritize well-

access to medically

department visits or

compensated surgical

compromised, pediatric,

hospital admissions.

services since the onset

and special needs

In turn, emergency

of the COVID epidemic.

patients requiring dental

department visits and

Larger, more profitable

services is detrimental

unplanned (non-traumatic)

services such as cardiology,

to the overall health

hospital admissions cause

orthopedics, and solid

of these marginalized

additional financial strain

organ transplant are given

groups. Structural

for individual patients, their

priority over dental care.

access barriers reduce

families, and healthcare

Although dental conditions

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are not often life threatening, the associated pain is truly debilitating and associated with a negative economic impact.

To address these layered problems, restructuring and reclassifying dental rehabilitation services under the Current Procedural Terminology (CPT) — Ambulatory Payment Classification (APC) coding to increase reimbursement will lower the burden faced by many dentists and patients across the country. Ideally, a more equitable reimbursement system will encourage hospitals and ambulatory surgical centers across the state and nation to offer and maintain dental services.

Introduction Over the last 5 decades, there has been a significant decline in dental caries thanks to public fluoridated water sources, toothpastes, acceptance of sealants, reduction of sugar consumption, and oral health awareness.1 Even so, tooth decay remains the most common U.S. ailment, with numerous portions of the population experiencing issues with barriers or access to care.

This is especially apparent in low socioeconomic populations, and the prevalence of caries and untreated decay is inversely proportional to family incomes.2 This growing concern significantly affects dentists that treat pediatric, geriatric, medically complex, and special needs groups, whose patients require specialized training and/ or operating room services to properly treat their oral health conditions in a safe environment.3 A recent survey showed that more than 60% of pediatric dentists have noted a decline in access to operating rooms, which has in turn increased wait times or even denials for treatment.4 This restriction has unfortunately produced suboptimal, inconsistent care for these patients, and places a burden

Authors Lianna Pulliam, DDS TAMCOD Dental Fellow, Dallas, Texas Nina Ray, DDS TAMCOD Clinical Assistant Professor, Dallas, Texas Katherine MillerNimmons, MPH, MSc TAMCOD Director of Evaluation, Dallas, Texas Carolyn Kerins, DDS, PhD TAMCOD Associate Professor, Dallas, Texas Dan Burch, DDS, MPH, MA TAMCOD Associate Professor, Dallas, Texas Corresponding Author: Dr Dan Burch, Texas A&M UniversityCollege of Dentistry, Department of Pediatric Dentistry, Dallas, Texas; dburch@ tamu.edu Conflicts of Interest: None

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The need to maintain financial solvency has pushed hospital and ambulatory surgical centers to prioritize on providers to respond to urgent and emergent dental patients with unmet needs.

Scope of Problem A 2001 survey by Lewis and Nowak noted that 81% of dentists requested more time in the operating room, while only 46% of those respondents reported actually receiving the requested time.

Some respondents expressed that their access denials came from anesthesiologists refusing to add Medicaid cases due to low reimbursement.

In reality, it was actually cheaper to not complete a dental case than to take Medicaid payment for dental services.5 To offset low reimbursement rates, hospitals may implement metrics or incentives to keep procedure times shorter, improve turnover between cases, or other measures that prioritize financial goals over patient care.

A national survey of American Association of Pediatric Dentistry Public Policy Advocates revealed that 72% reported operating room access concerns. Roughly 88% of surveyed dentists that

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well-compensated surgical services since the onset of the COVID epidemic. Larger, more profitable services such as cardiology, orthopedics, and solid organ transplant are given priority over dental care.

reported concerns attributed the denial to financial reasons. Additionally, 83% responded that hospitals are inadequately reimbursed for dental cases.4 While intravenous conscious sedation or in-office general anesthesia is often presented as solution to this problem, this treatment modality is neither safe nor appropriate for the youngest or medically complex patients.

Policy Recommendation It is recommended the Centers for Medicare & Medicaid Services reclassify full mouth dental rehabilitation within the Healthcare Common Procedure Coding System. HCPCS is a collection of standardized codes that represent medical procedures, supplies, products, and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers. Full mouth dental rehabilitation (CPT 41899, APC 5161) should be reclassified to the Level 4 Ear, Nose, and Throat (APC 51640) category, to align with other major ear, nose, and throat surgical procedures within the same category. Centers for Medicare & Medicaid Services should also work closely with national dental academies (American Dental Association, American Academy of Pediatric Dentistry, American Academy of Oral Maxillofacial Surgery, and the Special Care Dentistry Association) to adequately provide a more encompassing description of the CPT code and a national system for qualifying for treatment in the operating room.

Discussion Billing for surgical services in the operating room is a complex task, further complicated by numerous formularies, plan limitations, and reimbursement maximums. Current CPT codes list full mouth dental rehabilitation as a miscellaneous code with $0.00 of reimbursement. This code (CPT 41899) is also placed in an ambulatory payment classification (APC) level under an Ear, Nose, and Throat (ENT) code grouping. With 5 APC levels within the ENT surgical procedure group, dental surgery procedures currently hold position in the lowest level (APC 5161Level 1). This reimbursement level is lower than that for a ten-minute myringotomy (ear tube) procedure.

National average reimbursement for APC 5161—Level 1 procedures in 2018 were $199.21 while average geometric mean costs for full mouth dental rehabilitation were $2,265.68.6 Reimbursement at this level in grossly inappropriate. APC fees do not cover the cost of equipment, anesthesia, facility time, or any additional operating room expenses. Adding another layer of complexity, full mouth dental rehabilitation is also not covered by CPT codes. Without these associated costs being reimbursed, financial strain is placed on many hospital and surgical centers when offering dental services.3 Moving dental surgery procedures from APC 5161-Level 1 to Level 4 will increase the APC rate from $199.21 to $2,325.99.6 This effectively reclassifies dental surgeries to a level that is in line with other major ENT surgery procedures and reimburses the average geometric mean costs for full

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mouth dental rehabilitation ($2,265.68).

The increase in APC level also incentivizes surgical centers to allow dentists to provide services.

With many state Medicaid programs following the lead of Medicare as it relates to billing and payment policy, it is incumbent upon Medicare to create a new norm where hospital dentistry is an essential service. Proper reimbursement fees will maintain access for some of the most vulnerable populations across the country.

Conclusion Optimal oral health care has been impaired by issues of access to care.

Since the onset of the COVID pandemic, denial of dental rehabilitation under general anesthesia has quickly become a national issue in the field of dentistry.

Patients who are poor, elderly, or have intellectual/developmental needs are typically covered by Medicaid and/or Medicare and have numerous insurance plan restraints involving surgical center coverage. For patients in these groups with complex medical conditions or extreme anxiety, general sedation services are essential for alleviating pain and discomfort. Reclassifying procedure codes will better reflect the skill, scope, and quality of dental care delivered in operating rooms. Equitable reimbursement is a key influence on access to care. This brief supports oral health advocates in obtaining further operating room access while giving perspective on the subject area.

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Acknowledgements This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of awards totaling $3,350,000 with 0% financed with non-governmental sources, and $881,000 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

References 1. Lagerweij MD, van Loveren C. Declining Caries Trends: Are We Satisfied?. Curr Oral Health Rep. 2015;2(4):212-217.

2. Heng C. Tooth Decay Is the Most Prevalent Disease. Fed Pract.

2016;33(10):31-33.

3. Brief PC. Denial of Access to Operating Room Time in Hospitals for Pediatric Dental Care. AAPD Pediatric Oral Health Research and Policy Center. 2021.

4. Vo AT, Casamassimo PS, Peng J, Amini H, Litch CS, Hammersmith K. Denial of operating room access for pediatric dental treatment: a national survey. Pediatric Dentistry. 2021 Jan 15;43(1):33-41.

5. Lewis CW, Nowak AJ. Stretching the safety net too far: waiting times for dental treatment. Pediatric dentistry.

2002 Jan 1;24(1):6-10.

6. Cms.gov. 2019. APC Panel Archives | CMS. [online] Available at: <https:// www.cms.gov/Regulations-andGuidance/Guidance/FACA/APC-PanelArchives> [Accessed 1 October 2021].

YOUR PATIENTS TRUST YOU.

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Those in the dental community who have recently passed John E T Leonard

Bernard Emil Stratman Jr

Dallas February 8, 1931–December 8, 2021 Good Fellow: 1980 • Life: 1996 • Fifty Year: 2006

Austin March 15, 1931–January 5, 2021 Good Fellow: 1982 • Life: 1996 • Fifty Year: 2007

Herbert L Wade Jr

Jerry N McGown

Bryan December 12, 1941–December 16, 2021 Good Fellow: 1996 • Life: 2006 • Fifty Year: 2020

Jerry Ross Akers Paris September 7, 1939–December 26, 2021 Good Fellow: 1989 • Life: 2004 • Fifty Year: 2014

Bobby Lee Norton Denton March 20, 1929–January 1, 2022 Good Fellow: 1990 • Life: 1995 • Fifty Year: 2015

IN MEMORIAM

John Francis Brown Lubbock June 6, 1932–December 22, 2021 Good Fellow: 1990 • Life: 1997 • Fifty Year: 2015

Thomas James Clayton Granbury January 20, 1937–January 1, 2022 Good Fellow: 1992 • Life: 2002 • Fifty Year: 2017

Glen C Dyer Tyler December 18, 1933–January 12, 2022 Life: 1998 • Fifty Year: 2010

Clarence Feller Jr San Antonio February 22, 1954–August 16, 2021 Good Fellow: 2005 • Life: 2019

Rufus John Nelson Denton September 8, 1931–January 26, 2022 Good Fellow: 1984 • Life: 1996 • Fifty Year: 2010

Bryce Campbell Plano September 12, 1931–January 27, 2022 Good Fellow: 1982 • Life: 1996 • Fifty Year: 2007

Thomas N Lawrence Granbury July 5, 1934–December 20, 2020 Good Fellow: 1987 • Life: 2000 • Fifty Year: 2012

Bill J Watkins Abilene February 18, 1934–March 2, 2018 Good Fellow: 1989 • Life: 2000 • Fifty Year: 2014

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Houston January 26, 1937–February 3, 2022 Life: 2002

Edward Mack Longview March 26, 1926–December 6, 2021 Good Fellow: 1972 • Life: 1991 • Fifty Year: 1997

George S Kendrick Dallas June 8, 1926–January 26, 2022 Good Fellow: 1979 • Life: 1991 • Fifty Year: 2003

Daniel A Gestring Garland March 28, 1942–February 12, 2022 Good Fellow: 1999 • Life: 2007

Gottfred P Olsen Mesquite August 15, 1946–October 23, 2021 Good Fellow: 2010 • Life: 2012

Raymond Wilson Cozby Jr Dallas October 18, 1934–February 27, 2022 Good Fellow: 1990 • Life: 2000 • Fifty Year: 2015

William Allie Mitchell Jr Paris October 26, 1937–March 3, 2022 Good Fellow: 1993 • Life: 2002 • Fifty Year: 2012

James Quincy Barnes San Antonio October 2, 1921–March 3, 2022 Good Fellow: 1977 • Life: 1986 • Fifty Year: 1997

William Lloyd Glenn Jr Galveston November 12, 1923–March 21, 2022 Good Fellow: 1971 • Life: 1988 • Fifty Year: 1997

John L Gerloff Jr Fort Worth December 16, 1937–March 23, 2022 Good Fellow: 1990 • Life: 2002 • Fifty Year: 2015

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SMILECON is a trademark of the American Dental Association.

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The Emergence of

Artificial Intelligence in Dental Care Delivery

By Robert A. Faiella, DMD, MMSc, MBA, and Shaju Puthussery, MS Reprinted, with permission, from the Journal of the Michigan Dental Association, April 2021 issue.

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AI and machine-learning technology is here to improve our clinical intelligence in the delivery of care, improve practice profitability, and identify efficiencies in a standardized manner to advance the delivery of care to our patients.

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About the Authors Robert A. Faiella, DMD, MMSc, MBA, is currently the chief dental officer for Overjet Inc. He is a past-president of the American Dental Association, serves as director of the American Board of Periodontology, and as treasurer of the American College of Dentists.

He received his graduate training in periodontology at Harvard School of Dental Medicine, as well as a Master of Medical Science degree from Harvard Medical School. He also received his Master of Business Administration at the MIT Sloan School of Management.

Shaju Puthussery, MSc, serves as chief operating officer at Overjet Inc., an AIdriven enterprise applying artificial intelligence and machine learning to dentistry.

He is a frequent speaker at provider and payer communities and at various health care work groups. He has held several senior level leadership positions, as chief information officer at P&R Dental Strategies, chief analytics officer at DentaQuest, and chief technology officer and co-founder of his own technology firm at P&R Technologies.

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A

s oral health specialists, our role as dentists is to use scientific principles, clinical acumen, and technical

expertise to prevent, diagnose, and care for patients with oral disease or injury, and to help maintain and improve their oral health throughout their lifetime.1 Dentistry’s understanding of the etiology of oral diseases, as well as the techniques and interventions available for their management, continues to evolve. Simultaneously, the expansion of information related to collection of patient metrics, advanced treatment protocols, and the influence of oral-systemic disease relationships has implications for both patients and providers, particularly in the complexity of treatment options and the difficulty patients face in accepting treatment.

Artificial intelligence (AI) approaches are currently at the frontier for health care in medical imaging, therapeutic intervention, and drug design and manufacturing. The global health care market for AI is increasing at a rate of 44.9% and is expected to reach $45.2 billion by 2026, with growing adoption of AI health care imaging, diagnostics, and operational support projected at the highest growth rate.2 Can AI offer a breakthrough in advancing prevention through risk assessment, predicting diagnoses through radiographic visualization of diseases to enhance treatment planning and case acceptance, and demonstrably improve the delivery and outcomes of dental care?

In this review, the ambition of AI and computer visualization in transforming dentistry will be described, and current applications of models in the management of both clinical treatment and dental practice will be discussed.

Implications of AI on Health Information Management Health care, as an industry, is based upon a knowledge-driven economy, and clinicians are acutely aware of the challenges in assimilating new information to improve their understanding and patient care. In 1950, the time to double medical knowledge was considered to be 50 years; in 1980, 7 years; and in 2010, 3-1/2 years. Today it is projected to take just 73 days.3 The dental profession is certainly no exception to the challenges of health information management.4 Successful prevention strategies depend upon knowledge of disease causation, progression dynamics, and early detection and treatment, all challenged by access to data and inherent constraints (missing, unstructured, or nonstandardized patient information).5,7 The adoption and expansion of electronic health records has dramatically increased the quantity of clinical data available for our clinical treatment decisions. In addition, the implementation of data

analytics to gain insights beyond human capabilities across large data sets has created unique opportunities to predict disease occurrence, reduce inefficiencies, and advance patient care.6 Predictive analytics linking data from dental and medical records, claims, and patientreported sources will define the data elements to allow recognition of patterns within the disease process, leading to opportunities for earlier identification of known risk indicators, and timing of treatment.

Consider for a moment the knowledge and clinical expertise required to manage each patient individually. Providers and staff must acquire information from the medical and dental history, interpret the possible influence of medical conditions and current medications, record quantitative dental examination metrics and radiographic imaging, and abide by protocols to store and share the information securely.4,7 Once done, dental professionals must render a diagnosis and

offer recommendations for treatment in a manner to allow informed consent by the patient. As an additional challenge, the medical information, test results, and medications may change during the course of treatment.

Consultations with medical colleagues may be necessary, as patients become more acutely aware of the connection between oral health and their overall health. Over the course of a year, millions of data points are collected from thousands of patients seen by multiple providers, and in many cases, over multiple locations. The data collected is primarily used at the point of service for the patient, but it is rarely reviewed independently when the patient is not present for care.

An important element in the implementation of analytics at scale is to make it actionable.6 Systems that identify patients in need, while also making predictions available with minimal disruption to the existing workflows in the office, increase the ability for providers to take action www.tda.org | April 2022

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in treatment decisions at the point of care. The system must both inform the provider and educate the patient regarding the recommendation for treatment with objective reason. By allowing this level of access to information, AI technology can empower providers to identify needs for confirmation and discussion with each patient we serve.8

Expanding Digital Dentistry to Include Predictive Diagnostic Support

D

entistry is currently experiencing significant changes in the management and delivery of treatment due to the extensive introduction and expansion of digital capabilities. Most dentists are currently embracing digital workflows at some level, from submission of insurance claims with digital attachments, to treatment delivery through digital impressions connecting CT imaging, to CAD/CAM prosthesis fabrication by digital printing.9 The expanded computational speed and storage capacity required for these workflows would also allow AI algorithms to analyze radiographic images and unstructured patient data (such as digital images including intra-oral photos and digital impression files and electronic record notes and claim narratives) in order to aggregate

Figure 1. AI machine learning prediction pathway to determine the necessity of treatment with high-level accuracy.

Analyze and Identify Anatomy, disease, and past treatment

Dental Image

AI Engine

Treatment Guidelines + Patient History

Quantify Disease and quality of past treatments All images by permission from Overjet, Inc. (Cambridge, Mass.)

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Recommended Necessary Treatments

all practice data to improve our clinical cognition at scale.

Currently available AI models are expected to support providers with diagnostic accuracy for confirmation and interpretation to the patient in the delivery of care, and can accurately identify dental anatomy (tooth numbers, bone levels, enamel surfaces), oral diseases (caries, periodontitis, lesions, and endodontic obturations) and quality of restorations (open margins, marginal over-extensions) from dental radiographs (both digital and scanned).8,10 In addition, incorporation of additional digital data, seamlessly extracted from practice management software, can then be combined with known dental procedure code parameters and guidelines to identify clinically appropriate treatments, and presented to the clinician at the point-of-care.

This digitally enhanced process would allow for improved efficiencies in diagnosis, treatment decisions, workflow, and ultimately better treatment outcomes.11

Figure 2. The top panel demonstrates prediction of enamel and caries extent beyond the DEJ, and the bottom panel exhibits machine learning identification of endodontic obturation in the development of modules for clinical use.

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For example, findings of bone loss for specific teeth greater than 2.0 mm and probing depth greater than 4 mm, as well as the presence of root surface calculus, can be presented on annotated images relevant to the site in question.12-14 A dashboard will also present a timeline over the past 18 to 24 months, noting all dental procedures for each visit for the patient to determine if there has been a periodontal charting or comprehensive examination within that time frame. In addition, annotated radiographic images identifying the teeth exceeding criteria for bone loss, carious lesions, overextended restorative margins, and indications for crowns (such as a missing cusp, the size and condition of an existing restoration, and the percentage of the clinical crown that is decayed, missing or filled) are presented. The indication for appropriate treatment can be reviewed and presented to the patient during the appointment, allowing the provider to toggle the annotations on and

off to demonstrate the objective findings to the patient and inform them of the need for treatment.

Case acceptance has traditionally been based upon the trust between the patient and provider.15 The use of technology to provide objective findings at scale across the entire database of the practice shifts the treatment acceptance from “trust” to “trust with verification” by demonstration of need, while educating the patient with reason.16 This allows use of the AI model to determine indication for treatment, such as all the patients in the practice who have indications for SRP due to bone loss of 3 mm with 4 or more teeth in a quadrant, or the presence of caries. The ability for patients to visualize, recognize, and understand objective indications for treatment, with interpretation by the clinician, gives them more control in making the right decision for their condition.

The ability for patients to visualize, recognize, and understand objective indications for treatment, with interpretation by the clinician, gives them more control in making the right decision for their condition.

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A Treatment Planning Process Based upon Stratified Risk

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ealth care systems have generally used simple decision trees or logistic regression models to comorbidities such as smoking, diabetes, atherosclerotic cardiovascular disease, and other systemic diseases known to have shared risk factors with oral diseases. Health care organizations that currently use analytic systems have focused on identifying the algorithm that can best stratify data in near-real time, allowing actionable use for patient care.18 The use of current AI systems in dentistry to identify dental disease can enable the clinician to determine treatment needs, but stratification of risk requires segmentation of patients by defined co-morbidities that may influence the prevalence and severity of disease progression, as well as response to treatment protocols. Self-reported patient indicators identified by natural language processing models from the electronic health record within the practice can identify risk factors such as diabetes, smoking, frequency of maintenance appointments, and current medications.19,20 The ability to identify such predefined criteria can allow the clinician to stratify patients with a specific diagnosis into high-, intermediate-, and low-risk groups for dental disease development or progression, and can be a powerful predictor of treatment success. This approach for patient cohort stratification to guide prevention of highly

Figure 3. As compared to the original image (top), highly accurate unassisted prediction of caries by AI is presented on the bottom.

prevalent chronic diseases is meant to improve outcomes and increase the cost-effective use of health care resources.21 www.tda.org | April 2022

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Improving Payer-provider Alignment Through Better Code Identification and Submission

M

any health care insurers are currently placing AI into action.22 Using AI in claim lifecycle management between provider and payer systems improves payment accuracy, thereby reducing claim denials and cost through reduction of administrative overhead. One of the key initiatives from the payer community is in intelligent claims automation, which distinguishes between processing speed for pre-authorization and post-treatment claims for automatic determine risk levels. This is in part due to time constraints at the point of care.17 Identified risk has included those patients with adjudication.

A pre-authorization process provides a confirmation that the patient is a covered enrollee and the payer agrees with the provider’s recommended treatment before the treatment is performed.

This process of automation eliminates delays in approval and improves speed of treatment and payments to providers.

Patient eligibility verification

196

through AI-automated workflow also improves efficiency and increases the provider-payer interaction experience with speed and convenience.23 Improving quality of care through standardization of treatment protocols is a priority for every dental office. AI-assisted diagnostic support will analyze, identify, and recommend treatment options, to increase the accuracy of disease detection, and improve patient outcomes. Artificial intelligence can also analyze insurance claim rejection reasons, collection performance, and dental treatment coding profiles in dental office operations, as well as encode and verify insurance processing guidelines prior to claim submission. This process will reduce errors in claim submission and increase adjudication decisionmaking based on realtime insights from dental office data with sustained information accuracy.

For example, AI-assisted agents in the dental office can verify requirements

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for document attachments to insurance submissions proactively.

Considering the sea of information within our control, the challenge we face today is to establish interoperability across electronic medical records (EMR) systems to create a cohesive, holistic view of the patient health history.24 Social determinants of health (SDOH) are the conditions within the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, quality of life, risks, and outcomes. Incorporating SDOH indicators (such as economic stability and education) into overall health care delivery will produce potentially better outcomes.25 Artificial intelligence and machinelearning solutions can identify and analyze the SDOH factors that impact a patient’s health by mining these data from dental and medical EHR notes, and facilitate stratification of risk.26

The Ability to Monitor Treatment Effectiveness and Outcomes

T

he process of assessing risk for dental diseases, such as periodontal disease and caries, has been less quantitative and more qualitative in current provider-payer systems. The advent of AI to analyze and quantify patient risk factors from dental imaging, along with qualitative SDOH factors from patient behavioral questions, will make this process more quantitative and real-time.

Incorporating stratified risk levels proactively in the management of patient care will enable dentists and hygienists to intervene in real time, implement early preventive measures, and improve treatment outcomes over time. For example, if the patient has diabetes and is a smoker, and has evidence of bone loss and/or radiographic root calculus, the provider may modify treatment options, which could include

increased maintenance intervals, periodontal intervention, or smoking cessation methods.

It is common for dentists to defer specific treatments at the patient’s request and observe progression over time, but without objective metrics combined with stratified risk the timing of appropriate treatment may pass. AI-powered metrics offer the ability to identify disease progression over time.27 The appropriate documentation of treatment deferred or refused by the patient allows the clinician

Figure 4. A clinical intelligence dashboard demonstrating real-time caries, bone loss measurements, and calculus, with findings listed on the right that may be toggled on or off for clinical review or patient demonstration.

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to escalate the urgency for care and provides for an appropriate record of lagging patient compliance.

The use of AI technology also allows improved data-based oversight in the administrative management of the practice.28 Current dashboard configurations available can provide real-time key performance indicator (KPI) metrics, such as production YTD, collection ratio, active patients, and new patients MTD.19 In addition, the software can aggregate data to track the number of patients within the practice with indications for a certain procedure identified objectively by the software.

Dentists must also assume responsibility for the management of the practice as well as measures of quality control among the providers.

Maintaining the standard of care, and mandated regulatory compliance, demands careful oversight. The implementation of chart audits, the time required for review, and the scope of the work is beyond the capability of most practice administrators to assure identification of missed treatment needs (such as indications for SRP or early carious lesions), documentation (appropriate radiograph and charting intervals), and disrupted treatment workflows, as well as compliance with office protocols that may be overlooked in the context of a busy practice. How can we improve the process for the benefit of our patients and improve treatment efficiencies?

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Challenges and Perspectives for the Future

T

he adoption and implementation of artificial intelligence within the dental profession is poised to be a transformative technology in dental care delivery.

That said, it will not be

without the perspectives and challenges that come with innovation, and will require our focused attention as applications for use continue to evolve.

Technical challenges will arise as data attributes,

formats, and transfer speeds evolve. The ethics revolving around data privacy, the evolving assurance of data security in transit and at rest, and the exclusion of bias in the data used in the

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development of the algorithms will demand the attention of the health care informatics community as we broadly embrace artificial intelligence.29 In addition, the introduction of clinical AI-based solutions by the dental education community will be critical to foster the required digital literacy needed in the future dental workforce.8,30 The American Dental Association is an approved Standards Developing Organization, with authority to propose standards for the profession. The Standards Committee on Dental Informatics develops standards and technical reports for elec-tronic health records, interoperability across technology platforms, secure storage and transmission of patient data and digital images, and dental education and research systems. The Standards Committee on Dental Products addresses dental materials, digital devices, equipment, and oral hygiene products.31 The skill sets, techniques, and best practices to help our profession comply with the legal, ethical and regulatory oversight of AIbased information are currently being addressed by the ADA and will continue to evolve as AI applications continue throughout the dental industry.

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The Case for a Continuously Learning Health Care System in Dentistry

T

he aggregation of practice data allows for efficiencies in practice management, scheduling staff, reviewing practice goals, and streamlining patient treatment. By using the insights gained, the ability to perform a needs assessment to maintain a standard with performance benchmarks for quality metrics of care encourages the development of a continuously learning environment within the practice.

In 2001, the Institute of Medicine defined the six aims for high-quality care: safety, effectiveness, efficiency, equity, timeliness, and patientcenteredness. Simply expecting providers to keep pace with the expansion of the knowledge base alone will not improve the quality of care. A learning health care system is one in which “science, informatics, incentives, and culture are aligned for continuous im-provement and innovation, with best-practices seamlessly embedded in the care process…” and developed through the adoption of process improvements over time.32

AI and machine-learning technology is here to improve our clinical intelligence in the delivery of care, improve practice profitability, and identify efficiencies in a standardized manner to advance the delivery of care to our patients. It is likely that AI will transform all major verticals of the estimated $130 billion dental industry, including dental practices, payers, manufacturers, distributors, and laboratories.

The enhancement of our capacity to analyze patient needs objectively for continuous quality improvement will only expand in the coming years, and will provide digital frameworks in the transformation of dental care delivery. Most importantly, the ability to enhance the patient experience by providing timely treatment, engaging their

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understanding of treatment recommendations with reason, and improving their outcomes over time with objective metrics provides a patient-centric environment to advance patient health status and enhance the trust that is central to the delivery of care.

Management Information

5.

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F, Verheij T, Prout H,

The use of CAD/CAM in

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K, et al. Trust, openness

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and continuity of care

10. Stanfill MH, Marc DT.

influence acceptance of

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infections: a four country

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Patnaik S, Yang X,

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23. Forbes Insights: Can AI

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what it is and what could

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18. Murdoch TB, Detsky AS. The inevitable application of big data to health care.

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24. Gordon W, Catalini C. Blockchain technology for

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30. Ahuja AS. The impact of

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ORAL

and maxillofacial pathology diagnosis and management—from page 176

Giant Cell Fibroma or Retromolar Papilla (Variant of Retrocuspid Papilla)?

Discussion The histopathology of this finger-like mass was consistent with a giant cell fibroma (GCF), which typically occurs in the first three decades of life, with a mean age at diagnosis of 30 years, consistent with the onset in our patient.1-3 Additionally, the giant cells in our specimen showed positive immunohistochemical staining with vimentin (a generic stain for mesenchymal cells), similar to the giant cells of GCF.2 Bilateral, symmetrically oriented examples of GCF of the retromolar area have not been reported.

Moreover, the few lesions of the skin with a similar microscopic appearance, fibrous papule of the nose, ungual fibroma, acral fibrokeratoma, and fibroblastoma, have not been reported on the oral mucosa.4 A skin mass with a somewhat similar microscopic appearance, the multinucleated cell

angiohistiocytoma, has been occasionally found on the oral mucosa, but is typically much more vascular than the present lesion.5 A condition with exactly the same microscopic appearance as GCF, and a typically bilateral/ symmetrical localization, is the retrocuspid papilla (RP). The RP is found frequently, some would say routinely, on the attached lingual gingiva of the anterior mandible in children, especially behind the cuspids (Figure 3).612 This developmental lesion is typically bilateral in most racial and ethnic groups, is more common in females, and has a childhood prevalence rate of at least 11% (perhaps higher than 80%), and it is found far less frequently in adults.9 Some authors actually consider RP to be a variation of normal.9 The strongest immunohistochemical

reactivity or positivity in the cells of the RP is to Factor VIIIa, suggesting that the fibroblast-like cells are dendrocytes, macrophagetype connective tissue cells with immunological and phagocytic functions.4, 12 The pale purple cytoplasmic color change in these unique cells is secondary to a large increase in RNA within the cytosol.12 The present lesion was also Factor VIIIa positive, and it was bilateral, and it had a childhood onset. So, should we consider it a retrocuspid papilla out of its standard anatomic location, or a GCF? Given the clinical presentation and histopathology, it seems best to consider this lesion a variant of the RP, rather than GCF. True, our retromolar masses did not regress with age, as do most RPs, but disappearance is not a universal feature of RP, they remain throughout life in up to 8% of adults.10 www.tda.org | April 2022

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ORAL

and maxillofacial pathology, continued

Figure 3. Example of bilateral retrocuspid papillae (RP), with the left lesion protruding much more than the right lesion, which is more rounded and has less height (arrows).

Photo courtesy of Dr John Wright, Texas A&M School of Dentistry, Dallas, Texas.

True, no RP has been reported to present as a finger-like column of tissue, but many are unequal in size between right and left, just as was our case.

All things considered, “retromolar papilla” best fits the presentation of our case. It likewise seems logical to consider it to be a developmental anomaly; it is too rare, thus far, to be a simple variation of normal anatomy.

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This is not our first case of retromolar papillae. Two others have been observed by us, both remarkably similar to the present case: both were bilateral, both had childhood onset and both presented with a finger-like mass on one retromolar pad and a smaller rounded mass on the other (Figure 4). These previous examples were not biopsied, however, and so the unique histopathology

Texas Dental Journal | Vol 139 | No. 4

cannot be confirmed.

Whatever the true origin or diagnostic terminology, this is obviously an innocuous entity and the only problem we can think of is the one our present patient experienced: occasional food impaction between the tissue mass and the adjacent molar.

4A

4B

Figure 4. Another patient with bilateral retromolar papules (arrows). A) Left side lesion is sessile and only slightly elevated; B) Right side lesion is very similar to the present case: a columnar soft tissue mass 4 mm in height, located closely behind the third molar.

Conclusion We offer a possibly new variant, the retromolar papilla, of an old oral pathosis, the retrocuspid papilla. It is similar in every way except location and seems quite innocuous, with a very limited growth potential. Additionally, some might prefer to call this symmetrical giant cell fibromas.

References 1.

2.

3.

Magnusson B.C., Rasmusson L.G. The giant cell fibroma: a review of 103 cases with immunohistochemical findings. Acta Odontol Scand.

1995;53:293–296.

Neville B, Damm D, Allen C, Bouquot J. Oral and maxillofacial pathology, 3rd edition. Philadelphia, W. B. Saunders; 2008.

Kuo YH, Hwang MJ, Lee

4.

5.

6.

7.

8.

YP, Chiang CP. Oral giant cell fibroma: A report of three cases. J Dent Sci. 2021;16(1):552-554.

Mainville GN. Non-HPV Papillary Lesions of the Oral Mucosa: Clinical and Histopathologic Features of Reactive and Neoplastic Conditions. Head Neck Pathol. 2019; 13(1):71-79.

Javor S, Guadagno A, Chinazzo C, Pastorino C, Parodi A, Rongioletti F. Multinucleate cell angiohistiocytoma of the lower vermilion lip: an unusual site. G Ital Dermatol Venereol. 2019; 154:79-81.

Hirschfeld I. The retrocuspid papillae. Oral Surg Oral Med Oral Pathol. 1947;33:44757.

Easley JR, Weis RW. Incidence of the retrocuspid papilla. ASDC J Dent Child.

1970; 37(6):523-6.

Berman FR, Fay JT. The retrocuspid papilla. A clinical survey. Oral Surg Oral Med Oral Pathol. 1976; 42(1):805.

9.

Gorsky M, Begleiter A, Buchner A, Harel-Raviv M. The retrocuspid papillae in Israeli Jews. Oral Surg Oral Med Oral Pathol. 1986; 62(2):240-3 10. Buchner A, Merrell PW, Hansen LS, Leider AS. The retrocuspid papilla of the mandibular lingual gingiva. J Periodontol. 1990; 61(9):585-9.

11. D’Aoust P, Landry R, Ganske R, Carrier J. The prevalence of the retrocuspid papilla among three indigenous groups of patients. Study of the subjects in Ecuador, Honduras and Nicaragua. Ont Dent. 1991; 68(8):39-45.

12. Hedin CA, Gerner L, Larsson A. The retrocuspid papilla and factor XIIIa: an epidemiologic and histomorphologic study.

Scand J Dent Res. 1994; 102(5):290-4.

www.tda.org | April 2022

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VALUE

for your

Provided by:

profession

LET’S DEBUNK SOME COMMON MISCONCEPTIONS ABOUT STARTING A DENTAL PRACTICE

By Xite Realty

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Be discerning about the “facts” you may hear about starting a practice. Misconceptions swirl around debt, expected income, and location. Let’s clear up 5 common ones.

#1

Misconception #1: I have to be debtfree (with money in the bank) to start a practice.

Many young dentists think banks want you to have a clean slate before they will loan them money to start a practice. Nothing could be more untrue. Lenders examine debt-to-income ratio to determine whether to provide a practice loan.

Still have student loan debt from dental school? As long as you can show you can afford the student loan and practice loan payments, a lender will most likely approve you. Banks understand that dental school means student debt. The most important factor for the bank is your future earning potential.

Similarly, many dentists seeking to launch their own practice believe they will need a lot of money on hand to secure a loan.

In reality, if you deal with dental-specific lenders, they’ll typically fund your practice with zero down.

#2

Misconception #2: You won’t make money the first few years.

Risk is scary. But no one ever made a big play by standing on the sidelines.

Grabbing the opportunity to begin your own practice might seem like a financial risk with an initial reduction in your income, but that’s not the reality.

In their first year of practice, the average dental startup generates a revenue of approximately $350,000. After operational costs, which includes paying all your associated bills and employees, the average dentist will take home about 35% of their gross revenue. That’s about $100,000 to $120,000 on average.

But most dentists will also serve as an associate dentist the first year or two after starting their own practice. During this transition phase, you may work a few days each week for the practice you first worked at as professional or as an associate at another practice. This is why most new practices are open only 3-4 days per week. For example, you might earn income from your own practice Monday through Wednesday, but work for another practice Thursdays and Fridays.

As a result, many dentists can earn over $200,000 in their first year.

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#3

Misconception #3: I must know everything.

Don’t know anything about negotiating a lease? Not sure how to deal with a general contractor? Luckily, you don’t have to be an expert on every phase of starting your practice.

The industry has an expansive network of dental-specific vendors to assist you in achieving your dream of owning your own practice. There are real estate professionals who specialize in finding properties for dentists and are experts in demographics, and attorneys and lenders well-versed in the industry. You can also lean on general contractors, space designers, and marketing companies that specialize in the dental-practice industry.

These folks do dental practice-related work all day, every day. When you work with trusted experts, you’re never on your own.

Real estate services is an area where industry experts can save you money and protect you from challenges. For example, many dentists think they can just drive around a city and find a location for their practice themselves or use a realtor relationship that has never done a dental practice. But that can be a mistake, because they’re not trained to know what factors are important to the success of a dental practice;

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and it’s unlikely they have access to the metrics used to determine the long-term viability of a location. A professional who exclusively works with dentists regarding real estate will know not only how to negotiate a lease but why you should be considering that location for success.

They are also not aware of the areas that are needed to protect you if you later decide to sell your practice.

#4

Misconception #4: All major markets in Texas are saturated.

We hear this often from dentists hoping to open their own practice: “I don’t want to be in (this city or that city) because it’s saturated with dental practices.” Sure, a large metro area like Dallas or San Francisco might have loads of practices, but the number of practices in a city when looked at alone, is not a worthy metric for consideration.

Many people think a market is comprised of a city. But you must examine individual trade areas, which, in a metropolitan region, typically consists of a three-mile radius. By looking at an area on this micro level, the number of people within the radius can be identified as well as how many providers exist there or nearby.

Then a growth rate for the next five years can be projected. A healthy geographic sector for a practice will have high growth in home construction and robust employment, among other things.

When a metro area is broken down into sections like this, locations that offer vibrant growth opportunity for your practice are achievable.

#5

Misconception #5: A location is just an address.

The location of your office is one of the most important factors in the success (or non-success) of the practice. A good location is not simply a great piece of property or an attractive building near high-traffic areas. There are three factors that need to be considered when deciding on a location; and all of them are important.

The first major factor is the current population of an area under consideration.

For example, Xite Realty makes sure a client’s selected community has a high concentration of the dentist’s target patients and target payer (Medicare and Medicaid versus private or commercial insurance) mix to ensure it provides growth opportunities for the practice.

Second, a favorable competition ratio (and knowing what it is) and indications that market share is available are critical to enabling a new practice to thrive in an area.

Last, the availability of dominant real estate in the target area is very important.

With the retailization of healthcare in the last 10 years, visibility and accessibility are more important than ever. Even if a community has a high concentration of target patients and a favorable competition ratio, if a dominant real estate spot can’t be found, the success of your practice will be in jeopardy.

Some dentists hear “competition ratios” and think that’s all they need to look at. But you need to seek communities that have the highest ratios and targetcustomer base, as well as find an excellent real estate location.

Xite Realty finds the best location for a practice to increase a dentist’s probability of success. The company uses the most comprehensive real-estate database to provide a clear picture of competition in an area and identifies a target patient base using key demographic criteria that has been tailored for dentists. TDA members receive a free initial demographic analysis—both on existing space(s) as well as any new offices being considered. Xite can negotiate your lease and help with the purchase of a practice or building to suit. For more information on Xite, visit tdaperks.com (Financial & Real Estate) or call 512-443-3675 and ask for TDA Perks Program.

www.tda.org | April 2022

209

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the bells and whistles. The owner is surgically inclined, but that has ultimately led to an abundance of restorative, cosmetic, and ortho treatment being readily available for the incoming buyer. AUSTIN (ID #T532):

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SUBMISSION Ads must be submitted, and are only accepted, via www.tda.org/Member-Resources/TDAClassified-Ads-Terms. By official TDA resolution, ads may not quote specific incomes or revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”). Journal editors reserve the right to edit and/or deny copy.

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6 operatories, digital radiography, Cerec Omnicam with milling unit. The practice serves a large FFS/PPO patient base with over 2,700 active patients.

The office offers significant upside potential by way of keeping specialty procedures in-house, implementation of a marketing/advertising campaign, and the potential to expand office hours. AUSTIN (ID #T538): Stateof-the-art GD practice located in one of the most popular areas of Austin with great visibility in a busy retail

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(ID #H472): This established,

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www.tda.org | April 2022

211

ADVERTISING BRIEFS fully equipped operatories, digital

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the practice has seen 1,700+ active

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prepared for future expansion. This is

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Texas Dental Journal | Vol 139 | No. 4

ADVERTISING BRIEFS an excellent opportunity to purchase

location offers tremendous growth

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BAYTOWN: Dental practice for sale.

potential through expanding the

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to Methodist Hospital. Office building,

ANTONIO (ID #T501): Located in a highly sought-after area along Loop 1604 in north San Antonio.

The practice serves a large PPO/ FFS patient base and is located in a spacious office condo with 6 fully equipped operatories, digital pano, digital X-rays, and digital sensors.

SAN ANTONIO (ID #T531): GD

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with a major anchor tenant, this www.tda.org | April 2022

213

ADVERTISING BRIEFS loyal staff of 3 (full-time hygienist).

with high-6 figure gross production.

Will consider associate with intention

Comprehensive general dentistry in

to buy. Contact docboehme@yahoo.

the southwest Houston area focused

com.

on children (Medicaid). Very, very high profitability. 1,300 sq ft, 4 operatories

BEAUMONT—GENERAL

in single building. 95% collection

(REFERENCE “BEAUMONT”):

ratio. Over 1,200 active patients.

Small town practice near a main

20% Medicaid, 45% PPO, and 35%

thoroughfare. 80 miles east of

fee-for-service. 30% of patients

Houston. Collections in 7 figures.

younger than 30. Office open 6 days

Country living, close enough to

a week and accepts Medicaid. Contact

Houston for small commute. Practice

Christopher Dunn at 800-930-8017

in a stand-alone building built in

or Christopher@DDRDental.com.

1970. The office is 1,675 sq ft with

HOUSTON (BAYTOWN AREA)—

4 total operatories, 2 operatories

GENERAL (REFERENCE “BAYTOWN

for hygiene and 2 operatories for

GENERAL”) MOTIVATED SELLER.

dentistry. Contains, reception area,

Well established general practice

dentist office, sterilization area, lab

with mid-6 figure gross production.

area. Majority of patients are 30 to

Comprehensive general dentistry in

65 years old. Practice has operated at

Baytown on the east side of Houston.

this location for over 38 years. Practice

Great opportunity for growth! 1,400

sees patients about 16 days a month.

sq ft, 4 operatories in single story

Collection ratio of 100%. The practice

building. 100% collection ratio. 100%

is a fee-for-service practice. Building

fee for service. Practice focuses on

is owned by dentist and is available

restorative, cosmetic and implant

for sale. Contact Christopher Dunn

dental procedures. Office open 3-1/2

at 800-930-8017 or Christopher@

days a week. Practice area is owned

DDRDental.com. HOUSTON

by dentist and is available for sale.

(SHARPSTOWN AREA)—GENERAL

Contact Christopher Dunn at 800-930-

(REFERENCE “SHARPSTOWN

8017 or Christopher@DDRDental.com.

GENERAL”) MOTIVATED SELLER. Well established general dentist

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Texas Dental Journal | Vol 139 | No. 4

ADVERTISING BRIEFS HOUSTON AREA: Several acquisition

reference “Lufkin General or TX#540”.

opportunities in the greater

HOUSTON—GENERAL (SHARPSTOWN)

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practices available for sale. Visit

high six figure gross production.

lonestarpracticesales.com or email

Comprehensive general dentistry

houstondentist2019@gmail.com.

in the South West Houston area focused on children (Medicaid). Very,

HOUSTON, COLLEGE STATION,

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AND LUFKIN (DDR DENTAL

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collection ratio. Over 1,200 active

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patients. 20% Medicaid, 45% PPO,

DDRDental.com for full details. LUFKIN

and 35% fee-for-service. 30% of

—GENERAL practice on a high visibility

patients younger than 30. Office open

outer loop highway near mall, hospital

6 days a week and accepts Medicaid.

and mature neighborhoods. Located

Contact Chrissy Dunn at 800-930-

within a beautiful single-story, free-

8017 or chrissy@ddrdental.com

standing building, built in 1996 and is

and reference “Sharpstown General

ALSO available for purchase. Natural

or TX#548”. HOUSTON—GENERAL

light from large windows within 2,300

(PEARLAND AREA) GENERAL Located

sq ft with 4 operatories (2 hygiene

in southeast Houston near Beltway

and 2 dental). Includes a reception

8. It is in a freestanding building.

area, dentist office, a sterilization

Dentist has ownership in the building

area, lab area, and break room. All

and would like to sell the ownership

operatories fully equipped. Does not

in the building with the practice. One

have a pano but does have digital

office currently in use by seller. A 60

X-ray. Production is 50% FFS and 50%

percent of patients age 31 to 80 and

PPO (no Medicaid), with collection ratio

20% 80 and above. Four operatories

above 95%. Providing general dental

in use, plumbed for 5 operatories.

and cosmetic procedures, producing

Digital pano and digital X-ray.

mid-6 figure gross collections. Contact

Contact Christopher Dunn at 800-

Christopher Dunn at 800-930-8017

930-8017 or christopher@ddrdental.

or Christopher@DDRDental.com and

com and reference “Pearland General www.tda.org | April 2022

215

ADVERTISING BRIEFS or TX#538”. HOUSTON—PEDIATRIC

consultation room, 2 offices, a

(NORTH HOUSTON) This practice

breakroom, and storage. This

is located in a highly sought-after

FFS practice collects in the high-6

upscale neighborhood. It is on a major

figures annually. Current dentist will

thoroughfare with high visibility in a

participate in a 3- to 5-year transition.

strip shopping center. The practice has

Contact 713-781-3599 or email

3 operatories for hygiene and 2 for

bkkpallen@gmail.com.

dentistry. Nitrous is plumbed for all operatories. The practice has digital

KATY: Now is the time to join Grand

X-rays and is fully computerized. The

Lakes Dental Group and Orthodontics.

practice was completely renovated in

You will have opportunities to

2018. The practice is only open 3-1/2

learn new skills from our team of

and a half days per week. Contact

experienced professionals. If you’re

Christopher Dunn at 800-930-8017

ready to take your career to the next

or christopher@ddrdental.com and

level and gain valuable experience,

reference “North Houston or TX#562”.

apply today! You’ve invested the time

WEST HOUSTON—MOTIVATED SELLER.

to become a great dentist, now let

Medicaid practice with production in

us help you take your career further

mid-6 figures. Three operatories in

with more opportunity, excellent

1200 sq ft in a strip shopping center.

clinical leadership and one of the best

Equipment is within 10 years of age.

practice models in modern dentistry.

Has a pano and digital X-ray. Great

In working with our practice you will

location. If interested contact chrissy@

have the autonomy to provide your

ddrdental.com. Reference “West

patients the care they deserve. In

Houston General or TX#559”.

addition, you’ll enjoy the opportunity to earn excellent income and have

HOUSTON: Established general

great work-life balance without the

practice located in the Galleria/

worries of running a practice. You

Memorial Villages area of Houston

became a dentist to provide excellent

for sale. The 4,000 sq ft leased

patient care and have a career that will

space has 8 operatories, 2 dental

serve you for a lifetime. With us, you

labs, 2 sterilization areas, a private

will have a balanced lifestyle, fantastic

216

Texas Dental Journal | Vol 139 | No. 4

ADVERTISING BRIEFS income opportunities, and you’ll

contact a recruiter anytime. We’d love

work for an office that cares about

to chat, get to know you and share

their people, their patients and their

more about us. Pacific Dental Services

community. Our practice is an office

is an equal opportunity employer and

supported by Pacific Dental Services

does not discriminate against any

(PDS), which means you won’t have to

employee or applicant for employment

spend your career navigating practice

based on race, color, religion, national

administration. Instead, you’ll focus

origin, age, gender, sex, ancestry,

on your patients and your well-being.

citizenship status, mental or physical

Add on excellent benefits, including

disability, genetic information, sexual

malpractice insurance, medical, dental

orientation, veteran status, or military

and vision insurance, retirement plans

status. Apply here:http://www.

and much more and you’ll feel well

Click2Apply.net/gwy6pkn22knbzwzx

taken care of throughout your career.

PI106822492.

The average full-time PDS-supported associate dentist earns low-6 figures

WATSON BROWN PRACTICES FOR

in their first year. The average income

SALE: Practices for sale in Texas

for a PDS-supported owner dentist,

and surrounding states, For more

whose practice has been open at

information and current listings please

least 2 years, is mid-6 figures. As

visit our website at www.adstexas.com

an associate dentist, you will receive

or call us at 469-222-3200 to speak

ongoing training to keep you informed

with Frank or Jeremy.

and utilizing the latest technologies and dentistry practices. If you are

INTERIM SERVICE

interested in a path to ownership, our proven model will provide you with the

HAVE MIRROR AND EXPLORER,

training needed to become an owner

WILL TRAVEL: Sick leave, maternity

of your own office. PDS is one of the

leave, vacation, or death, I will cover

fastest growing companies in the US

your general or pediatric practice. Call

which means we will need excellent

Robert Zoch, DDS, MAGD, at 512-517-

dentists like you to continue to lead

2826 or drzoch@yahoo.com.

our growth in the future. Apply now or www.tda.org | April 2022

217

YOUR PATIENTS TRUST YOU.

WHO CAN YOU TRUST?

ADVERTISERS Anesthesia Education & Safety Foundation... 166 Choice Transitions................... Inside Back Cover E-VAC, Inc..................................................... 177 Henry Schein Financial Services.................... 169

If you or a dental colleague are experiencing impairment due to substance use or mental illness, The Professional Recovery Network is here to provide support and an opportunity for confidential recovery.

JKJ Pathology................................................ 185 Law Offices of Hanna & Anderton..................... 176

McLerran & Associates.................................. 213 Professional Recovery Network..................... 218 SmileCon 2022.............................................. 187 Southwest Sedation Education...................... 169 TDA Perks.............................. Inside Front Cover Texas Health Steps........................................ 163 UTHealth Houston Pathology......................... 177

PRN Helpline (800) 727-5152

218

Visit us online www.txprn.com

Texas Dental Journal | Vol 139 | No. 4

Watson Brown Practice Sales & Appraisals.... 167

Put the pliers down, let the pros do their job.

Some brokers just send you the candidate and leave all the heavy work to you Would your patient pull their own teeth?

Trust your practice sale to an experienced full service broker who has had hundreds of practice sales.

(877) 365-6786 choicetransitions.com

Considering selling to a DSO? Don’t, until you read this.

Choice walked me through the process, presented the best offers, and made the experience much less stressful by handling all the negotiations. In the end, I received more for my practice than I ever expected. The best part is that Choice provided all the consultation and services to me without charging any fees!

If you are considering selling to a DSO, I highly recommend you contact Choice instead of directly contacting the DSOs.

Commission free. DSO Choice.

(877) 365-6786 • choicetransitions.com

www.tda.org | April 2022

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Texas Dental Journal | Vol 139 | No. 4