2017 - Sept/Oct TFDA

5 STEPS TO PRESCRIBING CONTROLLED SUBSTANCES IN FLORIDA

VOL. 29, NO. 6 • SEPTEMBER/OCTOBER 2017

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

How Do Opioids Attack the Body?

FDA Wellness Plan Offers Hope to Members in Crisis

SPECIAL SECTION

FOR DENTISTS OPIOIDS BY THE NUMBERS FLORIDA'S OPIOID CRISIS THE BROWN BAG APPROACH TO PATIENT MEDS HOW TO SIGN UP FOR FLORIDA’S PDMP DATABASE

TRY OUR AGENT Mike Trout

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HELPING MEMBERS SUCCEED VOL. 29, NO. 6 • SEPTEMBER/OCTOBER 2017

special section

PAGE 29

Almost 2 million Americans abused or were dependent on prescription opioids in 2014.9

highlights

5

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

STEPS

TO PRESCRIBE CONTROLLED SUBTANCES IN FLORIDA

PAGE 37

Strategies for the Opioid Crisis from Florida's Surgeon General

PAGE 40

Tough Medical Marijuana Rules Could Be in Your Future 5 Tactics for Effectively Prescribing Pain Medication

PAGE 50

PAGE 59

features Ultimately they can be in jeopardy of losing their licenses, their health or even their own lives.

— Barton R. Blumberg, DMD

on the need for an FDA Well-being Committee to support denitsts in crisis

BOD Meets in Tampa 23 Special Section: Rx for Dentists 29-61 Opioids by the Numbers • Florida by the Numbers • For Providers • Florida's Prescription Drug Database • Death by Rx • 5 Steps to Prescribe Controlled Substances in Florida • Strategies for the Opioid Crisis from Florida's Surgeon General • How Do Opioids Attack the Body? • FDA Well-being Program Approved: Confidential Help for Dentists in Need • Tough Medical Marijuana Rules Could Be in Your Future • The Brown Bag Approach & More: Medication Reconciliation • 5 Tactics for Effectively Prescribing Pain Medication Corporate Dental Practice, Part 2 67

Upgrading technology can be a pain, but it forces you to clean up your mess.

— Larry Darnell, CMP, CAE

from this issue's "Information Bytes"

in every issue Staff Roster 3 President's Message 5 Legal Notes 8 Did You Know? 12 Information Bytes 15

news@fda 18 Compleat Dentistry 62 Diagnostic Discussion 71 Classified Listings 76 Off the Cusp 80

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For a complete listing: www.floridadental.org/calendar

2

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

FLORIDA DENTAL ASSOCIATION SEPTEMBER/OCTOBER 2017 VOL. 29, NO. 6

EDITOR Dr. John Paul, Lakeland, editor

STAFF Jill Runyan, director of communications Jessica Lauria, communications and media coordinator Lynne Knight, marketing coordinator

BOARD OF TRUSTEES Dr. Michael D. Eggnatz, Weston, president Dr. Jolene Paramore, Panama City, president-elect Dr. Rudy Liddell, Brandon, first vice president Dr. Andy Brown, Orange Park, second vice president Dr. Dave Boden, Port St. Lucie, secretary Dr. William D’Aiuto, Longwood, immediate past president Drew Eason, Tallahassee, executive director Dr. James Antoon, Rockledge • Dr. Steve Cochran, Jacksonville Dr. Richard Huot, Vero Beach • Dr. Jeannette Pena Hall, Miami Dr. George Kolos, Fort Lauderdale • Dr. Jeffrey Ottley, Milton Dr. Paul Palo, Winter Haven • Dr. Howard Pranikoff, Ormond Beach Dr. Rick Mullens, Jacksonville • Dr. Beatriz Terry, Miami Dr. Stephen Zuknick, Brandon • Dr. Ethan Pansick, Delray Beach, speaker of the house Dr. Tim Marshall, Spring Hill, Treasurer • Dr. John Paul, Lakeland, editor

PUBLISHING INFORMATION Today’s FDA (ISSN 1048-5317/USPS 004-666) is published bimonthly, plus one special issue, by the Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.

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EDITORIAL CONTACT INFORMATION All Today’s FDA editorial correspondence should be sent to Dr. John Paul, Today’s FDA Editor, Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.

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The last four digits of the telephone number are the extension for that staff member.

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3

BECOME A HEALTH-ENHANCER SMILE-RESTORER ESTEEM-BUILDER DIFFERENCE-MAKER LEGACY-CREATOR LIFE-CHANGER

Visit emeraldclub.floridadental.org to learn more and join the FDA Foundation’s Emerald Club.

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THE HEALTH CARE DEBATE, ADVOCACY, MEMBERSHIP …

WHERE DO YOU STAND?

A

s the health care debate rages, dentistry is but a small specialty in the vast ocean of medicine. As we try to navigate the rocky shoals of the health care delivery system, we must be wary of the unintended consequences of our decisions.

Our national debate primarily focuses on the complicated web that is the delivery of medicine in our country. There are many powerful and competing entities that are pushing their own agendas on one of the most pressing issues of our time. Relative to the medical model, there is consensus that the United States’ dental delivery system is not only the best in the world, but also is the most efficient health care dollar being spent, with the vast majority of every dollar going to direct patient care, not bloated administrative costs of private insurers or the massive fraud and bureaucratic inefficiencies of Medicaid. You only have to turn to our medical colleagues to see the tangled web of abuse and profiteering that has become so pervasive; it is choking what was once a viable medical delivery system. It is one path that we, as dentists, can agree that we DO NOT want to pursue.

However, there still are shortcomings and inequities that must be, and will be, addressed. We can either be proactive and attempt innovative ideas or bury our heads in the sand and say we think the current system doesn’t need improvement. The reality is, in our highly charged political climate (which we are all subject to, like it or not), discussions and decisions are being made as you read this. The decision-makers (our state governmental agencies, legislators and the governor) are at the table making these decisions either with us or without us. I would like a seat

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LEADERSHIP

at the table to educate, influence and hopefully have a positive effect on potentially sweeping reforms involving the protection of the public’s dental health with which all Florida-licensed dentists are charged.

Who knows more about what’s best for the public’s dental health than the profession itself?

As a profession, we must put aside petty internal politics and conflict and speak with a clear united voice to our legislators­— or we risk the mistakes and consequences our medical colleagues made many years ago!

The Florida Dental Association (FDA), along with the tripartite structure of the American Dental Association (ADA) and your district dental association, is the only entity that has the structure and mechanisms in place to interface and engage with our governmental agencies on multiple levels on our behalf. Your professional organization needs your input, involvement and support to face unprecedented challenges from powerful groups outside of dentistry.

PRESIDENT’S MESSAGE MIKE EGGNATZ, DDS

Dr. Eggnatz is the FDA president and can be reached at meggnatz@ bot.floridadental.org.

We need to educate our decision-makers that we are different from the rest of medicine.

Our delivery of care, the untapped capacity of existing dentists, economic efficiency and ratio of general practitioners to specialists (80/20) makes dentistry uniquely qualified to treat the existing public demand for primary dental services.

We have the innovative solutions to improve maldistribution in our state, and both political parties have already agreed on legislation to incentivize young, fully educated dentists to move to underserved areas of our state to proSEE PAGE 7 TODAY'S FDA

SEPTEMBER/OCTOBER 2017

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F L O R I D A D E N TA L C O N V E N T I O N : T H E O F F I C I A L M E E T I N G O F T H E F D A

O Y U R E T G A A V M E E EL

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LEADERSHIP

FROM PAGE 5

vide comprehensive care and a true dental home for those who seek it. We are, and have been, shaping improvements to an imperfect system for all who seek and deserve the same quality of care by qualified dental professionals with the appropriate doctoral degrees.

Nationally, our schools are producing 2,000 more dentists a year than 10 years ago. Those who advocate for a mid-level provider or a dental therapist with less than half the education of our young dentists are advocating for a false equivalency to a doctorate degree so invasive surgical procedures can be performed on the public in the name of access to care. These populations often are more medically compromised and have more complex needs than the general population. They deserve the same quality of diagnosis and care that all Floridians deserve. Those who advocate for dental therapists appear to believe in a two-tiered health care system for those with less. Access to quality care for all is a bedrock principle of our profession.

One would think that those who are educating the next generation of dentists in our dental schools with a doctorate level degree would find it difficult to reconcile their stringent standards of school acceptance and their high-quality educational requirements with the minimal standards and educational requirements of a separate mid-level provider, working without the oversight of a dentist at the head of the team.

YOUR PROFESSIONAL ORGANIZATION NEEDS YOUR INPUT, INVOLVEMENT AND SUPPORT TO FACE UNPRECEDENTED CHALLENGES FROM POWERFUL GROUPS OUTSIDE OF DENTISTRY.

So, I ask you, all Florida-licensed dentists: Why would you spend the time, money and effort on being educated through four years of undergraduate studies, four years of dental school and for many of you, post graduate residencies or specialty schools, and not want to shape your own future as a professional and for many, as a small-business owner? If you have made it your life’s work to be the best you can be in your chosen profession, then why would you not want to engage with the people who are going to dictate your future professional life?

The tripartite is trying their best to advocate for you and resolve some complicated societal issues. No one is more affected than you, both as a patient and as a professional! Your profession needs you and whether you realize it or not, you need your profession. When it comes to the health care debate, dentistry, advocacy and membership — where do you stand?

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TODAY'S FDA

SEPTEMBER/OCTOBER 2017

7

HOW WELL DO YOU KNOW THE BOARD OF DENTISTRY DISCIPLINARY PROCESS? PART 6

LEGAL NOTES

This is Part 6 of a continuing series.

STEP 10: Investigative Report

GRAHAM NICOL, ESQ.,

Under section 456.073(2), Fla. Stats., after the Department of Health (DOH) completes its investigation, it prepares a written investigative report for the Board of Dentistry (BOD) Probable Cause Panel (PCP). The report contains the investigative findings and the recommendations of the department concerning the existence of probable cause.

HEALTH CARE RISK MANAGER, BOARD CERTIFIED SPECIALIST (HEALTH LAW)

TIP: You have a right to get a copy of the report and all attachments to it. You must request the report in writing within 20 days and you may — and should — have your lawyer file a written response.

Graham Nicol is the FDA chief legal officer.

When the investigative report is done, the department is given another opportunity to dismiss the case against you. This underscores the importance of counsel submitting written responses within 20 days of when the file is opened and after the investigation is complete. Without your written response, the department and the PCP have only the complainant’s side of the story.

LEGAL CE What Florida Dentists Need to Know about Prescription, Controlled Substance and Pain Management Laws (LC01) Patient Abandonment (LC02) Take these courses online to earn free CE credit. For links, go to floridadental. org/members.

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8

TODAY'S FDA

TIP: You want the case to be dismissed at this point rather than go forward to the PCP. Once a case reaches the PCP step, it becomes increasingly expensive to defend, and the risk of licensure discipline and public embarrassment rises dramatically. A finding of probable cause is the point of no return.

Letters of Guidance and Notices of Noncompliance TIP: Your written response at the close of the investigation should specifically ask for a “letter of guidance” or a “notice of noncompliance” in lieu of a recommendation of probable cause. The DOH may dismiss your case, or any part of it, if the investigator and DOH attorney determine that there is insufficient evidence to support the allegations. Often, in lieu of find-

SEPTEMBER/OCTOBER 2017

ing probable cause, the department may issue a notice of noncompliance or the PCP may issue a letter of guidance.

A letter of guidance or a notice of non-compliance shortcuts a finding of probable cause by the PCP and is in lieu of finding probable cause. Thus, it does not constitute formal public discipline against your license. If your case is dismissed before a finding of probable cause, then the investigative report, the letter of guidance and the notice of noncompliance are confidential and exempt from section 119.07(1), Fla. Stats, the state’s public records statute.

TIP: Always ask, because the DOH prosecuting attorney has discretion (albeit limited), without input from the PCP, to dismiss your case at this stage.

A notice of noncompliance is an option for an initial offense of a minor violation.

The BOD has established by rule what offenses constitute minor violations for a notice of noncompliance. They are violations that do not demonstrate a serious inability to practice dentistry and that pose no threat to public safety. If you get a notice of noncompliance, be grateful and take action to correct the violation within 15 days from the notice or you will be formally prosecuted.

TIP: If you write a letter or do anything other than accepting, signing and returning the notice of noncompliance, then you have rejected it, the case goes to formal prosecution. You will probably not get a second offer.

TIP: Make sure you pay the fine and document that you’ve corrected the deficiency.

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Letters of guidance are similar to notices of noncompliance. If you have already been issued a letter of guidance for a related offense, the DOH cannot issue you issue you a letter of guidance. Also, the PCP may request to review the investigative files pertaining to a case prior to its dismissal by the DOH. If this occurs, and the DOH nevertheless dismisses the case, then the PCP may retain independent legal counsel, employ investigators, and continue the investigation and prosecution of the case. This is very bad news indeed, because you want a confidential notice of noncompliance or letter of guidance rather than a finding of probable cause by the PCP.

Citation Offenses In 1997, the Florida Legislature enacted section 456.077, Fla. Stats., which authorizes the DOH to issue “citations” in simple matters in order to speed up processing of cases.

TIP: Citations are another way to bypass the PCP step; however, unlike letters of guidance and notices of noncompliance, citations are publicly available and may constitute formal discipline that will appear on your license.

After basic investigation, some cases are resolved by the DOH’s legal staff sending an offer of citation that gets served to you personally or via certified mail, restricted delivery, to your last known business address. Citations will be issued within six months from the complaint filing date to facilitate swift resolution of simple disciplinary matters.

Citations involve violations where there is no substantial threat to the public health and no violation of standard of care involving injury to a patient. Typical citation offenses include: missing continuing education requirements; failing to timely pay required fees and fines; failing to comply with advertisWWW.FLORIDADENTAL.ORG

ing requirements; and, failing to display licenses and permits.

The citation will be issued directly to the subject and will list the subject’s name and address, the subject’s license number, a brief factual statement, the sections of the law allegedly violated and the penalty imposed. The citation will clearly state that you may choose, in lieu of accepting the citation, to follow the formal PCP and disciplinary procedure under section 456.073, Fla. Stats.

If you dispute the matter in the citation, the formal PCP and disciplinary procedure must be followed. But if you do not dispute the matter in the citation with the DOH within 30 days after the citation is served, the citation becomes a public final order. Importantly, it does not constitute discipline for a first offense. However, it does constitute discipline for a second or subsequent offense.

The penalty usually is a fine and remediation of the underlying violation.

The DOH also will recover the costs of investigation and prosecution as part of the fine under the citation. The costs assessed will be itemized and will include salaries and benefits of personnel, the time spent by the attorney and investigator, and any other expenses. The BOD will determine the costs by reviewing an affidavit submitted by the DOH. You have the right to file written objections to how costs were assessed against you.

STEP 11: Probable Cause Determination If you don’t get a dismissal, a notice of noncompliance, a letter of guidance or a citation offer, then your case will proceed to the PCP. Getting to this step dramatically increases the seriousness of the matter and the speed with

which it will progress. For example, the PCP has 15 days to request additional investigative information from the DOH if needed. It must make its determination of probable cause within 30 days of receiving the final investigative report.

Extensions of the 15-day and the 30-day time limits may be granted, but only by the surgeon general.

The determination as to whether probable cause exists is based on the investigative report, any expert witness opinions and your written response(s).

TIP: In most cases, neither the licensee nor his lawyer can participate so, again, the only way you can tell your side of the story is via written response(s).

Whether probable cause exists is decided by majority vote of the PCP. The BOD’s PCP consists of three members, and a quorum necessary to vote consists of two members. In the event only two members attend, probable cause shall be determined only if both members vote in the affirmative. Each board under the DOH may provide by rule for multiple PCPs. Currently, the BOD only has one PCP, but medicine and nursing have multiple panels.

One or more PCP members may be former board members with active licenses.

Notably, the PCP may include a former or present consumer member at the BOD chair’s direction. Having a nondentist on the PCP may — depending on the circumstances of your case — be to your advantage (e.g., they may have more respect for a doctor or be more lenient than a professional peer) or disadvantage (e.g., they may defer to the dentists regarding scope of practice and standard of care). The PCP also must include a present BOD member.

TODAY'S FDA

SEE PAGE 10 SEPTEMBER/OCTOBER 2017

9

LEGAL NOTES FROM PAGE 9

Under section 456.073(4), PCP proceedings are confidential, exempt from the Sunshine Law and the notice requirements under section 120.525, Fla. Stats., and kept non-public until “10 days after probable cause has been found to exist by the panel or until the subject of the investigation waives his or her privilege of confidentiality.”

TIP: If the PCP finds no probable cause, the case is dismissed and no public record is kept.

But, if probable cause to believe that a violation has occurred is the majority finding, then the PCP directs the department to file a formal complaint, and 10 days later the Administrative Complaint (AC) becomes public record, even if you ultimately prevail.

TIP: Think of a finding of probable cause and the AC as “the point of no return,” beyond which you will have a public record. It is not a finding that you are actually guilty of violating the rules, but nevertheless, it is public record. Anyone can look up an AC by going to: https://appsmqa.doh. state.fl.us/MQASearchServices/EnforcementActionsPractitioner. At this step, you are “in the system” and no longer “off the grid.” Plaintiffs’ attorneys can see what you were charged with, as can current and potential patients, and your professional peers. The record never goes away and may be used by credentialing committees, managed-care plans, other states where you have a license and the federal government. It will probably impact your ability to get malpractice coverage or the cost of premiums you pay for liability insurance. After you serve whatever discipline is imposed via the Final Order, you may be eligible to return to practice — but no matter what you do, the record will follow you throughout your career.

STEP 12: The Administrative Complaint (AC) Once the PCP determines there is proba-

10

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ble cause to believe a violation occurred, it directs the DOH to formally prosecute the case. At this step, you will be served with a formal AC. Defense costs rise dramatically after this step.

violations or misrepresentation. If the DOH loses on all counts, you stand an excellent chance of recovering attorneys’ fees and court costs against the DOH. Multiple counts, therefore, is the easiest way for the government to avoid paying fees and costs.

TIP: The AC looks very much like a criminal complaint and has the same appearance as a civil lawsuit. The DOH is referred to as the “Petitioner” and the licensee being prosecuted is referred to as the “Respondent.” The AC gets filed with the clerk’s office of the Florida BOD and is assigned a case number. The patient involved will be referred to by their initials. Subsequent treating providers seen by the patient for further treatment also will be referred to by their initials.

Finally, the AC will end with a “wherefore clause” that:

The first part of the AC contains the factual allegations against you, which are incorporated by reference into Count I. For each count in the complaint, there will be a reference to the statute you are alleged to have violated. Typically, ACs get filed for serious matters, such as “incompetence or negligence by failing to meet the minimum standards of performance in diagnosis and treatment,” which violates section 466.028(1) (x), Fla. Stats. Other common counts are improper delegation of duties, sexual misconduct with a patient, lack of informed consent, improper prescribing, fraud, practicing outside the scope of licensure, and being unable to practice with reasonable skill and safety by reason of illness or use of alcohol, drugs, or mental or physical condition.

TIP: It is not at all unusual for the AC to contain multiple counts. For example, failing to keep records that justify your diagnosis and treatment plan usually coincide with standard of care or informed consent violations. Similarly, not providing records to the patient or the department, and making deceptive, untrue or fraudulent representations in the practice of dentistry also frequently accompany standard of care violations.

TIP: One reason to expect multiple counts in the AC filed against you is so that, even if the DOH loses the standard of care counts, they will prevail on the ancillary counts of records

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respectfully requests that the Board of Dentistry enter an order imposing one or more of the following penalties: permanent revocation or suspension of Respondent’s licensure, or restriction of Respondent’s practice, imposition of an administrative fine, issuance of a reprimand, placement of Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the board deems appropriate.

At this step, “things just got real” and you may have wished you had used the FDA’s Peer Review program — but now it is too late.

TIP: Usually, the mere filing of an AC, without an Emergency Suspension Order, means you can remain in practice. You need to first correct the infractions alleged in the AC if there is any truth to them. For example, enter an intensive outpatient program if substance abuse is alleged. It helps mitigate the charges against you and may just save your life and career. It also allows you to continue earning money to pay legal expenses. Coordinate your return to work with your lawyer so that you are not charged with unlicensed practice or further disciplinary matters.

Look for Part 7 of this series in the next issue of Today’s FDA. This article is for informational purposes only and is not intended to be a substitute for professional legal advice. If you have a specific concern or need legal advice regarding your dental practice, you should contact a qualified attorney.

WWW.FLORIDADENTAL.ORG

BYLAWS CHANGES HOUSE OF DELEGATES TO CONSIDER BYLAWS CHANGES Following the recommendation of the Florida Dental Association (FDA) Council on Ethics, Bylaws and Judicial Affairs, chaired by Dr. Drew Johnson, the House of Delegates (HOD) will be asked to consider a proposed bylaws change. The change would prohibit FDA line officers, trustees and alternate trustees from serving on the FDA HOD. Currently, the FDA Bylaws prohibit FDA line officers and trustees — but not alternate trustees — from serving on the FDA HOD. The text of the proposed bylaws change is as follows: 2017H-006

[Policy] RESOLVED, that the FDA Bylaws, Chapter VI, House of Delegates, Section 20, Representation, be amended as follows:

SECTION 20. REPRESENTATION The HOD has 103 certified delegates: 100 delegates from the components and one student delegate from each of the three accredited Florida dental schools. FDA line officers, trustees, and alternate trustees may not be delegates or alternates to the FDA HOD. The HOD will hold its semi-annual session Jan. 26-27, 2018 at the Tampa Airport Marriot, 4200 George J. Bean Parkway, Tampa, Fla. 33607. The FDA encourages all members to seek information about this important matter from their district’s delegates to the HOD and their trustees to the Board of Trustees.

Underline = Addition

DIRECTOR OF THIRD PARTY PAYER & PROFESSIONAL AFFAIRS LOOKING FOR HELP? We can address your concerns in the complex arena of managed care. We also can gather data on problems and create momentum for finding solutions. Contact the FDA Director of Third Party Payers & Professional Affairs Casey Stoutamire: 800.877.9922; 850.681.3629; cstoutamire@floridadental.org

MEMBERS ONLY!

TOP 5 LEGAL RESOURCES

YOU WANT ME TO SIGN WHAT? A Florida Dentist’s Handbook on Managed-care Contracts is a comprehensive reference including information on reimbursement, risk, negotiating, and rights and duties of both parties.

HIPAA & FLORIDA PRIVACY LAW Being fully HIPAA-compliant does not guarantee compliance with Florida law. FDA members have a comprehensive collection of FREE forms that comply with federal and Florida law.

FDA LEGAL FAQS The FDA website houses the answers prepared by the FDA’s experienced legal counsel to our members’ legal FAQs, including: patient records, patient abandonment, advertising and more.

For more information: fda@floridadental.org or call 800.877.9922

ADA CONTRACT ANALYSIS SERVICE This service analyzes third-party contracts, including contracts from

managed-care companies. This service is available at no cost to FDA Find FDA legal resources online at: www.floridadental.org/member-center/member-resources/legal-resources. members. Simply call the FDA for this free service.

REMEDIABLE TASKS

?

DIDYOU

INFORMATION ABOUT THE FLORIDA BOARD OF DENTISTRY

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MONTHS

MONTHS

DR. DON ILKKA FDA LIASON TO THE FLORIDA BOARD OF DENTISTRY

D

id you know that a recent revision to the Board of Dentistry (BOD) rule 64B5-16.001, Definitions of Remediable Tasks and Supervision Levels, now allows any authorization for remediable tasks to be performed by a dental hygienist under general supervision to be valid for no more than 24 months? Previously, the authorization was valid for no more than 13 months. This rule applies to services in all dental settings unless otherwise contradicted by statute. However, a dentist can still choose to require authorization every 13 months or at a time interval he/she determines is best for the patient.

MS. CASEY STOUTAMIRE FDA DIRECTOR OF THIRD PARTY PAYER & PROFESSIONAL AFFAIRS

64B5-16.001 Definitions of Remediable Tasks and Supervision Levels.

(7) Any authorization for remediable tasks to be performed under general supervision is valid for a maximum of 24 months; after which, no further treatment under general supervision can be performed without another clinical exam by a Floridalicensed dentist.

If you have any questions, please contact Director of Third Party Payer and Professional Affairs Casey Stoutamire, Esq. at cstoutamire@ floridadental.org or 850.350.7202, or FDA Liaison to the Florida Board of Dentistry Dr. Don Illka at donjilkkadds@aol.com or 353.787.4748.

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TODAY'S FDA

SEPTEMBER/OCTOBER 2017

WWW.FLORIDADENTAL.ORG

 REMINDERS! HERE'S ONE RIGHT NOW! RENEW YOUR LICENSE BY FEB. 28, 2018!

Every biennium, we request a list from the Board of Dentistry of dentists who have not yet renewed their license. FDA MEMBERS in this category receive a reminder to renew.

 CE BROKER The FDA automatically posts all your FDA completed CE courses to CE Broker. In addition, FDA MEMBERS receive a discount on CE Broker upgrades.

5 WAYS

WE PROTECT YOUR LICENSE For more information, go to www.floridadental.org, contact us at fda@floridadental.org or call 800.877.9922.

WWW.FLORIDADENTAL.ORG

 FREE CE: ONLINE AND FDC FLORIDA DENTAL CONVENTION: FDA MEMBERS pre-register for FREE and can earn up to 18 FREE CE credits.

FDA ONLINE CE: Earn up to 30 FREE CE hours per year. Available 24/7, only to FDA MEMBERS. Take advantage of these courses until Dec. 12, 2017

 LIAISON WITH BOARD OF DENTISTRY The FDA sends staff and an appointed FDA MEMBER to every Board of Dentistry (BOD) meeting. Whenever your license, your ability to practice or your pocket book is affected, the FDA is part of the decision making process at the BOD.  INFORMATION Do you have questions about the biennium, the renewal process, CE Broker or your FDA-earned CE credits? Contact the FDA at fda@floridadental.org, 800.877.9922 or 850.681.3629. Information!

It's one of the benefits provided to FDA MEMBERS. TODAY'S FDA

SEPTEMBER/OCTOBER 2017

13

TECHNOLOGY

UPGRADING TECHNOLOGY: A VALUABLE CONSIDERATION

T

he iPhone 8 was just released. I am a bleeding-edge technology guy, obviously, so I’ll get one as soon as possible. A new phone is an exciting endeavor until I think about the process of upgrading. Moving over contacts, applications, settings and email accounts makes me almost think twice. The same thing happens when I upgrade my computer, my router, my tablet — literally almost any new electronic device brings significant pain. However, there are tools to assist in the upgrade process. Cloud services like iCloud help with my iPhone or my iPad. Upgrading a computer is more challenging, though. So, most people hang on to their older technology for way longer than they should have — all as the result of the pain of the upgrade.

Let me give you a real-life analogy. About a year ago, I moved into a new house. It’s less than a mile from where I had lived, but it was a significant upgrade. I spent weeks preparing for the move. I packed things up in a bunch of boxes, took a week off and moved all this stuff into the garage at my new house. During the move, I learned some things that are applicable to the technology upgrade dilemma. I got rid of things I no longer used or needed. I restricted my clothing options to a certain number of hangers, so I prioritized things. Today, you can find some of those boxes still in my garage. Guess what? Apparently, I don’t need that stuff anymore. It’s been a year, and I haven’t opened those boxes. It must go, but I never would have known without the upgrade. How is this applicable to upgrading your technology?

INFORMATION BYTES LARRY DARNELL, MBA, CAE

Mr. Darnell is the FDA director of information systems and can be reached at ldarnell@ floridadental.org.

Upgrading technology can be a pain, but it forces you to clean up your mess — get rid of apps you no longer need or use, and reorganize and prioritize information. If it wasn’t for the upgrade, you’d probably never make the time to do this. After a painful few days, you have technology that is better, faster and more in tune with the way you need it to be. So, do not fear the upgrade. Endure that pain to make you more efficient and organized going forward. So, go ahead and upgrade that iPhone 3 and get rid of that Windows XP computer — it’s time.

Here’s my recommendations for getting started: q q q q q

Get rid of apps you no longer need or use.

Reorganize and prioritize information.

Don’t be afraid to try new technology.

Make regular backups of your data.

You don’t have to be the first to upgrade but don't be the last.

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

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DENTAL THERAPIST WHY IS FLORIDA A TARGET FOR DENTAL THERAPISTS?

A

dental therapist is a mid-level provider whose purpose is being promoted as a way to increase access to dental care. It also is being advertised as a means for dentists to “generate higher revenue” by paying dental therapists lower salaries and delegating routine procedures.

The Florida Dental Association (FDA) is not supportive of creating a new licensed provider — dental therapist — in Florida. What is the rationale for adding another layer of bureaucracy to a health care system that already is costly due to multiple layers of rules and regulations that ultimately impede access to care? There are groups outside of Florida and individuals who have announced that they are building coalition groups, hiring public relation firms and consultants to bring dental therapists to Florida. This is alarming. Resources by these groups that could be used to help promote initiatives proven effective in Florida, will instead be used to force a treatment model that is not supported by organized dentistry.

Why has Florida become the target for adding dental therapists? Does Florida have a shortage of dentists? No, Florida does not have a shortage of dentists. The Department of Health (DOH) includes a dental workforce survey completed by dentists during licensure renewal. This survey clearly shows that Florida does not have a shortage, but instead has a maldistribution of dentists around the state. So, why not support an initiative to help incentivize dentists to go to these underserved areas?

Good question. The FDA supports creating a dental student loan repayment program that will incentivize dentists to practice full time as Medicaid providers in underserved areas. In return, they would get assistance in repaying their student loan. These are trained professionals skilled in assessing comprehensive health care for their patients. They are not just trained to do a few procedures — which would include performing tooth extractions.

LEGISLATIVE CORNER JOE ANNE HART

Ms. Hart is the FDA chief legislative officer and can be reached at jahart@floridadental.org.

BE ON THE LOOKOUT ... for additional information as it becomes available. If you would like to share your thoughts about dental therapists, please send your comments to gao@floridadental.org.

This article first appeared in LCD Exchange, August 2017.

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TODAY'S FDA

SEPTEMBER/OCTOBER 2017

17

UPDATES FOR MEMBERS *PLEASE NOTE THAT FDA MEMBERS HAVE THEIR NAMES LISTED IN BOLD.

The FDA received an outpouring of support from the ADA and other state dental associations after Hurricane Irma.

To donate to the FDA Foundation Disaster Fund, or to complete an application for ADA and FDA Foundation Disaster Assistance Grants, go to floridadental.org.

Also, the State of Florida Small Business Emergency Bridge Loan Program will provide short-term, interest-free loans to small businesses impacted by Hurricane Irma.

Before Oct. 31, go to floridadisasterloan.org/

Questions? Call 800.877.9922 or email foundation@floridadental.org Look for a recap of Hurricane Irma’s impact on Florida dentists in the next issue of Today’s FDA.

Update Your Find-a-Dentist Profile on My ADA Today!

You told the ADA that you wanted more patients. The ADA has responded with the new, enhanced Find-a-Dentist tool. Completed profiles closest to the patient’s location will be prioritized in results on the Find-a-Dentist tool, so help your patients find you! Go to ADA. org/MyADA to update your member profile today!

Go to http://bit.ly/2w7M5Mk for more information on updating your profile, and http://bit.ly/2eKWTO6 for headshot tips.

Renew Your License!

All Florida-licensed dentists must renew their license by midnight on Feb. 28,

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TODAY'S FDA

2018. As a reminder, all verified continuing education (CE) courses taken at the 2016 and 2017 Florida Dental Conventions have been reported to CE Broker on your behalf. Don’t wait until Feb. 28 to report or review your CE. Go to CEBroker.com to log in to your account to review your current CE credits or self-report credit for other courses you may have attended. Do you still need CE hours to renew your license? Go to fda. peachnewmedia.com/store/provider/ provider09.php to view the free FDA online CE courses available to you.

Save the Date for FDC2018 Mark your calendar for the 2018 Florida Dental Convention (FDC), June 2123! FDC2018 will offer more than 120 lecture and hands-on courses, more than 300 leading dental exhibitors and nightly social events. The 2018 dates do not conflict with Father’s Day! Go to https://vimeo.com/232502790 to watch a video on what you can expect at the 2018 convention.

FDAS Alert: Florida Workers’ Comp. Rate Decrease Proposed The National Council on Compensation Insurance (NCCI) proposed a statewide workers’ compensation rate decrease when they submitted their rate filing to the Florida Office of Insurance Regulation (OIR) on Monday, Aug. 28. If the OIR approves, we could see a 9.6 percent rate decrease for new and renewal business effective Jan. 1, 2018. A hearing

SEPTEMBER/OCTOBER 2017

on the proposed rates is expected in October. We will keep you up to date!

To learn more about the proposed rate decrease, go to http://bit.ly/2j53iEP. Increase your workers’ comp. savings with The Zenith 20 percent dividend for FDA members. Dental offices that have an earned annual premium as low as $1,000 and have been claims-free the past three years (current year plus two prior years) are eligible. Go to http://bit. ly/2xaKv1h to get a quote.

Crown Savings Spotlight: Serve First Solutions Have you checked out one of our newest Crown Savings merchants, Serve First Solutions? They offer solutions to all your practice payment-processing needs at an FDA member-exclusive rate!

“Serve First Solutions has an excellent reputation in the payment processing industry and will offer exceptional member savings and service exclusively for FDA members,” said FDA Services Chief Operating Officer Scott Ruthstrom.

FDA member perks: v save as much as $2,600 annually v transparent pricing with no hidden fees v customer support specialists Go http://www.fdaservices.com/affiliate/serve-first-solutions/ to learn more about Serve First Solutions and get started.

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Seeking Consultants with Sedation Permit for Inspections Working as an anesthesia inspector offers a range of benefits, from flexible working arrangements and receiving CE hours to networking and observing how others in your profession work in your field. The Board of Dentistry (BOD) is looking for dentists who hold a sedation permit to serve as dental consultants to perform new and routine inspections on sedation permit holders. Specifically, there is a need for inspectors in north, central and southwest Florida who hold a general anesthesia permit. Inspectors are compensated and receive two hours of CE. For more information, or to request an application, please email the BOD at info@floridasdentistry.gov.

Welcome New FDA Members These dentists recently joined the FDA. Their membership allows them to develop a strong network of fellow professionals who understand the day-to-day triumphs and tribulations of practicing dentistry.

Atlantic Coast District Dental Association Anthony Adkins, Plantation Michael Aston, Port St. Lucie Odelsis Barrero, Miami Geoffrey Bennett, Boca Raton Diego Camacho, Dania Morgan Clay, Vero Beach Ashley Dolberry, West Palm Beach Shanice Dyer, West Palm Beach Emmy Estenoz, Plantation Kathleen Foreman, Margate Michael Gaffney, Boca Raton Derek Gatta, Delray Beach Helem Gutierrez, Margate Leslie Haller, Lauderhill

WWW.FLORIDADENTAL.ORG

Mona Herold, Wellington Sandra Hosh, Royal Palm Beach Sida Huang, Short Hills Sravanthi Kadiyala, Davie Michael King, Gainesville Leonardo Lander, Hialeah Caroline Larson, Davie Karina Leiva-Lopez, Plantation Maria Magalhaes, Boca Raton Natalie May, Boca Raton Sarah Mccourt, Davie Raynald Michel, Fort Lauderdale Douglas Nartker, Port St. Lucie Bogdan Negrut, Davie Summer Niles, Plantation Deisy Norena-Otero, Weston Alexandra Ortiz Javier, Boca Raton Ronak Parikh, West Palm Beach Daylis Perez Borroto, Hialeah Christopher Pham, Fort Lauderdale Mike Roig, North Miami Beach Perla Salazar, Homestead Leonardo Serrano Socarras, Lake Worth Chase Thomas, Boynton Beach Jessica Titherington, Delray Beach Nancybel Urena, Parkland Paola Wainberg, North Lauderdale Roula Yazaji, Pembroke Pines

Central Florida District Dental Association Victoria Adams, Gainesville Michael Aguirre, Gainesville Carolyn Allen, Jacksonville Carlos Alvarez Cuenod, Orlando Mohammad Bawany, Ormond Beach Martha Brown, Louisville Amandeep Chadda, Port Orange Lona Chen, Grant Kelsey Cronauer, Gainesville Alfonzo Cruz, Port Orange Walmir Da Costa, Gainesville Matthew Davidson, Plantation Christopher Ferreira, Orlando Anthony Froyan, Orlando Elena Garcia, Kissimmee Dale Gerber, Gainesville Lisset Gonzalez, Ormond Beach Shaina Henriquez, Ocala Susana Hernandez, Gainesville Michael Hoang, Palm Bay Monica Iskander, Daytona Beach Jerry Karedan, Pembroke Pines James Kortbus, Port Orange

In Memoriam The FDA honors the memory and passing of the following members: Louis R. Joblove Hollywood, FL Died: 6/16/17 Age: 89

Howard I. Dollinger Tequesta, FL Died: 8/6/17 Age: 83

Jack H. Soutar Miami, FL Died: 7/21/17 Age: 84

Reginald Ligon St. Petersburg, FL Died: 8/20/17 Age: 66

Marcos H. Barrera Tallahassee, FL Died: July 28, 2017 Age: 87

Andre Buchs Winter Park, FL Died: 8/25/17 Age: 78

Martin Lalama, Gainesville Aliuska Lopez, Orlando Kevin Lopez, Seminole Rafael Loss, Orlando Jasmine Mabjeesh, Palm Bay Scott Mccauley, Altamonte Springs Alexis Meyers, Lexington Hamza Mir, Orlando Adele Mirbey, Orlando Jacklyn Mitchell, Gainesville Nouman Mujahid, Daytona Beach Shores Reza Navabi Shirazi, Mount Dora Jared Nestle, Saint Cloud Sabrina Nguyen, Mount Dora Elizabeth Pages, Ocala Melissa Palmer, Ormond Beach Maitri Patel, Orlando Radha Patel, Orlando Vicky Patel, Okeechobee Geidys Perez, Ocala Nicholas Potter, Winter Garden Lina Ramirez, Pembroke Pines William Rockey, Flagler Beach Renata Santeli, Port Orange Steven Schmid, Merritt Island Apurwa Shukla, Daytona Beach Tarek Sirage, Ocala Kejia Sun, Orlando Richard Tamayo, Gainesville Nathan Taylor, Orlando Ishaq Thalji Alshrouf, Bayonne

TODAY'S FDA

SEE PAGE 20 SEPTEMBER/OCTOBER 2017

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UPDATES FOR MEMBERS FROM PAGE 19 Tim Tiralosi, Lake Mary Helen Truong, Port Orange Christian Vidalon, Weston Tyler Wahl, Gainesville Danling (Dana) Yu, Bradenton

Northeast District Dental Association Joshua Allore, Gainesville Rusha Awad, Jacksonville Pavneet Bains, Lake City Rose Cummins, Atlantic Beach Tej Diah, Fernandina Beach Maliha Fatima, Gainesville Austin Fowler, Jacksonville Kendall Frazier, Jacksonville Ryan Garske, Baltimore Yuntao Jiang, Jacksonville Zachary Jin, Tallahassee James Nguyen, Jacksonville Jessica Nixon, Baltimore Tanvi Patel, Jacksonville Marie Pucillo, St. Augustine Bang Quach, Jacksonville Blair Simeon, Las Vegas Denise Six, Jacksonville Shankeertha Sundaralingam, Jacksonville Damone Weaver, Gainesville Ashleigh Weyh, Jacksonville Sean Williams, Lake City Amy Yang, Jacksonville Zoryana Yufan, Jacksonville

Northwest District Dental Association James Bowen, Chipley Jonathan Casiano, Birmingham Christian Davillier, Navarre Atticus Deacon, Defuniak Springs Charles Elwell, Chester James Garland, Lynn Haven Astrid Gonzalez, Tallahassee Hanna Ivalha, Crestview Laura Knowles, Gainesville Austin Lyman, Panama City Rodney Torres, Crestview William Windham, Panama City

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South Florida District Dental Association Mina Adinemehr, Miami Frank Alarcon Marimon, Pinecrest Humza Arif, Davie Anthony Baldwin, North Miami Gretchen Barban Rodriguez, Miami Cynthia Bustillo, Cutler Bay Hanna Butenko, Miami Amanda Caravia, Miami Ximena Checa, Miami Ada Chung, Davie Aaron Delgado, Miami Ivette Delgado Rey, Miami Italo Di Prisco, Coral Springs Elianet Diaz, Hialeah Arturo Echemendia, Hialeah Manuel Estrada, Miami Claudia Ferreiro, Hialeah Joel Figueredo, Miami Lisset Gata-Garcia, Miami Natalie Godoy, Miami Brien Hedstrom, Hollywood Jenny Hernandez, Pembroke Pines Karina Hernandez, Miami Tania Herschdorfer, North Miami Beach Roshan Kalra, Davie George Khazoum, Davie Adam Lau, Plantation Chung Lee, Fort Lauderdale Alvaro Maya, Key Largo Gloria Mondragon Velez, Plantation Yamillia Morejon Suarez, Miami Paridhie Patel, Miami Annabel Perez, Miami Lakes Susel Perez-Nieves, Miami Beach Ermy Pinchevski Duque, Pembroke Pines Sinai Rey Consuegra, Miami Miguel Rielo, Miami Karolina Rincon, Davie Lina Rivera, Miami Yoelvis Rodriguez, Miami Camilo Rodriguez, Miami Ivet Romero Vazquez, Miami Alan Seidenfeld, Hollywood

SEPTEMBER/OCTOBER 2017

Jean Paul Taveras, Valrico Vu Tran, Davie Sandor Valls, Cutler Bay Ruben Villarreal, Pembroke Pines

West Coast District Dental Association Hillel Abramov, Lutz Vanja Alagic, St. Petersburg Bilal Alnahass, Crystal River Namra Amin, Gibsonton Sibel Arditi, Tampa Michael Barbick, Tampa Jacob Berger, Lakewood Ranch Gregory Brandau, Rotonda West Alejandra Brazao, Naples Luan Chau, Fort Myers Joshua Colkmire, Sarasota Paige Collins, Sarasota Wade Combs, Palm Coast Vincent Corona, Sarasota Judy Delgado, Port Richey Alexis Del Rosario, St. Petersburg Garrett Dennis, North Fort Myers Ujjwal Dhankhar, Palm Harbor Alexis Diaczynsky, Naples Annie Diaz, Miami Michael Diez, Fort Lauderdale Parker Duke, Frostproof Andrew Fagin, Bradenton Fady Fakhoury, Bonita Springs Rachel Franz, Wesley Chapel Hannah Frebel, Naples Frank Gassler, Tampa Jay Ghiya, Tampa Farah Habib, Lakeland Joshua Hall, Palmetto Daniel Hultgren, St. Petersburg Daniel Izaguirre, Homestead Ibrahim Jadun, Davie Michael Jauch, Palm Harbor Nadine Jean-Baptiste, Santa Rosa Beach Timothy Johnson, Ocala Nathan Jones, Davie Youngjin Kang, Defuniak Springs

WWW.FLORIDADENTAL.ORG

to Dr. Johnny Johnson

Johnny Johnson Jr., DMD, MS

Recipient of the 2017 Health Equity Heroes Following his work as a pediatric dentist and leadership of a comprehensive dental program for low-income community members, Dr. Johnson recently helped found the American Fluoridation Society and is a leading advocate for community water fluoridation in Florida and communities across the country.

Each recipient receives a $1,000 donation from DentaQuest’s Citizenship Fund toward a nonprofit that promotes health equity of his or her choice. Dr. Johnson generously redirected his award donation to the FDA Foundation.

Shannon Kelso, Lakeland Andrew Kelso, Lakeland Troy Kemahli, Englewood Stephen Klement, St. Petersburg Violet Laurey, Sarasota Malory Leblanc, Palm Harbor Jason Ledger, Winter Haven Nicholas Letteri, Tampa Theresa Manrique, Wesley Chapel Anjelika Marti, Winter Haven Zineb Mediouni, Tampa Justin Mitchell, Wesley Chapel David Moffa, Greensburg Sejal Naik, Fort Myers Tanya Naravane, Palm Harbor An Nguyen, Davie Yamila Noriega-Abreu, Toms River Margaret Ordonez, Riverview Mitul Patel, Arcadia Monica Perez, Tampa Lindsey Pikos Rosati, New Port Richey Paiyal Popat, Tampa Roya Rabbanifard, Riverview George Raffoul, St. Petersburg Jared Riley, New Port Richey Jose Rivadeneira, Tampa Oliver Roberts, Lutz Gabriela Rocha, Erie Ion Rotaru, Wesley Chapel Diego Sanchez, Hialeah Alexander Shafiey, Bradenton Sarah Shuayb, Spring Hill Ann Siassipour, Lake Wales Erik Skates, Fort Myers Kerry Stanisic, Lakewood Ranch Alex Thanh, Gainesville Broch Thomas, Fort Myers Michelle Thomas, Nokomis Vanesa Vaquer, Naples Jensen Walker, Homosassa Hanief Williams, West Palm Beach Shaun Young, Palm Harbor Usman Zafar, Tarpon Springs

from the

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TODAY'S FDA

SEPTEMBER/OCTOBER 2017

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BOD MEETS IN TAMPA The Florida Board of Dentistry (BOD) met in Tampa on Aug. 18. The Florida Dental Association (FDA) was represented by FDA BOD Liaison Dr. Don Ilkka and Director of Third Party Payer of Professional Affairs Casey Stoutamire. Other FDA members in attendance included: Drs. Leonard Britten, Bob Churney, Curtis Hill and Zack Kalarickal. Nova Southeastern University College of Dental Medicine Dean Dr. Linda Niessen also was in attendance.

BOARD OF DENTISTRY

Eight of the BOD members were present, which included: Ms. Cathy Cabanzon, vice chair (acting chair); Drs. Joe Calderone, Naved Fatmi, Bill Kochenour, Claudio Miro, Robert Perdomo and T.J. Tejera; and, consumer member, Mr. Tim Pyle. Ms. Angie Sissine, hygienist, was absent. There are two positions open on the board that the governor has not yet filled; one for a dentist and one for a consumer member.

The BOD heard an update on the Prescription Drug Monitoring Program (PDMP)

by Dr. Rebecca Poston. She discussed data points reported by dispensers, provided an overview of the dispensing data and discussed how research is used to optimize PDMP information to improve public health. BOD Executive Director Ms. Jennifer Wenhold then provided an update on the Medical Quality Assurance Multi-board Workgroup held on June 2, 2017. Drs. Tejera, Miro and Fatmi represented the BOD, along with members from the Boards of Medicine, Nursing and Pharmacy. Discussion topics included wrong site surgeries, telehealth, controlled substances and anesthesia. A subgroup was formed to continue discussion on the opioid crisis and is scheduled to meet on Friday, Nov. 3 in Orlando.

The BOD issued a declaratory statement filed by two professors from Nova that confirmed a dental professor is exempt from the anesthesia permitting requirements as long as they are performing anesthesia as part of the curriculum. Whether in a classroom or in the clinic, either students or residents must be involved. It is incumbent upon the dean to assure that faculty with these exemptions are properly trained and the care that they provide as part of the curriculum is safe.

MS. CASEY STOUTAMIRE FDA DIRECTOR OF THIRD PARTY PAYER & PROFESSIONAL AFFAIRS

If you have any questions, please contact Director of Third Party Payer and Professional Affairs Casey Stoutamire, Esq. at cstoutamire@floridadental.org or 850.350.7202.

There were eight disciplinary cases, two determinations of waiver/hearings not involving disputed issues of material fact and three voluntary relinquishments that dealt with failure to meet the standard of care, substance abuse and failing to keep proper dental records.

If you have not yet attended a BOD meeting, it is suggested that you take the opportunity to attend and see the work of the BOD. The FDA would like to congratulate Ms. Cabanzon, as the BOD voted her chair until the November 2017 meeting. She served as vice chair this past year, and chaired this meeting as Dr. Thomas retired from the board after the May 2017 BOD meeting. In addition, this was the last meeting for Drs. Thomas and Perdomo and both were recognized for their time on the BOD. The FDA also thanks Drs. Perdomo and Thomas for their many years of service to their profession on the BOD.

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

NEXT BOD MEETING The next BOD meeting is scheduled for Friday, Nov. 17, 2017 at 7:30 a.m. EST at the Radisson Resort OrlandoCelebration.

SEPTEMBER/OCTOBER 2017

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Update your Find-a-Dentist profile!

THREE-YEAR CAMPAIGN: The ADA has launched a threeyear, $18 million program that will focus on directing consumers to make an appointment with an ADA dentist.

Through search improvements and digital advertising, this campaign will make it easier to find you online. As part of the program, we have enhanced the Find-a-Dentist tool, including more ways to search for you.

WILL PATIENTS FIND YOU? APPEALING! • LAND AT THE TOP of an online search by updating your profile.

WHAT’S YOUR STATUS? AS LIFE EVENTS OCCUR, don’t forget to notify the FDA of any changes to your contact information.

READY TO RETIRE or have questions about your membership status? Contact the FDA Member Relations department to learn about retired membership or eligibility for other membership incentives.

CALL OR EMAIL the FDA at 800.877.9922 or fda@floridadental.org. * Florida licensed dentists must notify the Florida BOD with any new information. Go to floridasdentistry.gov or call 850.488.0595.

• Profiles with photos get 11 TIMES MORE CLICKS than those with no photo.

• Provide MORE INFORMATION about your practice.

OVERLOOKED? • LAST in a search • FEWER CLICKS • ONLY BASIC information about your practice.

• LOSE the advantage of an important, free member benefit.

VISIT ADA.ORG/MYADA and log on to highlight your practice by uploading your picture and completing your practice information. If you’re unsure of your user ID or password, call the ADA Member Service Center at 800.621.8099.

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

27

Dental financing promotions Q3 2017

Debt consolidation promotion 2.99% for the first 24 months ●

●

●

●

Pay off high interest rate business loans, and consolidate into one loan Flexible loan terms up to 15 years to improve cash flow of practice You’ll also get a competitive rate through maturity, and you’ll know the rate up front Debt consolidation applications must be received by October 31, 2017 and close loan by December 31, 2017

Practice acquisition promotion 1.89% for the first 12 months ●

●

●

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Eligibility includes practice acquisition, partnership buy-ins, and second location purchases Flexible loan terms up to 15 years to improve cash flow of practice You’ll also get a competitive rate through maturity, and you’ll know the rate up front Debt consolidation and practice acquisition applications must be received by October 31, 2017 and close loan by December 31, 2017

Established dentists project promotion 1.89% for the first 12 months ●

●

●

Let’s talk To apply, contact your Practice Solutions specialist:

Call 800.428.2847 Or visit bankofamerica.com/practicesolutions

●

Loan types that qualify are expansions, practice remodels, relocations, and additional locations Flexible loan terms up to 15 years to improve cash flow of practice You’ll also get a competitive rate through maturity, and you’ll know the rate up front Established project loan applications must be received by October 31, 2017 and interim project opened by January 31, 2018 to be eligible for promotion

OOCRE/Equipment Promotion 0% for the first six months

1

2

3 4

All programs subject to credit approval and loan amounts are subject to creditworthiness. Some restrictions may apply. The term, amount, interest rate and repayment schedule for your loan, and any product features, including interest rate locks, may vary depending on your creditworthiness and on the type, amount and collateral for your loan.

Promotional rate only available with specific prepayment agreement. Not eligible with interestonly in payment structure. Your rate after the promotional period ends will be fixed for the remaining term, up to 15 years.

Bank of America will pay the appraisal fee at the time the commercial real estate loan is closed.

Loan must close by January 31, 2018 to be eligible.

On terms 48 months or greater. Property must be owner-occupied commercial real estate. Owneroccupied commercial real estate is defined as property occupied by the borrowing entity and/or its affiliates. The primary source of repayment must be dependent on the cash flow generated by these entities and less than 50% of cash flow may come from third party, nonaffiliated rents.

51% owner occupancy required. This offer does not apply to construction loans or lines of credit secured by real estate or equipment.

Bank of America is a trademark of Bank of America Corporation. Bank of America Practice Solutions is a division of Bank of America, N.A. ©2017 Bank of America Corporation | ARV3PMFK

●

●

●

●

Loans from $150,000 to $2,500,000 We’ll pay your appraisal fee when you close a commercial real estate loan3 0% interest rate for the first six months and then lock in a competitive rate through maturity4 Apply by October 31, 2017 and close by January 31, 2018

Your Local Dental Financing Expert Jonathan Burns 614.309.7611 jonathan.burns@bankofamerica.com

SPECIAL SECTION  OPIOIDS BY THE NUMBERS 30  FLORIDA BY THE NUMBERS FOR PROVIDERS 32  FOR PROVIDERS 33  FLORIDA'S PRESCRIPTION DRUG DATABASE 34  DEATH BY RX 36  5 STEPS TO PRESCRIBE CONTROLLED SUBSTANCES IN FLORIDA 37  STRATEGIES FOR THE OPIOID CRISIS FROM FLORIDA'S SURGEON GENERAL 40  HOW DO OPIOIDS ATTACK THE BODY? 44  FDA WELL-BEING PROGRAM APPROVED: CONFIDENTIAL HELP FOR DENTISTS IN NEED 48  TOUGH MEDICAL MARIJUANA RULES COULD BE IN YOUR FUTURE 50  THE BROWN BAG APPROACH & MORE: MEDICATION RECONCILIATION 54  5 TACTICS FOR EFFECTIVELY PRESCRIBING PAIN MEDICATION 59

10-15 PERCENT OF DENTISTS will have a drug and/or alcohol problem sometime in their lives1

1 http://www.ada.org/en/member-center/member-benefits/ health-and-wellness-information/substance-abuse-disorder

Deaths from prescription opioids — drugs like oxycodone, hydrocodone, and methadone — have more than QUADRUPLED since 1999.2

2 https://www.cdc.gov/drugoverdose/epidemic/index.html

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

29

Die every day from an opioid overdose (includes prescription opioids and heroin).1

Are treated in emergency departments for not using a prescription opioid as directed.2

OPIOIDS

BY THE NUMBERS Took opioid drugs in amounts considered too large under CDC standards in 2016.3

Every 25 minutes, a baby is born suffering from opioid withdrawal. In 2012, an estimated 21,732 infants were diagnosed with a postnatal opioid withdrawal syndrome, Neonatal Abstinence Syndrome.5

Enough for every American adult to have their own bottle of pills.4

In 2013-2016, American taxpayers spent about $327 billion on drug-control efforts.6

OVERDOSE DEATHS INVOLVING OPIOIDS

BY TYPE OF OPIOID UNITED STATES, 2000-20158

CDC LOOKS AT FOUR CATEGORIES OF OPIOIDS:

11

1. Natural opioid analgesics, including morphine and codeine, and semi-synthetic opioid analgesics, including drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone;

ANY OPIOID

10 9

2. Methadone, a synthetic opioid;

4. Heroin, an illicit (illegally-made) opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance.7

DEATHS PER 100,000 POPULATION

8

3. Synthetic opioid analgesics other than methadone, including drugs such as tramadol and fentanyl; and

7 6 5

HEROIN NATURAL & SEMI-SYNTHETIC OPIOIDS OTHER SYNTHETIC OPIOIDS (e.g., fentanyl, tramadol)

4 3 2 1

Almost 2 million Americans abused or were dependent on prescription opioids in 2014.9

Deaths involving synthetic opioids, mostly FENTANYLS, have risen to more than 20,000 in 2016, up from 3,000 in 2013.16

ELEVEN TIMES MORE people were in prisons and jails for drug offenses in 2015 (469,545) than in 1980 (40,900).6

SOURCES OF PRESCRIPTION OPIOIDS FOR NON-MEDICAL USERS 2008-201110

70

2015—

2014—

2013—

2012—

2011—

2010—

2009—

2008—

2007—

2005—

2006—

2004—

2003—

2002—

2001—

METHADONE 2000—

0

60

PERCENTAGE OF USERS

50

40

30

20

 GIVEN BY A FRIEND OR RELATIVE FOR FREE  PRESCRIBED BY ONE OR MORE PHYSICIANS  STOLEN FROM A FRIEND OR RELATIVE

10 0

 BOUGHT FROM A FRIEND OR RELATIVE  BOUGHT FROM A DRUG DEALER OR OTHER STRANGER ANY

1-29 30-99 100-199 NUMBER OF DAYS OF PAST-YEAR NON-MEMDICAL USE

200-365 DATA COMPILED AND DESIGNED BY LYNNE KNIGHT, FDA MARKETING COORDINATOR

6

FLORIDA

BY THE NUMBERS This ranking includes: adults who needed, but didn’t receive treatment; number of substance abuse treatment facilities; and, number of admissions to substance abuse treatment services.11

FLORIDA DEATHS CAUSED

BY FENTANYL OVERDOSE 13 JAN.-JUNE 2016

704 417

JULY-DEC. 2015 JAN.-JUNE 2015

PRESCRIPTION RATES FOR OPIATES

BY AGE AND GENDER, FLORIDA 201511

2,000

 FEMALE  MALE PRESCRIPTIONS PER 1,000 POPULLATION

In 2016, fentanyl caused more deaths in Florida than any other drug.11

1,500

1,000

500

294 0

DATA COMPILED AND DESIGNED BY LYNNE KNIGHT, FDA MARKETING COORDINATOR

32

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

18-24

25-34

35-44

45-54

55-64

65-OLDER

WWW.FLORIDADENTAL.ORG

FOR PROVIDERS RISK FACTORS FOR PRESCRIPTION OPIOID PAIN RELIEVER ABUSE & OVERDOSE14 Obtaining overlapping prescription from multiple providers and pharmacies.

Having mental illness or a history of alcohol or other substance abuse.

Taking high daily dosages of prescription opioid pain relievers.

Living in rural areas and having low income.

10 RECOMMENDATIONS: PRESCRIBING OPIOIDS TO TREAT DENTAL PAIN15 1.

Take a medical and dental history including: current medications; potential drug interactions; and, history of substance abuse.

2.

Follow CDC and Florida law and recommendations for safe opioid prescribing.

3.

Use the Florida Prescription Drug Monitoring Program to promote appropriate use and deter misuse and abuse of opioids.

7.

Use multimodal pain strategies for management for acute postoperative pain to avoid using opioid analgesics.

8.

Coordinate with other treating doctors, including pain specialists, when prescribing opioids for management of chronic orofacial pain.

9.

Dentists who are practicing in good faith and who use professional judgment regarding the prescription of opioids for the treatment of pain should not be held responsible for the willful and deceptive behavior of patients who successfully obtain opioids for non-dental purposes.

4.

Talk to patients about responsibilities for preventing misuse, abuse, storage and disposal of prescription opioids.

5.

Consider treatment options that use best practices to prevent exacerbation or relapse of opioid misuse.

10. Seek continuing education in addictive disease and pain management.

6.

Consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.

Access the Centers for Disease Control information on prescribing guidelines, “Assessing Benefits and Harms of Opioid Therapy,” at www.cdc.gov/drugoverdose/prescribing/guideline.html (https://www.cdc.gov/drugoverdose/pdf/assessing_benefits_harms_of_opioid_therapy-a.pdf.

1

2

“Drug overdose deaths in the United States continue to increase in 2015,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2016 (https://www.cdc.gov/drugoverdose/epidemic/index.html).

Prescription Opioid Overdose Data, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2016 (https://www.cdc.gov/drugoverdose/data/overdose.html).

3

Lenny Bernstein, “Half a million Medicare recipients were prescribed too many opioid drugs last year,” Washington Post, July 13, 2017.

4

Rachael Rettner, “America’s Opioid-Use Epidemic: 5 Startling Facts,” Sept.

23, 2016 (https://www.livescience.com/56248-america-opioid-use-epidemic.html).

5

Patrick et. Al., JAMA 2012, Patrick et. Al, Journal of Perinatology, 2015

6

John S Kiernan, “Drug Use by State: 2017’s Problem Areas,” May 15, 2017

WWW.FLORIDADENTAL.ORG

(https://wallethub.com/edu/drug-use-by-state/35150/).

7

“Categories of opioids,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2017 (https://www.cdc.gov/drugoverdose/data/analysis.html).

8

CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: U.S, Department of Health and Human Services, CDC; 2016. (https:// wonder.cdc.gov/).

9

“Opioid Basics,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2016 (https://www.cdc.gov/drugoverdose/opioids/index.html).

10 “Prescribing Data,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2016 (https://www.cdc.gov/drugoverdose/data/prescribing. html).

12 “Synthetic Opioid Data,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2016 (https://www.cdc.gov/drugoverdose/data/fentanyl.html).

13 “Drugs Identified in Deceased Persons by Florida Medical Examiners: 2016 Interim Report,” Florida Department of Law Enforcement, 2017.

14 “Risk Factors for Prescription Opioid Abuse and Overdose,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2016 (https://www.cdc. gov/drugoverdose/opioids/prescribed.html).

15 “American Dental Association Statement on the Use of Opioids in the Treatment of Dental Pain,” (http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain).

16 Josh Katz, “The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years” New York Times, Sept. 2, 2017.

11 2015-2016 Prescription Drug Monitoring Program Annual Report, Florida Department of Health, 2016.

TODAY'S FDA

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33

REPORTING TIME

24 HOURS

EFFECTIVE JAN. 1, 2018, DISPENSERS OF CONTROLLED SUBSTANCES MUST REPORT ALL TRANSACTIONS THROUGH THE ELECTRONIC SYSTEM WITHIN 24 HOURS OR THE NEXT WORKING DAY.1

FLORIDA’S PRESCRIPTION DRUG DATABASE

The Florida Prescription Drug Monitoring Program, known as E-FORCSE® (Electronic-Florida Online Reporting of Controlled Substance Evaluation Program), was created by the 2009 Florida Legislature to NUMBER OF CONTROLLED encourage safer prescribing of controlled substances and to reduce drug abuse and diversion within the SUBSTANCE DISPENSING December 1,state 2016 of Florida. As of 2016, none of the top 100 U.S. opioid dispensing physicians reside in Florida.5

RECORDS REPORTED

216,187,278 TO THE FLORIDA PDMP SINCE IT BEGAN COLLECTING DATA ON SEPT. 1, 2011.3

The database collects and stores prescribing and dispensing data for controlled substances in Schedules II, III and IV. Section 893.055, Florida Statutes, and requires health care practitioners to report to the PDMP each time a controlled substance is dispensed to an individual. Effective Jan. 1, 2018, dispensers of controlled substances must report all transactions through the electronic system within 24 hours or the next working day. This reporting timeframe ensures that health care practitioners have the most up-todate information available.1,2

FLORIDA DENTISTS

REQUEST AN E-FORCSE ACCOUNT4 E-FORCSE grants system access accounts to practitioners and pharmacists, and their designees, so that they may look up, view, and print controlled substance dispensing information on their specific patients directly via user name and password.

Florida-licensed practitioners and pharmacists, and their designees, may request a user account to access information in the system. Access is granted to individuals only — not to clinics, hospitals, pharmacies, or any other healthcare facility.

Note: Once your account request is approved, you will receive emails from flpdmp-info@apprisshealth.com (FLPDMINFO) containing your account login information. Your email system should be configured to receive emails from this address.

1. In your Internet browser window, type the following URL in the address bar: www.hidesigns. com/flpdmp.

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

REGISTRATION RATE FOR E-FORCSE

2. Click the Practitioner/Pharmacist & Designee link located on the left menu. A window similar to the following is displayed:

1,012 out of 13,402 OF LICENSED DENTISTS3

3. Click the Terms and Conditions link to open and read.

4. After reading the terms and conditions, click the Registration Site link. A login window is displayed.

DATA COMPILED AND DESIGNED BY LYNNE KNIGHT, FDA MARKETING COORDINATOR

34

7.6%

STEPS TO REQUEST AN ACCOUNT:

1

http://www.flpdmpfoundation.com/

2

http://rxsentry.net/flpdmp

3

http://www.floridahealth.gov/statistics-and-data/e-forcse/_ documents/QuarterlyDashboard2017March31.pdf

4

“Training Guide for Florida Practitioners and Pharmacists,” Florida Department of Health Prescription Drug Monitoring Program, 2017.

5

http://www.nsc.org/RxDrugOverdoseDocuments/Prescription-Nation-2016-American-Drug-Epidemic.pdf

WWW.FLORIDADENTAL.ORG

E-FORCSE INFORMATION FLOW REP OR TIN

G

E-FORCSE DATA BASE

QUERY

TYPES OF QUERIES:4 PRACTITIONERS & PHARMACISTS

DISPENSER

G

TI N OR REP

PRACTIONER

LAW ENFORCEMENT QUERIES Law enforcement agencies, Department of Health Investigative Services Unit and Medicaid Fraud Unit investigators may request confidential controlled substance dispensing information from E-FORCSE during active investigations regarding potential criminal activity, fraud or theft regarding prescribed controlled substances. They also may query an impaired practioner consultant who has been authorized by the practioner to release their information.2

QUERY

1. Recipient Query – invidual recipient’s controlled substances use.

QUERY

2. Search History Query – history of all queries performed using their E-FORCSE user ID. 3. Prescriber DEA Query – practitioners can query history of all dispensed prescriptions using their DEA number.

LAW ENFORCEMENT

DOCTOR SHOPPING

INDIVIDUALS RECEIVING CONTROLLED SUBSTANCEPRESCRIPTIONS FROM FIVE OR MORE PRESCRIBERS & FIVE OR MORE PHARMACIES3

0

2012

2013

2014

2015

2016

789

614

682

773

910

500

1006

1056

1103

1417

1355

1198

1254

1468

1415

1000

1680

1613

1726

1500

1861

2017

2000

2174

2500

2864

NUMBER OF INDIVIDUALS RECEIVING CONTROLLED SUBSTANCE PRESCRIPTIONS

3000

2017

YEARS BY QUARTER

The Florida PDMP Foundation board of directors, appointed by the State Surgeon General, seeks funding support from health care practitioners, corporations, law enforcement agencies and private partners to assist in the database’s continued operations. Since its formation, the PDMP Foundation has raised more than $2.2M to fund E-FORCSE operation.

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

35

2016 • U.S. drug overdose deaths surged 19 percent to at least 59,000, as drugs like fentanyl intensified a national opioid addiction crisis. The addition of fentanyl, which can be 50 times more powerful than heroin, to heroin and prescription opiates is one of the key factors in the surge in deaths.1

FLORIDA’S TOP 10 CONTROLLED SUBSTANCE PRESCRIPTIONS2

DRUGS THAT CAUSED THE MOST DEATHS IN FLORIDA • 20163

• HYDROCODONE/ACETAMINOPHEN (VICODIN, LORTAB) • ALPRAZOLAM (XANAX, NIRAVAM) • OXYCODONE HCL/ACETAMINOPHEN (PERCOCET, XOLOX) • TRAMADOL HCL (ULTRAM) • ZOLPIDEM TARTRATE (AMBIEN) • CLONAZEPAM (KLONOPIN) • DEXTROAMPHETAMINE/AMPHETAMINE (ADDERALL) • OXYCODONE HCL (OXYCONTIN) • TEMAZEPAM (RESTORIL) DRUGS THAT CAUSED THE MOST DEATHS IN U.S. • 20144

• HEROIN • 10,863 • COCAINE • 5,856 • OXYCODONE (OXYCONTIN) • 5,417 • ALPRAZOLAM (XANAX, NIRAVAM) • 4,217 • FENTANYL (FENTORA) • 4,200 • MORPHINE • 4,022 • METHAMPHETAMINE (ADDERALL) • 3,728 • METHADONE (METHADOSE, DOLOPHINE) • 3,495 • HYDROCODONE (VICODIN, LORTAB) • 3,274 • DIAZEPAM (VALIUM) • 1,729 DATA COMPILED AND DESIGNED BY LYNNE KNIGHT, FDA MARKETING COORDINATOR

36

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

• FENTANYL (FENTORA) • 704 • COCAINE • 643 • BENZODIAZEPINES (ATIVAN, VALIUM, HALCION, KLONOPIN, LIBRIUM, RESTORIL, XANAX) • 632 (INCLUDING 355 ALPRAZOLAM [XANAX] DEATHS)

• MORPHINE • 559 • HEROIN • 406 • ETHYL ALCOHOL • 405 • OXYCODONE (OXYCONTIN) • 324 • METHADONE (METHADOSE, DOLOPHINE) • 156 • FENTANYL ANALOGS (ALFENTANIL, REMIFENTANIL, SUFENTANIL) •

149

DRUG-RELATED DEATHS IN U.S. • 20161

AT LEAST

59,000 1

https://medicalxpress.com/news/2017-06-drug-overdose-deaths-soar.html

2

http://www.floridahealth.gov/statistics-and-data/e-forcse/_documents/QuarterlyDashboard2017March31.pdf

3

“Drugs Identified in Deceased Persons by Florida Medical Examiners: 2016 Interim Report,” Florida Department of Law Enforcement, 2017.

4

“National Vital Statistics Reports,” Vol. 65, No. 10, Dec. 20, 2016, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.

WWW.FLORIDADENTAL.ORG

5 1 2 3 4 5

STEPS

TO PRESCRIBE CONTROLLED SUBTANCES IN FLORIDA DO YOU PRESCRIBE ANY CONTROLLED SUBSTANCE LISTED IN SCHEDULES II, III OR IV FOR THE TREATMENT OF CHRONIC NONMALIGNANT PAIN?

YOU MUST DESIGNATE YOURSELF as a controlled substance prescribing practitioner in your DOH practitioner profile. This can be done online at www.floridahealth.gov/ licensing-and-regulation/practitioner-profile/maintain/index.html.

YOU ALSO MUST REGISTER with the U.S. Drug Enforcement Agency (DEA) at www. deadiversion.usdoj.gov and renew that registration every three years. DEA Form 224 has a space to list the Drug Schedules of controlled substances that you wish to handle, but you must be authorized by the state of Florida to handle those drugs for which you are applying. And, you will ONLY be authorized to handle those drugs that are checked on the application form.

A SEPARATE REGISTRATION is required for each principal place of business or professional practice where you store, administer or dispense controlled substances.

If you will only be prescribing from another location(s) situated within the same state, then an additional registration is not necessary,

IF YOU MOVE offices (to a new physical location), you must request a modification of registration.

?

FOR ADDITIONAL INFORMATION, contact FDA Director of Third Party Payer & Professional Affairs Casey Stoutamire: 800.326.0051 • 850.224.1089 cstoutamire@floridadental.org

COMPLY with the standards of practice requirements in section 456.44, Florida Statues.

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

37

course recordings NOW AVAILABLE TO PURCHASE!

RELIVE YOUR FAVORITE COURSES FROM FDC WITH YOUR TEAM OR LISTEN TO THE ONES YOU WISH YOU COULD HAVE TAKEN. Course recordings are $20 each, or purchase all recorded sessions for $199.

Purchase your course recordings today at floridadental.org/convention-ce/ convention/education/course-recordings.

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

39

SURGEON GENERAL

STRATEGIES FOR THE OPIOID CRISIS FROM FLORIDA'S SURGEON GENERAL As a nation, we are in the midst of an opioid overdose epidemic that will require a longterm comprehensive strategy to overcome. In 2015, there were more than 33,000 deaths nationwide and nearly 3,900 deaths in Florida attributed to opioid overdoses. As health care professionals, we all share the responsibility of providing optimal care to our patients while following safe pain-management practices.

Many of us were trained to assess pain as the fifth vital sign; the potential consequences of opioid addiction for some patients after only a few days were not known. As we learn more about the harmful consequences of opioids, we must be nimble and responsive in adapting our practices to the newest guidelines.

BY CELESTE PHILIP, MD, MPH, STATE SURGEON GENERAL AND SECRETARY, FLORIDA DEPARTMENT OF HEALTH

Dr. Philip is the State Surgeon General and Florida Department of Health Secretary, and can be reached at Celeste.Philip@flhealth.gov.

References: 1. https://www.cdc.gov/mmwr/volumes/65/rr/ rr6501e1.htm 2. http://www.flgov.com/wp-content/uploads/ orders/2017/EO_17-178.pdf 3. http://www.floridahealth.gov/_documents/ newsroom/press-releases/2017/08/081717-pheopioid-re-dec-6-30-17-004.pdf 4. http://www.floridahealth.gov/provider-andpartner-resources/dpac/_documents/prescription-brochure-fact.pdf

40

TODAY'S FDA

It is our responsibility as providers to review these recommendations, take into account the risks associated with prescribing opioids and adjust our approach to pain management when applicable.

Late last year, the Centers for Diseas Control and Prevention published opioid prescription guidelines1, which provide recommendations for clinicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care. A few highlights: u

Evaluate risk factors for opioid-related harms.

u

Start low, go slow; prescribe no more than needed.

u

Use immediate-release opioids when starting.

u

Follow up and re-evaluate risk of harm.

u

Avoid concurrent benzodiazepine and opioid prescribing.

I’d like to share with you the steps the Florida Department of Health (DOH) currently is taking to combat and prevent opioid addiction and overdoses, and the important role that you can play as a part of the statewide solution.

This spring at the direction of Gov. Rick Scott, I joined the Department of Children and Families and the Florida Department of Law Enforcement for a series of opioid workshops in communities around the state — specifically in Palm Beach, Manatee, Orange and Duval counties — hearing valuable feedback from local leaders and community members. Many parents shared their heartbreak of losing a child to an opioid overdose, and the dismay of knowing that the addiction began with a prescription, some after minor dental procedures.

Following the workshops, Gov. Scott signed an executive order2 directing a Public Health Emergency across the state for the opioid epidemic. As state surgeon general, I issued a standing order3 for naloxone for emergency responders.

SEPTEMBER/OCTOBER 2017

WWW.FLORIDADENTAL.ORG

The Florida DOH Division of Medical Quality Assurance is tasked with administering the Prescription Drug Monitoring Program (PDMP), which supports sound clinical prescribing, dispensing and use of controlled substances. In 2016, there were nearly 200 million controlled substance prescription dispensing records maintained in the program, and there were 36,718 registered health care practitioners in the system. The PDMP is an important resource for health care professionals, allowing you to view patients’ controlled substance prescription history, leading to more informed and responsible prescribing practices. I urge you to take advantage of this program and review PDMP records as you care for patients.

Following legislative direction, the department developed a patient-centered brochure4 to highlight the risks associated with opioid use. We share this brochure with you as a helpful resource you can share with your patients.

In June, a multi-disciplinary panel made up of members from the boards of dentistry, medicine, osteopathic medicine, nursing and pharmacy met to discuss several topics, including opioid overdoses in Florida. At that meeting, the panel agreed to further review all issues and jointly make recommendations for further action by

WWW.FLORIDADENTAL.ORG

their respective boards or other partners.

As we work with other state agencies and local partners statewide to combat opioid overdoses, I ask each of you to examine the guidelines and documents referenced, and to assess and adjust your practice to provide the highest level of safety for your patients who require acute and chronic pain management.

I look forward to sharing additional actions and ways we can collaborate in the coming months. Our patients are looking to us to be leaders in addressing opioid overdoses, and I thank you in advance for being a part of the solution.

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

41

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pioids are synthetically manufactured chemical compounds that mimic the drug opium. They are primarily used in dentistry for the treatment of acute and chronic oral pain. The natural byproduct of opium includes morphine, codeine and their synthetic derivatives (opiates) like hydrocodone and oxycodone. Opioids work by competitively binding to the three opioid receptors: mu, kappa and delta. The mu receptor is the primary receptor affecting respiratory depression. These receptors are distributed primarily in the central and peripheral nervous system and smooth muscle of the gastrointestinal tract.

Opioids are considered agonists, antagonists or agonists/antagonists. Agonists include morphine, codeine and the synthetic codeines. They bind the mu and kappa receptors for their analgesic effects. Antagonists, such as naloxone, bind the same receptors as the agonists, but with higher affinity and no stimulation of the affected receptor. Agonist/ antagonist medications like pentazocine bind both the mu and kappa receptors, but only stimulate the kappa receptor.

These narcotics have many positive and negative effects in the body. The main positive effect is analgesia. The use or abuse of opioids can affect many systems of the body. Some of the main effects include respiratory depression (mu), nausea and vomiting (chemoreceptor trigger zone of the medulla), mental clouding, sedation and euphoria. Other side effects include constipation, hypotension, urinary retention and pruritis. Opioids decrease gastric and intestinal motility, causing the constipation. They also increase arteriolar vasodilation, leading to hypotension. Urinary retention is caused by an increased tone of smooth muscle of the bladder and urinary sphincter. The pruritis is due to the release of histamine.

The consumption of narcotics (opioids) can lead to tolerance, dependency or addic-

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OPIOID USE AND ABUSE tion. Tolerance is where constant use of a drug causes the drugs physiologic effects to decrease over time. Dependency is secondary to the continual use of an opioid, leading to physiologic and psychiatric manifestations of withdrawal if stopped. Addiction is the physical need for more drug, mainly related to long term use of the narcotic.

The immediate treatment for opioid use and abuse includes airway assessment, ventilatory support with supplemental oxygen, aggressive monitoring of vital signs to include pulse oximetry and capnography, intravenous fluid administration and the use of a narcotic antagonist such as naloxone.

Once stabilized, the patient should be evaluated and treated by professionals in opioid management. There are specialists who deal solely with addiction. As part of the treatment, physicians may use medications such as naloxone, methadone, suboxone, buprenorphine and clonidine to aid in detoxification. The process of addiction treatment starts with detoxification, which can be performed on either an inpatient or outpatient basis. Psychotherapy, relapse prevention, cognitive therapy and aversion therapy also are used in the long-term treatment of opioid use and abuse. Most of these therapies can be performed by pain management specialists.

Dentists are the fifth largest prescribers of opioid medications. Narcotics are used in dentistry for both acute and chronic pain scenarios. Acute pain would be expected in patients who have undergone procedures such as extractions, removal of impacted wisdom teeth, bone grafting, dental implant surgery, periodontal surgery, apical surgery and other invasive dental procedures. Oral and maxillofacial surgeons also prescribe

BY DR. DAN GESEK

Dr. Gesek is an oral and maxillofacial surgeon and practices in Jacksonville, Fla. He is on the FDA Political Action Committee, Governmental Action Committee, FDA Alternate Trustee, Board member on the PDMP and Past Board of Dentistry member. He can be reached at dsgesek@comcast.net.

References: 1. American Dental Association.

In: ADA Current Policies: Adopted 1954-2009-Substance Use Disorders Statement on the Use of Opioids in The Treatment of Dental Pain. American Dental Association, Chicago;2010:227 2. American Dental Association.

In: ADA Current Policies: Adopted 1954-2005-Statement on Provision of Dental Treatment for Patients with Substance Use Disorders. American Dental Association, Chicago;2010:329 3. Becker DE. Pain Management Part 1: Managing acute and postoperative dental pain. Anesthesia Progress 2010; 57:67-78.

4. Becker DE. Drug therapy in dental practice: general principles.

Part 2-pharmacodynamic considerations. Anesthesia Progress 2007; 54:19-23.

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mentorship program

HELPING MEMBERS SUCCEED In my travels to the dental schools around the state and in my interactions with students, a common request is that they really want to hear from you — someone who has walked in their future shoes and can help them figure out the most important things to focus on as they transition from dental student to dentist.

KERRY GÓMEZ-RÍOS FDA Director of Member Relations

The Council on the New Dentist needs your help in fulfilling this need. Please consider completing an online mentor profile and volunteering to mentor a D4 student from one of our three Florida dental schools. The more volunteers we have, the more quickly we can roll out the program to more students who are looking forward to hearing from you.

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narcotics for more complex surgical procedures such as orthognathic surgery, facial cosmetic surgery, TMJ surgery, cleft lip and palate surgery, and the treatment of complex facial fractures. Chronic oral and facial pain patients many times are treated with a medication list that includes opioids. Chronic pain pathologies include patients with a history of parafunctional habits, atypical facial pain, myofascial pain, fibromyalgia, and many other central and peripheral complex mediated pain pathologies.

As dentists, we need to adhere to certain protocols prior to prescribing opioid medications to our patients. Before prescribing or administering narcotics to our patients, a thorough history and physical exam should be performed. A history should include the types of medications the patient is taking and has taken. The history should include a social history to assess for signs of prior use and abuse of opioids. A growing organization, E-FORCSE, developed the prescription drug monitoring program (PDMP), which is extremely helpful in evaluating the types and amounts of opioids a patient may have been prescribed in the past and by whom. The PDMP is an elective option a practicing dentist can use in his or her practice to aid in the decision-making process of prescribing narcotics to patients. The use of the PDMP helps prevent the overprescribing of narcotics, which can lead to misuse of the drug.

Narcotics are one of the most widely used medications for pain management. As seen previously, dentists prescribe opioids routinely for a variety of dental procedures. Current thinking suggests that we should use NSAID as a first-line drug for any acute pain management. NSAID are excellent medications for the treatment of inflammation and peripheral pain. The sooner one stops taking narcotics, the more likely dependence or addiction can be avoided. Patients with chronic pain pathologies who take narcotics have a much higher incidence of tolerance, dependence and addiction. Adhering to this principle of starting with NSAIDs instead of narcotics will most likely decrease the use and abuse of opioids in our patient population.

Finally, as dentists, we are always taking continuing education courses to maintain and improve our skills as practicing dentists. The same is true of the use of opioid medications and the management of both acute and chronic pain. To avoid the increase in use and abuse of narcotics in our practice, we need to keep current in this ever-expanding field of dentistry.

WELL-BEING

FDA WELL-BEING PROGRAM APPROVED: Confidential Help for Dentists in Need

According to recent American Dental Association (ADA) statistics, 19 percent of all dentists will have problems with drugs or alcohol sometime in their careers. The fallout from this affects their health and well-being, as well as that of their patients, their staff and their families. Ultimately, they can be in jeopardy of losing their licenses, their health or even their own lives.

BY DR. BARTON BLUMBERG

Dr. Barton Blumberg is an oral and maxillofacial surgeon in The Villages, Fla. He is the special consultant for the FDA Well-being Program recently approved by the FDA Council on Ethics, Bylaws and Judicial Affairs and the FDA Board of Trustees. Dr. Blumberg can be reached at 352.446.7910 (his private cell number) or gatorbart@drbartblumberg.net.

Anyone needing information and help can anonymously contact Dr. Blumberg at 352.446.7910.

Alcoholism and drug addiction are diseases, just as diabetes and heart disease are. There is good scientific evidence that there is a genetic predisposition for it, and all addictions basically affect the brain in the same way — they stimulate the production of dopamine, which in turn, stimulates the pleasure or euphoria centers. This repeated exposure essentially hijacks the brain in an individual with addiction potential and prevents them from making rational choices when faced with using their drug of choice.

Part of the disease process is an individual’s strong denial that they have a problem. Sometimes the first ones to notice they have a problem are staff or family members. They might see some of the warning signs: the doctor showing up late or completely missing unscheduled days off. They also may show physical signs, such as unusual irritability with patients or staff, or slurred speech. However, staff or family members may be reluctant to confront the individual for fear of repercussions.

The Florida Dental Association’s (FDA) new Well-being Program is a non-threatening way for dentists to get help for his/her illness. Again, this is a disease — and we would not expect someone close to us not to seek help for cancer or heart disease. So why should they not receive help for their addiction?

The FDA Well-being Program is a project under the Council on Ethics, Bylaws and Judicial Affairs.

It is not meant to supplement or replace the Professionals Resource Network program. The FDA program is designed for doctors to contact a trusted source who understands dentistry and its difficult challenges. The conversations can be on an anonymous basis and will always be kept confidential. Doctors are not required to give their name or membership information, and there is no stigma or judgment attached to doctors who reach out to the well-being consultant.

As someone in recovery, I can tell you that my life is so much better in every way. I have great relationships and joy with my family, patients and staff in ways I could have never dreamed possible — and even more so than before my addiction problems. My personal growth, health and peace of mind on a daily basis is incredible, and is something that I wish everyone could enjoy.

There is no need to suffer the consequences of addiction to your health, your patients, your family or your license. Help is available now! Complete confidential assistance for dentists, their loved ones and staff is available. Any dentist in recovery who would like to be on the Well-being Committee, please contact me. Other dentists around the state are needed to participate on the committee and be a confidential resource for those who suffer from this disease.

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YOU are NUMBER

1

YOUR COLLEAGUES ARE “HELPING MEMBERS SUCCEED” EVERY DAY!

DEDICATED VOLUNTEERS HELP YOU SUCCEED Helping my fellow members succeed is one of my priorities as I serve my affiliate, the Volusia-Flagler County Dental Association as vice president this year. Sixteen years ago, one of my fellow colleagues introduced me to the association and showed me the importance of joining organized dentistry at the affiliate level and beyond. Since then, I have dedicated myself to our dental profession. I have made numerous trips to Tallahassee for Dentists' Day on the Hill to discuss important dental legislation with state lawmakers; provided services for the Ryan White Foundation patients, and also to local veterans through the VA. I also currently serve as an FDA delegate from my district and actively promote membership and volunteerism to all my colleagues.

The FDA has supported me since I started my private practice 16 years ago. The FDA has a very strong political action staff that constantly fights to safeguard our profession at both the state and national levels. I have also used the many benefits the FDA provides such as countless hours of free continuing education, practice-marketing tools, and the many benefits of FDA Services and its products. The FDA certainly helps members succeed! I ROD MACINTYRE, D.M.D., M.S. strongly encourage members to get involved by volunteering at all levels of organized dentistry. Only then can we as a profession maintain our strength and more importantly, help our patients toward better oral health.

EAST COAST ENDODONTICS INC. DAYTONA BEACH

— Rod MacIntyre, DMD, MS coastene@bellsouth.net

Interested in opportunities to get involved? Simply email the FDA’s Membership Concierge and she’ll put you in touch with your local dental society. Contact Christine Trotto at ctrotto@floridadental.org.

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MEDICAL MARIJUANA

TOUGH MEDICAL MARIJUANA RULES COULD BE IN YOUR FUTURE

BY CHRISTINE SEXTON

Ms. Sexton is the POLITICO Florida Pro health care reporter.

Doctors in Florida who improperly add a patient to the state’s medical marijuana registry could get their licenses revoked for a first-time violation under emergency rules being considered by the state’s medical boards.

A trio of proposals — two amendments dealing with disciplinary action against physicians and a rule for a standardized and mandatory consent form — were discussed at a joint meeting of the Board of Medicine and Board of Osteopathic Medicine on Aug. 3 in Miami.

Under the proposed amendment to the Board of Medicine’s disciplinary rule, a firsttime violation for a medical doctor who doesn’t take the steps to properly certify a patient who is seeking marijuana ranges from probation to revocation, or denial (which only applies to a first-time applicant), of their license and an administrative fine between $1,000 and $5,000. A second violation ranges from suspension to revocation, or denial, and an administrative fine ranging from $5,000 to $10,000.

Other less severe sanctions the board could take against a physician —such as a reprimand or letter of concern or corrective action — aren’t included as punishment options in the proposed rule. The committee voted to accept the proposed disciplinary guidelines at their August meeting.

Tallahassee attorney Allen Grossman, who has provided legal counsel to a wide variety of state boards, said the proposed amendment to the rule gives the Board of Medicine full discretion and sends a message that the board is going to take these “violations very seriously.”

“They allowed themselves in this proposed rule to be as harsh as they want to be,” Grossman told POLITICO Florida.

Reference: 1. http://www.politico.com/states/ f/?id=0000015d-960b-dd39-a75d-9f9b8deb0000

Reprint permission granted by POLITICO Florida Pro. This article first appeared on politico.com/pro/state-policy-news-coverage/florida-politics-government-issues on July 31, 2017.

The Board of Osteopathic Medicine is considering a rule that also enumerates the minimum and maximum punishment for first and second time offenses. An osteopathic doctor faces denial or probation and an administrative fine of $1,000 at a minimum for the first offense, and the maximum punishment is denial or revocation and an administrative fine of $5,000. For second-time offenders, the minimum punishment for the osteopathic physician is denial or suspension and an administrative fine of $5,000, and the maximum punishment is denial or revocation and an administrative fine of $10,000.00.

The tough disciplinary message isn’t surprising to those who have watched the medical marijuana debate in Florida over the last several months.

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Florida voters overwhelmingly approved a constitutional amendment that allows access to medical marijuana by patients who suffered from a spate of diseases and whose physicians certify that the use of medical marijuana outweighs the risks. The amendment banned the smoking of medical marijuana in public places.

But in a special legislative special session, lawmakers passed a bill that narrowed the amendment, supporters of medical cannabis say. Under the law, medical marijuana is available only to people who agreed to have their health information anonymously shared with researchers. The 2017 law also banned physicians from using telehealth for the exam — something several physicians complained about at the board’s Orlando meeting in February.

The Legislature also put restrictions on patients under 18 years of age and pregnant women. The law also bans people from smoking medical marijuana altogether, which proponents say is contrary to the constitutional amendment allowing people to smoke marijuana in private places. People United for Medical Marijuana has filed a challenge against the ban in Leon County Circuit Court.

Despite the restrictions, the numbers of statewide patients on the registry has climbed to more than 23,000. At the time of publication, 948 physicians have completed the required medical marijuana course and can certify patients.1 Raphael Bones, an Orlando doctor specializing in internal medicine, has certified about 100 patients in the last seven months. He wants to see rules adopted and followed for certifying medical marijuana, but maintains that the rules in place for certifying patients for medical marijuana discussion shouldn’t be any tougher than those currently in place for prescribing controlled substances which, he noted, allow him to write a prescription without having to enter the information into a database as he does with medical marijuana.

A review of the Board of Medicine rules shows that, similar to the proposed medical marijuana disciplinary amendment, the first offense for a medical doctor who inappropriately or excessively prescribes drugs, also calls for probation or revocation or denial of a license. But the probation is limited to one year, whereas the probation on the proposed marijuana rule is open ended.

The potential fine for a first-time prescribing violation, though, is upward of $10,000. It’s $5,000 for the first-time medical marijuana violation.

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“There should be no difference. They should make it the same. Make it equal,” said Bones, who noted that although the marijuana infraction has a lesser financial penalty, it could adversely affect physicians more to have longer probation periods. Given the consequences of the proposed amendments to the disciplinary rules, Bones said he would like the state to do a better job of teaching physicians how to use the reporting and tracking system, especially if their licenses are going to be on the line.

The new law requires that physicians report to the registry the qualifying condition, the dosage, the amount and forms of marijuana authorized for the patient, and any types of marijuana delivery devices needed by the patient. Physicians also are required to review the patient’s history in the prescription drug monitoring program database, which tracks controlled substances.

This isn’t easy for physicians, says Bones, and the state hasn’t been helpful when it comes to training. “We have leaders in Florida who want to obstruct the implementation of the second amendment; voted by 71 percent of Floridians. We should not keep giving them the space to do so against the will of the majority.”

The proposed amendments to the disciplinary rules are under discussion only and still need final approval from both respective boards.

The third proposed rule that was discussed at the Miami meeting contains a standardized consent form for patients to sign.

The law lays out topics that must be addressed in the form, including, among other things, a statement that the federal government classifies marijuana as a Schedule I controlled substance, which is illegal, and the side effects, including addiction. It also puts patients on notice that their health information may be used anonymously for research purposes.

If they don’t agree, they can’t obtain the cannabis.

Most of what’s in the consent form was prescribed by law, so disagreeing with the content may be moot, said one lobbyist. But the form contains 16 different spaces where a patient must sign, which could increase the chance of an inadvertent mistake. “The boards are being restrictive,” said the lobbyist.

“Surprise, surprise.”

The proposed rules can be found at http://politi.co/2uma0aM.

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MEDICATION RECONCILIATION THE BROWN BAG APPROACH & MORE: MEDICATION RECONCILIATION

BY DONALD WOOD, CRNA, CPHRM, PATIENT SAFETY RISK MANAGER II, THE DOCTORS COMPANY

References 1. National Center for Health Statistics, Health, United States, 2016: With Chartbook on Long-term Trends in Health, Table 79, p293.

Hyattsville, MD 2017, https://www.cdc.gov/ nchs/data/hus/hus15.pdf#079, Table 79, page 272, accessed June 2017.

2. Navarro V, Ikhlas K, Bjornsson E, et al, Liver injury from herbal and dietary supplements, Hepatology, 2017; 65:363-373, onlinelibrary.wiley.com/doi/10.1002/hep.28813/full, accessed June 2017.

The guidelines suggested here are not rules, do not constitute legal advice and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

M

edication reconciliation — the process of creating the most accurate list possible of all the medications a patient is taking — should be accomplished with each patient visit. The substantial number of medications available today and the variety of indications for their use can make the process challenging before prescribing or administering any medications necessary for dental treatment. There are two important tasks for successful medication reconciliation outcomes. Determine the medication currently taken by the patient, and ask the patient if he or she has any allergies to medication, food or other substances.

A 2015 study by the Centers for Disease Control and Prevention (CDC) estimated that 47 percent of people used at least one prescription medication within the previous 30 days, while more than 10 percent were on five or more prescription medications. In the age group of 65 years and older, 89 percent of people had taken a prescription medication in the previous 30 days, while 39 percent had taken five or more prescription medications in the same timeframe.1 Always ask the patient to provide a list of his or her medications, but keep in mind that the actual number of medications used by the patient may be higher

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than what’s listed. You also may want to consider reconciling a patient’s medication with a technique known as the “brown bag method.” Ask the patient to bring all medications that he or she takes to the next office visit, including any nonprescription or over-the-counter medications. The medications also should include any herbal medications and nutritional supplements.

If the purpose of the medication isn’t labeled on the container, ask the patient to explain why he or she is using the medicine. Many drugs that have been on the market for a long time are being used to treat illnesses for which they were not originally intended. For example, propranolol was originally marketed in the United States in 1965 as a beta blocker for the treatment of hypertension. Other indications have since been studied, and propranolol is now used for the treatment of performance anxiety, essential tremors and the prevention of migraine headaches. Currently, studies are underway to determine the effectiveness of propranolol in the treatment of posttraumatic stress disorder. If the reason for the medication is not clear, consult the dentist or physician who ordered the medication.

Another reason to review the original containers is to verify the origin of the SEE PAGE 56 WWW.FLORIDADENTAL.ORG

MEDICATION RECONCILIATION FROM PAGE 54

medications and supplements. Was the prescription filled by a pharmacy licensed in the United States or was it received from an overseas location? Was the prescription necessary for treatment of the patient? Low prices for medications can persuade patients to purchase medications online from questionable sources. Counterfeit medications are frequently purchased by patients. Those counterfeit products may include an incorrect dosage, the incorrect medication or may be completely void of medication. The quality of the medication also may be questionable if it does not have an imprint on the pill to aid in identification, or if the packaging is delivered in an unidentifiable envelope.

Many states have a prescription drug monitoring program (PDMP). When a pharmacy or other dispenser fills a prescription for a controlled substance,

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they must enter specific information into a searchable database that includes the patient’s name, name of controlled substance and who prescribed it. Health care providers can review this information to see if there are any suspicious patterns of activity or conflicts with the medication to be prescribed.

In Florida, the PDMP is the ElectronicFlorida Online Reporting of Controlled Substances Evaluation (E-FORCSE).

While there is a registration process for prescribers to use the system, there is no charge to access the system and review patient information. The E-FORCSE website (floridahealth.gov/statisticsand-data/e-forcse/index.html) will provide you with registration information, practitioner information and general information about the program.

Nonprescription medications can have significant adverse effects. Recent studies have implicated green tea extract, used in some over-the-counter weight

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loss products, as a major source of liver failure. The study, sponsored by the National Institutes of Health, notes that one out of five cases of hepatotoxicity in the United States are induced by herbal and dietary supplements.2 Your medication reconciliation process should also include possible effects on your patients regarding the use of nontraditional items used as medications or for recreation. For example, cannabis has been approved for medical use in several states. Consider the impact the use of cannabis or other nontraditional items might have on any medications you prescribe or administer in your office.

Preventing harm from the medications you prescribe or administer to your dental patients requires accurate medication reconciliation. Engage the patient as your partner in this important process.

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5 TACTICS FOR ADDICTION EFFECTIVELY PRESCRIBING PAIN MEDICATION Drugs are a modern miracle. Modern narcotic analgesics, which arose with the development of morphine in the 1820s, have served to reduce pain — from wartime wounds to labor pain. These medicines help those recovering from surgery and are invaluable for those with terminal conditions, such as cancer. Drugs should not be demonized.

However, with the rate of opioid addiction skyrocketing, and the resulting increase in overdose deaths and drug-related crimes, prescription narcotics (and the doctors who prescribe them) have come under intense scrutiny. Florida gained notoriety as a haven for “pill mills” where patients can get an abundant supply of OxyContin or Xanax. Well-meaning providers have had to establish a policy of strict limitations on opioid prescriptions to decrease the possibility of diversion, to protect the public and to safeguard their medical license. While this has likely made it more difficult for drug traffickers, it possibly has impacted the quality of care for patients who could benefit from such medicines.

So, what are we to do? There is no definitive solution. Individualized patient care is a hallmark of clinical practice, and doctors need the freedom to prescribe based on clinical judgment, not on legislative rule. Until a medication comes along that provides powerful pain relief without abuse potential, medical providers will be doing a balancing act. A greater understanding of the nature of addiction can serve as a useful tool in clinical decision-making for pain management.

To reduce addiction to just the repeated the act of drug use is an oversimplification. Addiction is better characterized as a dysfunctional or diseased state that impacts the cognitive, emotional, physical and behavioral functioning of an individual. A key psychological principle in understanding the development of addiction is called the Law of Effect, first coined by Thorndike in 1905 — when a behavior has reinforcing consequences (pleasure or reduction in pain), a person will be motivated to repeat the behavior, and when it brings punishing consequences (pain or loss), a person will be motivated to avoid the behavior. The more powerful the reinforcer or SEE PAGE 60 WWW.FLORIDADENTAL.ORG

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punisher, the more powerful its impact on behavior. For instance, if I have a headache, taking aspirin may provide reduction in pain (reinforcement), without having any negative side effects (punishers). Because of this, any time I have a headache, I am likely to take this drug to feel better. However, if the first time I took aspirin, it reduced my headache, but also brought on an allergic reaction of hives and swelling, I would quickly decide that taking aspirin is not a good choice. This principle generally applies to all behaviors, and is what shapes our habits and choices. It is hard to find any behavior as reinforcing as taking drugs, due to drugs’ direct effect on the brain’s experience of pleasure and satisfaction; and everyone, regardless of moral character, likes to feel good.

ADDICTION FROM PAGE 59

BY MELANIE ALEXANDER, LMHC-S, CAP, NCC

Ms. Alexander is a licensed mental health counselorsupervisor, certified addiction professional and national board certified counselor. She can be reached at melexander@ hotmail.com.

Resources: 1. CAGE is derived from the four questions of the tool: Cut down, Annoyed, Guilty and Eye-opener. Assessment can be found at: http:// www.hopkinsmedicine.org/ johns_hopkins_healthcare/ downloads/CAGE%20Substance%20Screening%20Tool. pdf.

2. The Drug Abuse Screening Test is a self-administered test designed to provide a brief screening for drug abuse, followed by further assessment by a health care professional if necessary. Assessment can be found at: https://www. opioidrisk.com/node/936.

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Addiction can develop at any age, but young people are at an increased risk for drug-related problems and developing dependence.

Initial exposure to opioids may start due to legitimate medical need, out of curiosity or with friends at a party. Many may enjoy the feeling of these drugs, but never feel compelled to use again or will be able to use only occasionally. However, certain people are at much greater risk for developing drug addiction after experiencing their first “high.”

Many opioid addicts I have worked with describe their first use of narcotics as, “I was 15, and got pills when I had my wisdom teeth removed. I took one and for the first time in my life I felt normal.” Some people, for a variety of reasons, have not found ways to manage their sense of deprivation or emotional pain.

This may be due of longstanding developmental issues, family problems, or mood and anxiety symptoms. Stressful events over the lifespan, such as relationship or job loss, peer rejection, divorce in the family, etc. also increase the vulnerability to abusing drugs to cope. For these people, the sense of psychological relief, coupled with the high provided

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by these drugs, ignites a wildfire that is not easily extinguished by fear of consequences or the fact that everyone “knows better.” As tolerance develops and a person increases the amount of the drug taken to get high, they can fall into a physical dependence — a state in which abstinence from the drug leads to the distressing physical and psychological consequences of withdrawal.

For those who have been using narcotics, withdrawal symptoms include intense pain, nausea and vomiting, sleeplessness, sweating, muscle spasms, and an emotional state characterized by intense dysphoria and anger. At this point, abstaining from the drug has become punishing, and the quickest way to get relief from being “dope sick” is to take another dose of the drug. The withdrawal state is so uncomfortable that people feel desperate to find relief, which leads to the deceitful and often criminal behavior associated with addiction.

Developing a dependence on prescription narcotics is an insidious process. Most people have almost no negative consequences during their early using experiences.

They feel good without getting sick, getting in trouble or feeling desperate. Most addicts report that early in their addiction, they actually performed better at work and had greater stress tolerance. Since it may take a long time for consequences, such as slurred speech or major coordination problems, to become severe enough for someone to see this as a real problem, many people are in denial about their addiction. This is especially true for those who have been using narcotics for legitimate pain relief. They have likely never bought “street drugs,” and consider themselves upright citizens. Their doctors often accommodate increasing tolerance by writing stronger prescriptions. With the stronger dose, they will experience increased withdrawal pain.

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Despite the complicated and powerful pull of addiction, recovery is possible. People with addiction need comprehensive treatment to establish abstinence, address emotional and spiritual problems, and build skills to prevent relapse. Maintaining abstinence is challenging since the obsession and desire for the substance can endure long after the acute withdrawal period. For persons with opioid dependence, this becomes especially risky if they find themselves needing a surgical procedure or dealing with a medical condition that causes acute pain. It can be easy to fall prey to the belief that, “It is OK for me to take these pills if a doctor gives them to me.” And even if an addict intends to avoid returning to active addiction, the reintroduction of narcotics can spark the strong craving and return of addictive symptoms.

What Dentists Can Do Dentists cannot be expected to police their patients to prevent them from abusing prescriptions. People who are in active addiction are compelled to keep using, and become skilled liars. Trying to be a human lie detector often will fail and increase the stress of an already stressful profession. Of course, if you get a strong sense that someone is drug seeking, it is best to refuse care or refuse to prescribe narcotics; but it is rarely that easy to judge such a situation. However, a thoughtful approach to prescribing opioids is likely to be effective in reducing the risk of abuse and dependence in at-risk populations. Rational practices can mitigate risk for vulnerable populations and allow patients to make informed choices. These practices can effectively discourage drug-seeking patients and reduce the risk of diversion.

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1. Screen to Identify Those at Greater Risk for Substance Abuse Problems.

Initial paperwork and history should include questions about family history of addiction, personal history of addiction or admission to a drug rehabilitation center, history or current symptoms of mood or anxiety disorders, and for adolescents, the presence of ADHD or behavioral problems. There also are simple self-report measures that can be included in the initial paperwork that indicate relative risk. Examples include the CAGE1 and the DAST2, which are open-source tools. If a patient appears to be at risk, their chart can be flagged to alert the dentist to take extra precautions when that patient may need analgesic or anxiolytic medications.

2. Consider Alternative Pain Management Interventions.

Dental problems and procedures can be painful, and it is good practice to help patients be more comfortable. But, a person does not have to be completely pain-free to be able to tolerate the pain. If there are medications or other interventions that can ease pain without the side effect of euphoria, it is prudent to consider these first.

3. Consider Alternative Formulations.

Although no narcotic is “abuse proof,” there are formulations that nullify the rewarding effect of the drug if it is tampered with, such as by crushing or chewing. Also, consider the half-life of the drug used. Drugs with shorter half-lives tend to deliver a high with a greater “punch.” Choosing drugs that deliver a slower, steadier dose of medication decreases the risk that someone in pain will be at risk by feeling the “rush” of the drug.

ADDICTION 4. Communication and Education with Patients and Families is Essential.

Many patients fall into the category of “opioid naïve.” They aren’t seeking narcotics and are unaware of the powerful effects and risks associated with these drugs. Patients should be counseled that these medications are for short-term use only. Tell patients that they may like the way the medicine makes them feel, but it is that feeling that causes addiction and overdose. Almost all teenagers know about pills. Being straightforward with them and their parents about the risks allows for honest dialogue. Parents often think that only “bad kids” would like drugs. But, these drugs are powerful, and any teenager would like the feeling when they produce a high. Parents should always be instructed to maintain control of the medication, to put it in a locked container if possible, and to dispose of any remaining pills. If a patient tells you that they are in recovery from addiction, addictive medications should be the last resort. If it seems that this will be necessary, encourage the patient to engage a supportive person to take responsibility for holding and administering the medication.

5. Consider Limited Dispensing.

Many medical procedures cause initial acute pain that could require narcotic medications. But, often after the first 24-48 hours, any pain that remains could be manageable with other strategies. Consider limiting the amount of medication dispensed to last only about that long. If a patient is experiencing acute or intense pain after that, they may need to be seen in the office to evaluate the need for further treatment.

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COMPLEAT DENTISTRY

The Second Best Investment I Ever Made A DR. EDWARD HOPWOOD

Dr. Hopwood is restorative dentist in Clearwater and can be reached at edwardhopwood@gmail.com.

Compleat dentistry is a slowerpaced, deliberate style of dentistry, espoused by Pankey, Dawson and so many others, in which the dentist knows the patient well, knows the work, knows their own abilities and limitations, and uses this knowledge to take care of the patients who trust them with their care. The world will change, but the principles of compleat dentistry will remain the foundation of an exceptional practice. The spelling is an homage to Isaak Walton, whose book, “The Compleat Angler,” was about so much more than fishing.

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t a recent presentation, the gentleman who spoke was an accountant and he certainly knew his way around numbers and finances. He worked for a large firm that catered to the very audience he was in front of that day. He needed to be sharp — there were potential clients in the audience — and he was well prepared and presented a powerful message. The topic was retirement planning, and we have all been in these lectures before: start early, geometric growth curves, if you had only started when you were 12, then you would be a millionaire today.

He proceeded to show us that if we could save $50,000 a year for 30 years, then we would have $7.5 million and could retire comfortably.

But the problem was the next part of his lecture. After showing us how to save up $7.5 million by saving $50,000 per year, he then proceeded to show us how we could hire his firm to enable us to save $250,000 per year.

And that part got me thinking — about Jim. Jim was an old man who lived across the hall from me and my wife when we lived in our first apartment. We had a two-bedroom apartment with a lovely corner back porch and a view of some cypress trees. Jim lived across the hall in a one-bedroom with a cement block-enclosed porch with a view of the parking lot. I got to know Jim the way any one of us would get to know a neighbor — brief conversations on the way up the

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stairs or while collecting the mail. Then, late one night Jim knocked on our door, as he was in trouble — it was a heart attack, so we took him to the hospital.

After he recovered, Jim took me to lunch to thank me for helping him out. I learned that Jim was a multi-millionaire. It was amazing to me because at the time, I had $220,000 in student loans, which put my net worth at around negative $215,000 when you took into account the equity I had in my car.

So, he was worth so much and I owed so much, but I had a better apartment and I had friends and family I could call if I was having a heart attack. We talked further and I learned that his wife was dead and his children don’t talk to him. His closest “friend” was his financial advisor, who he recommended.

You see, what Jim taught me was that in financial planning, like in so many other areas in my life, I needed to make balance my primary goal. This contrasted with Jim, who made wealth his primary goal. And the accountant lecturing our group was making wealth the primary goal. The problem with making wealth our primary goal is that we often have to give up so much in order to gain it.

I didn’t ask, but I think that Jim, in hindsight, probably would’ve given up some of his money in order to have taken a nice vacation with his wife — one that he could look back upon now and remember.

Perhaps he would have given up some of WWW.FLORIDADENTAL.ORG

his earnings to spend time with his children — maybe he would’ve taken a day or two off and taken them fishing, possibly building relationships that he could enjoy to this day. Or, maybe I am wrong, and Jim enjoyed sitting alone, reading his financial statements while looking out over the parking lot.

But this isn’t about Jim, it is about me, and he taught me that balance is best for me.

When I think carefully, I have been through three distinct levels when thinking about money. The first level is developing comfort with spending. Understanding that I do not need to buy the newest toys and gadgets and that I don’t need to spend every penny I make. I think most of our society never transcends this level, they are stuck on a treadmill to keep up with each other. The next level is to become comfortable with saving, setting aside enough each year so that you will be able to retire comfortably. And I really like the plan to save $50,000 per year for 30 years (or whatever number makes sense to you).

But then, something magical happened after I hit my savings goal each year for enough years: I ended up with enough left over that I got to decide what to do with it. That is the third level, and when I got there, it became crucial to remember that money is a means to an end, it is not an end in and of itself.

In other words, the reason we make money and the reason we save money is to use it.

Which is why my financial advisor was shocked when he asked me if my boat was a good investment. He asked, thinking he already knew the answer — you know, the two best days are the day you buy it and the day you sell it. B.O.A.T. stands for bust out another thousand. But my response surprised him: My boat was the second best investment I ever made.

I explained that the boat was where my family and I spent countless hours together, away from technology. It was where we learned to fish; went skiing, swimming and picnicking; talked about nonsense as well as important things; entertained friends and spent some quiet time alone; and, learned to love the outdoors. We joked, laughed and formed closer relationships. We even enjoy memories of the fish we lost. The value of the time we spend together is so much more than the cost of the boat.

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THE POINT IS, THERE ARE SOME THINGS IN WHICH THE VALUE OF THE MEMORIES IS WORTH MUCH MORE THAN THE MONEY SPENT.

Now, some people don’t love boating and they value ski trips or vacation houses or sports games. But the point is, there are some things in which the value of the memories is worth much more than the money spent. Once we have mastered spending and saving, then we get to spend the extra on those things. And when we get it right (like for me and my boat) the result is magic.

So, my financial advisor was shocked, but undeterred. “OK then, what was the best investment you ever made?” he asked, hoping it was one of his recommendations.

My answer to that one was easy: “An engagement ring.”

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SAVE THE DATE! 2018 FLA-MOM

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PROFESSIONAL STAFF I help members succeed by answering queries related to membership and directing questions outside of my realm to the appropriate person. By understanding the different aspects of the FDA and how each department relates to member needs, I can assist each member on a personable level.

It is my goal to make our members’ interaction with the FDA positive and memorable.

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Have a question about the FDA? 800.877.7597 • 850.350.7100 • mlong@floridadental.org www.floridadental.org

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COMPREHENSIVE CORPORATE DENTAL PRACTICE: PART 2

CORPORATE DENTAL

A CONTEMPORARY ANALYSIS DRIVEN BY PORTER’S FIVE FORCES Introduction

BY S. DONOVAN ESSEN, DDS, MBA

Dr. Essen has an implant and cosmetic dentistry practice in Palm City, Fla. and can be reached at dressen@essendentistry.com.

Private group and solo dental practices are facing numerous challenges in the new millennium. Autonomy and quality of care are becoming issues of concern. Private dental practice has come under pressures of rising costs, competition, insurance industry mandates, business rivalries and government regulations. With persistent challenging economic conditions, managed health care, industry rivals and smaller profits, the idea of a dentist-owned and -operated, comprehensive corporate dental practice (CCDP) within a regional dental center (RDC) or community dental center (CDC) must be considered. Corporate dental practice has been a much-discussed topic in recent literature and usually refers to practices owned and operated by dental management conglomerates or dental service organizations (DSOs), as recently defined by the Academy of General Dentistry.7 This is Part 2 of an article that is a topical analysis of Porter’s Five Forces (Fig. 1) and how those forces influence the dental industry and justify dentist-owned CCDPs. It begins with The Power of Suppliers and continues to make the case that CCDPs can hedge against unchecked market threats and proposes a model for a successful solution.

The Power of Suppliers Powerful suppliers capture more of the value for themselves by charging higher prices, limiting quality or services or shifting costs to industry participants. Powerful suppliers, including suppliers of labor, can squeeze profitability out of an industry that is unable to pass on cost increases in its own prices.1 According to Blaes, dentists’ gross producWWW.FLORIDADENTAL.ORG

NEW ENTRANTS

SUBSTITUTES

EXISTING COMPETITORS

BUYER’S BARGAINING POWER

SELLER’S BARGAINING POWER

Fig. 1 Porter’s Five Forces tion has increased by 12.6 percent, but profits have only gone up 1.56 percent.2 This is due to unabated increases in fixed and variable costs. Dental suppliers have passed on rising costs of goods sold (COGS), while inflationary pressures spur labor to demand more compensation.

Mergers and acquisitions of numerous dental supply houses and dental laboratories narrow competitive choices and diminish competition, which may leave less room for buyers to negotiate the best price. In an article first published in 2005, DiMatteo states, “Manufacturers are acquiring other companies in order to round out their product offerings to distributors purchasing smaller and/or regionally based businesses to broaden or strengthen their reach, competition and the desire to control more of the market share have led to more than 60 dentistry-related acquisitions in 2005 worldwide.”8 Suppliers are more capable today than ever before in reacting to and controlling market elasticity.

Dentists must recognize this trend and begin SEE PAGE 68 TODAY'S FDA

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CORPORATE DENTAL FROM PAGE 67

to strategize immediate short-term responses and draft long-term goals.

The Power of Buyers According to Porter’s theory: Powerful customers — the flip side of powerful suppliers — can capture more value by forcing down prices, demanding better quality or more service (thereby driving up costs), and generally playing industry participants off against one another, all at the expense of industry profitability.

Buyers are powerful if they have negotiating leverage relative to industry participants, especially if they are price sensitive, primarily using their clout to pressure price reductions.1 This is the largest challenge the dental practitioner is facing today. With increasing numbers of DSOs, dental graduates, immigration and licensing of foreign-trained doctors, and freedom of geographic movement for practicing dentists due to licensure by credentials and reciprocity, doctors are faced with buyers who have more choices than ever before. Since small dental practices and solo practitioners have limited access to competitive intelligence, it is easy to play one dentist against the other in price negotiations. Price-sensitive customers or “dentist shoppers” are those who seek the best value for their investment.

These customers commoditize dentistry by not recognizing differences in the quality of products or the provider’s skills. The cost of switching dentists is low; if practitioners refuse to adjust fees to accommodate price-sensitive patients, then they risk losing productivity and income. It is not uncommon

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for dentists to enter price wars within their markets to gain business. This is not only harmful to practitioners, but also many believe it is detrimental to the delivery of quality health care.

A few large-volume buyers, such as third-party payers, can impact dentists in many ways, including unyielding demands for discounted fees. In competitive markets, many practices have no choice but to relent to third-party demands. Solo general dentists with office overhead costs greater than or equal to the national mean likely find that the capitation amounts paid by insurance companies are an unfair compensation or are incompatible with their income objectives. Participation by solo general practitioners in capitation plans with such compensation levels is highly problematic.9 This not only hurts industrywide profitability, but also may compromise the dentist’s autonomy by necessity.

Threat of Substitutes A substitute performs the same or a similar function as an industry’s product by a different means … when the threat of substitutes is high, industry profitability suffers. Substitute products or services limit an industry’s profit potential by placing a ceiling on prices. If an industry does not distance itself from substitutes through product performance, marketing or other means, it will suffer in terms of profitability — and often growth potential … substitutes not only limit profits in normal times, they also reduce the bonanza an industry can reap in good times.1 Dentistry is in a dynamic state of disruption and is facing many substitutes entering its industry. Mid-level providers (also called dental therapists) are being promoted as modalities to treat

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underserved areas, but the industry fears that this is the first step to degrade the dentist’s role as the sole provider. As of 2012, proponents in at least 15 states — including Kansas — were pushing their legislatures to license mid-level dental providers as a way to extend basic oral health care access to thousands who have none.10 Low fees diminish the ability of fully equipped businesses to provide best-cost delivery.

Denturists also are providing product substitution for many seeking low-cost removable dental prosthetics. Denturism is currently legal in Arizona, Idaho, Maine, Montana, Oregon and Washington, and is vigorously opposed by organized dentistry. The American Dental Association (ADA) feels that this substitute is such a threat to public health that it defines a denturist as a person who is educationally unqualified to practice dentistry in any form on the public.11 Recent trends toward medical tourism compete with industry profitability.

The ADA defines dental tourism as the act of traveling to another country for the purpose of obtaining dental treatment.11 Patients seeking reduced-fee dental treatment combined with a vacation may opt for dental holidays in the Caribbean, Latin America and the Far East. Often, these foreign clinics are owned and operated by dentists trained in the West, yet the quality of care is not guaranteed or regulated by western laws. Many individuals see these as an attractive price-performance trade-off to traditional modalities and consider the substitute as a better relative value.

Rivalry Among Existing Competitors Rivalry among existing competitors takes many familiar forms, including WWW.FLORIDADENTAL.ORG

price discounting, new product introductions, advertising campaigns and service improvements. High rivalry limits the profitability of an industry.

The degree to which rivalry drives down an industry’s profit potential depends — first, on the intensity with which companies compete and second, on the basis on which they compete.1 Numerous offices that offer similar services have no distinct advantages over their competitors. As fixed costs steadily rise and margins become thinner, dentists may be forced into price wars, poaching and aggressive advertising to attract more clients. Low prices cause brand dilution, which in many instances becomes permanent.

Once dentists establish a business they face staggering exit barriers. With high sunk costs, very few offices can close or move. Instead, many practitioners commit to their segment and remain for their entire career engaged in protracted battles for market share. Ailing businesses that persevere may damage the profitability of the healthier ones. If local markets suffer saturation, excess capacity — often equated with chair time — is difficult to sell. Unlike other businesses, dental offices rarely close but rather, undergo ownership transitions for reasons including sales to corporate management companies, retirement, illness or desire to relocate. According to Prokes, based on value, established dental practices can indefinitely remain active.

When all or many competitors aim to meet the same needs or compete on the same attributes, the result is zerosum competition. Here, one firm’s gain often is another’s loss, driving down profitability … price competition runs a stronger risk than non-price competition of becoming zero sum. Rivalry can be a positive sum, or actually increase WWW.FLORIDADENTAL.ORG

the average profitability of an industry, when each competitor aims to serve the needs of different customer segments, with different mixes of price, products, services, features or brand identities.

Such competition can not only support higher average profitability, but also expand the industry as the needs of more customer groups are better met. The opportunity for positive-sum competition will be greater in industries serving diverse customer groups. With a clear understanding of the structural underpinnings of rivalry, strategists can sometimes take steps to shift the nature of competition in a more positive direction.1 Porter provides a clear direction to reverse zero-sum games by advising industry rivals how to create positivesum competition. By recognizing the etiology of dwindling profits, dentists can respond and take action to reverse the growing trend of non-dentist owned corporate practice.

Recommendations In the past, the provision of health care services has been viewed as a “cottage industry,” revolving around the physician who assumed responsibility for all aspects of care. Leaders across the industry concur that the traditional physician-centric model will no longer hold. Given the complexity of medicine today, no individual or entity can function effectively alone.13 Success depends upon an agile longterm strategy. It is worth suggesting that organized dentistry, clinicians and educators prepare dentists to think about protracted missions, goals and strategies to survive increasingly challenging regulatory, competitive and economic conditions.

The number of solo and small group practices creates unnecessary redundancy of services, technology and physical plants. The unlimited amount of small dental firms may be harmful to the growth of the profession. Shea and Cahill have both recognized the benefits of merging — Shea emphasizes earnings14 and Cahill stresses efficiency.15 It is now critical for existing practitioners and new graduates to consider partnering with their peers to form CCDPs. As CCDPs become an established delivery modality, there will no longer be the need for duplicate technology, aggressive marketing campaigns or price wars.

In 2014, it was estimated that the national expenditure on dental services was $122.4 billion, and by 2022 it is projected to be $191.3 billion.16 Given this level of spending, it is obvious that dentistry has become a significant part of domestic spending and will be the target of more regulation and commercial interest. In order to meet these challenges, new models are going to develop; among these are the CCDP-driven RDC and CDC. RDCs will insure a sustainable health care model, creating better access to quality care for communities and urban centers.

Conclusion Michael Porter defined the five forces that drive industry competition. Dentists should begin open and frank discussions on how to begin beneficial mergers of their local practices into a CCDP housed as a CDC or RDC. New dentists should plan on joining or forming these centers. RDCs and CDCs will be the future model of dental care. If dentists recognize and respond to the arriving transformation, they will mainSEE PAGE 70

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tain their ability to ensure autonomy and high standards of care for their communities. Porter’s Five Forces Model fortifies the benefit of CCDPs that are owned, managed and serviced by dentists. Recent fines levied by the New York State Attorney against a major DSO suggest these entities may use profit-driven strategies that are not in the patient’s best interest.20 CCDPs will help ensure patient-centered decisions.

Dentists and physicians share common problems associated with managed care. Many alternatives to group practice still exist, but concentrating resources under one entity should prove to be a better value for patient and practitioner.

If dentists recognize and respond to the arriving transformations, they will maintain their ability to ensure autonomy, which will result in higher standards of care. Understanding the key forces that are moving these changes will define the profession’s destiny. Dental schools and tripartite dental societies may be the ideal venue to facilitate change. Organizations can work together to navigate students, new dentists and solo practitioners to the new, beneficial CCDP model.

Due to space limitations, please email jrunyan@floridadental. org for a list of references.

Fig. 1:

BY DRS. REKHA REDDY1, INDRANEEL BHATTACHARYYA, NADIM M. ISLAM AND DONALD COHEN

A 68-year-old male presented to Dr. Christie Eastman Craighead, a periodontist at Eastman Periodontics in Bradenton, Fla. for routine dental care.

During the appointment, the patient reported a history of intermittent tongue swelling primarily at nighttime that was present upon awakening. He reported the incident occurring about six to seven times over the past four to five years with no particular preceding event (Figs. 1-2). He did not elicit a history of any food allergies. He could not relate to any food or drink ingested the night before, nor could any external agent be identified consistently as an etiology.

The patient’s medical history is significant for hypertension and hypercholesterolemia. The patient related a distant history of smoking one-and-a-half to two packs of cigarettes per day, but had quit more than 25 years ago. He currently drinks one to two glasses of wine per day. He reported an allergy to penicillin and in the past, had experienced tissue swelling of the head and neck region as a reaction to penicillin. He is careful to avoid penicillin and related medications.

His list of medications include atorvastatin, hydrochlorothiazide/lisinopril, omeprazole, fluoxetine, atenolol, amlodipine, fluticasone spray, multivitamins, vitamin D3 and niacin. He also reported that his physician recently switched his medication from hydrochlorothiazide/ WWW.FLORIDADENTAL.ORG

Fig.2:

*We apologize for the image quality. Both are self-taken photographs by the patient off a mobile phone.

lisinopril to only hydrochlorothiazide and since this switch in drugs, his swelling has not recurred.

Question: What is the most likely diagnosis?

A. Vascular Anomaly B. Amyloidosis-related Macroglossia C. Pernicious Anemia D. Acromegaly E. Angioedema SEE PAGE 72 TODAY'S FDA

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DIAGNOSTICS FROM PAGE 71

Diagnostic Discussion A. Vascular Anomaly Incorrect, but a good guess. Similar to our case, a vascular anomaly on the tongue may result in macroglossia, and may exhibit increase and decrease in size due to ebb and flow of blood into the lesion. However, this increase and decrease in size usually isn’t transient, takes a few days to subside and may produce symptoms. Macroglossia caused by vascular anomalies can lead to several problems, including swelling, bleeding, dentoskeletal deformities, masticatory and breathing difficulties. However, the patient in our scenario is 68 years old and states that the swelling has occurred for four to five years. Vascular anomalies, in contrast, usually are present at birth (or shortly after) and either regress over time or grow commensurately with the patient. Vascular anomalies can be divided into two categories: hemangiomas and vascular malformations.

Hemangiomas are the most common tumors of infancy, occurring in 4-5 percent of 1-year-old children. They are much more common in females than in males, and they occur more frequently in Caucasians than other racial groups.

They are small or absent at birth, but proliferate during the first eight weeks of life. Over time they regress, usually completely by age 5-7 years old. Because they undergo involution, management often consists of “watchful neglect.” For larger lesions, pharmacologic therapy with propranolol is recommended.

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Vascular malformations, in contrast, are noted at birth and persist throughout life. They can be categorized according to the type of vessel involved (capillary, venous or arteriovenous) and hemodynamic features (low flow or high flow).

Small, stable vascular malformations may not require treatment. Larger, problematic lesions may be treated with a combination of sclerotherapy and surgical excision. In particular, vascular malformations of the jaws are potentially dangerous lesions because of the risk of severe bleeding, which may occur spontaneously or during surgical manipulation. Needle aspiration of any undiagnosed intrabony lesion before biopsy is recommended to rule out the possibility of a vascular malformation.

B. Amyloidosis-related Macroglossia Incorrect, but an important entity to include in the differential diagnosis of tongue swelling. The patient’s chief complaint most likely isn’t due to amyloidosis because his macroglossia waxes and wanes. Macroglossia due to amyloidosis typically wouldn’t be transient and is more or less permanent. When amyloid proteins are folded abnormally, they cannot be broken down. This results in the deposition of amyloid, an extracellular proteinaceous substance, in tissues and organs. Amyloid can be formed in a variety of settings. For example, it can be acquired over time for unknown reasons, inherited due to a genetic mutation or result from diseases like multiple myeloma, arthritis and Hodgkin’s lymphoma. The deposition can be localized to one small area of the body, or systemic and deposited in several organs. The most common sites of amyloid deposition in the oral cavity are the tongue, floor of the mouth and buccal mucosa. Amyloid deposition on the

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tongue usually results in macroglossia, with the tongue protruding beyond the alveolar ridge. Other symptoms include speech impairment and dysphagia. The patient’s medical history would have revealed a history of myeloma or other significant chronic inflammatory condition. In addition, the oral cavity usually isn’t the only site involved by amyloid deposition.

C. Pernicious Anemia Incorrect, but good choice given the fact that pernicious anemia affects the tongue. However, it is important to note that pernicious anemia does not produce any significant swelling, but is rather symptomatic. The tongue displays a smooth, “bald” appearance with significant burning/pain. However, the patient did not present with a painful, smooth, red tongue. Enlargement of the tongue is unusual in this condition.

Pernicious anemia is caused by poor absorption of vitamin B-12 (cobalamin).

Patients with pernicious anemia lack intrinsic factor — which is needed for vitamin B-12 absorption — because of autoimmune destruction of the parietal cells of the stomach where intrinsic factor is produced. Antibodies directed against intrinsic factor also are found in the serum of these patients. Pernicious anemia occurs with greatest frequency amongst older patients of Northern European heritage. Symptoms commonly reported include fatigue, weakness, shortness of breath, headaches and feeling faint. Since vitamin B-12 also functions to maintain myelin throughout the nervous system, patients with pernicious anemia may report paresthesia, tingling or numbness of the extremities.

Difficulty in walking and diminished vibratory and positional sense also may be present. Psychiatric symptoms of memory loss, irritability, depression WWW.FLORIDADENTAL.ORG

and dementia have been described. Oral symptoms include a burning sensation of the tongue, lips, buccal mucosa or other mucosal sites. The tongue is affected in 50-60 percent of patients with pernicious anemia, where it appears erythematous and atrophic. Treatment traditionally consists of monthly intramuscular injections of cyanocobalamin or high-dose oral cobalamin therapy. The condition responds rapidly once therapy is initiated, with reports of clearing of oral lesions within five days.

D. Acromegaly Incorrect — but good guess! Very similar to amyloidosis, it is unlikely that the patient in this scenario has acromegaly, as his tongue swelling was transient rather than progressive. In addition, the macroglossia seen in acromegaly is uniform and not unilateral. Furthermore, he did not present with other features that are characteristic of acromegaly.

Acromegaly is a rare condition caused by a pituitary gland tumor that produces excessive growth hormone. Clinical features include enlarged extremities, thickened skin, widened nose, prominent cheekbones, course facial lines and frontal bossing. Oral manifestations include mandibular overgrowth, maxillary widening, dental malocclusion, enlarged lips and macroglossia. These symptoms

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tend to occur gradually and often aren’t recognized immediately. The involved patient also presents with visual disturbances, hypertension, heart disease, hyperhidrosis, arthritis and peripheral neuropathies. Our patient had none of these important and common accompanying signs and symptoms.

E. Angioedema Correct! Great job! Angioedema is a diffuse edematous swelling of the soft tissues that involves the subcutaneous and submucosal connective tissues. The most common cause is mast cell degranulation, which leads to histamine release and IgE-mediated hypersensitivity reactions to various stimulants, such as food, medications, rubber dams, heat, cold or stress. In our patient, the angioedema was unusual and related to the angiotensin-converting enzyme (ACE) inhibitor drug, lisinopril. One class of drugs, ACE inhibitors, can produce severe forms of angioedema that is not mediated by IgE. It usually involves the face, lips, tongue or arms. Examples of ACE inhibitors include captopril, enalapril and lisinopril.

In the majority of affected patients, the angioedema arises within hours of initial use of the drug. However, in up to 30 percent of the cases, the angioedema is delayed. The risk of angioedema associated with ACE inhibitors is significantly

DIAGNOSTICS greater in African-Americans (three to four times that of other races). The swelling associated with these drugs is thought to be due to excess bradykinin.

Because this reaction is not mediated by IgE, antihistamines, corticosteroids and epinephrine, which are used in managing allergic angioedema, they are not effective in treating ACE inhibitor-induced angioedema. Rather, it is recommended that the responsible medication be discontinued and the patient should be switched to an angiotensin receptor blocker (ARB) such as losartan or valsartan. This is because ARBs provide similar benefits as ACE inhibitors, but with a lower risk of angioedema. The patient in our case previously was on a combination of hydrochlorothiazide/ lisinopril, but the swelling resolved once his physician took him of the lisinopril and switched him to hydrochlorothiazide alone. This helpful clue is a good indication that his chief complaint was caused by the ACE inhibitor, lisinopril.

Dentists should be familiar with this less common side effect of ACE inhibitors SEE PAGE 74

EARN FREE CE CREDIT TO RENEW YOUR LICENSE!

“DIAGNOSTIC DISCUSSION”

Visit the FDC & CE page on the FDA website and click the “Online CE” button for this free, members-only benefit. You will be given the opportunity to review this column and its accompanying photos, and will be asked to answer five additional questions.

Questions? Contact FDC Meeting Coordinator, Brooke Martin at bmartin@floridadental.org or 800.877.9922. * This issue’s course expires on 10/31/2018.

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FROM PAGE 73

Drs. Bhattacharyya, Islam and Cohen can be reached at oralpath@dental.ufl.edu.

since this is a commonly prescribed anti-hypertensive medication. In rare occasions, this angioedema has caused life-threatening situations due to blockage of airway, and even death has been reported.

Diagnostic Discussion is contributed by UFCD professors, Drs. Indraneel Bhattacharyya, Nadim Islam and Don Cohen, who provide insight and feedback on common, important, new and challenging oral diseases.

Dr. Rekha Reddy is Junior resident in

1

DR. BHATTACHARYYA Oral and Maxillofacial Pathology at the

University of Florida College of Dentistry.

The dental professors operate a large, multi-state biopsy service. The column’s case studies originate from the more than 10,000 specimens the service receives every year from all over the United States.

Clinicians are invited to submit cases from their own practices. Cases may be used in DR. ISLAM the “Diagnostic Discussion,” with credit given to the submitter.

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Conflict of Interest Disclosure: None reported for Drs. Bhattacharyya, Cohen and Islam.

The Florida Dental Association is an ADA CERP Recognized Provider. ADA CERP is DR. COHEN a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.

Useful References: Baram M, Kommuri A, Sellers SA, Cohn JR. ACE inhibitor–induced angioedema. J Allergy Clin Immunol: In Practice 2013; 1:442-5.

Bezalel S, Mahlab-Guri K, Asher I, Werner B, Sthoeger ZM. Angiotensinconverting enzyme inhibitor-induced angioedema. Am J Med. 2015 Feb;128(2):120-5.

Vasekar M, Craig TJ. ACE Inhibitor–Induced Angioedema. Curr Allergy Asthma Rep. 2012 Feb;12(1):72-8.

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As an added benefit, we will continue to publish the basic text of paid, online classified ads in Today’s FDA, at no additional cost to you. All ads posted to the online classified system will be published during the contracted time frame for which you have posted your online classified advertisement.

Today’s FDA is published bimonthly; therefore, all active ads online will be extracted from the system on roughly the following dates of each year:

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OPPORTUNITIES Associate. I am seeking a full-time associate for an established, state of the art Prosthodontic Practice in Hallandale Beach. Applicant must have a great attitude and positive personality. Applicant must also be courteous and caring and possess outstanding clinical and patient skills. This is an amazing long-term opportunity for the right person. Please email cover letter and curriculum vitae to gatordmd@yahoo.com.

Established group practice seeking Full Time General Dentist-Williston FL. Christie Dental is seeking a General Dentist who shares our values of quality care and service to join our growing team. Community outreach, employee retention, and patient satisfaction are at the core of all that we do. This is a full-time position in Williston, FL with a mix of FFS/PPO/HMO patients. Christie Dental is a multispecialty group practice, founded in 1999. Since our founding, we’ve used our core values of fiscal, social, and ethical excellence to guide us. Today, our group is a PPO/Fee for Service dental group practice with 16 locations serving communities across central Florida. Christie Dental is proud to provide a competitive compensation and benefits package. Please send CV & Cover Letter to kateanderson@amdpi.com. https://www. christiedental.com/.

General Practice. Destin, FL. Highly profitable, efficient general dental practice for sale in the heart of the Emerald Coast. FFS/PPO. E-mail for particulars. hpk32541@gmail.com.

Clinical Assistant/Associate Professor of General Dentistry. The University of Florida College of Dentistry is seeking applications for a full time clinical track faculty position in the Department of Restorative Dental Sciences, Division of General Dentistry at the Assistant/Associate Professor rank. Responsibilities include serving as a student group leader in the DMD Clinical Program, participation in intramural faculty practice, excellence in academic pursuits and service, and some limited participation in the development of research and/or scholarly activities. Minimum requirements: DDS/DMD, or equivalent dental degree and commitment to working with and building teams.

Post-graduate training, DMD teaching experience, scholarly activities, and private practice experience is preferred. To apply, please go to http://jobs.ufl.edu/ and search for job number 503421. http://explore. jobs.ufl.edu/cw/en-us/job/503421/clinical-assistantassociate-professor-of-general-dentistry.

Dentist ($215K+ Average Annual Income) - Jacksonville, FL. Dr. Rick Woodward has select/upcoming opportunities for Lead Dentists and Associate Dentists to join our growing dental teams in Jacksonville, FL! (Beaches, Southside, Northside, Westside, Baymeadows, St. Johns and St. Augustine). Compensation: Unlimited Earning Potential: Our Average Florida General Dentist Earns over $215,000 annually! Benefits/Perks: Practice Leadership: Clinical Freedom and Treatment Autonomy; Patient Focus: Established and Growing Patient Foundation; Partnership Model – Investment Opportunities/Doctor Career Path; Full Benefits Offered – Healthcare Benefits, 401K, Short Term/ Long Term Disability, Time Off; Malpractice Coverage Assistance; CE Reimbursement, Paid ADA & State Society Dues; Group Practice Camaraderie; Courses: Please view our Doctor Career Path video: http:// www.screencast.com/t/M3xWM5CYN. Molly McVay | Sr. Clinical Recruiter | phone 248-430-5555 https://careersclinical-greatexpressions.icims.com/ jobs/11427/dentist-%28%24215k%2b-average-annualincome%29---jacksonville%2c-fl/job?mode=view.

General Dentist Associate. Established private practice located in beautiful Vero Beach is looking for an experienced, full time Associate to join our team. Excellent opportunity to join a very busy office that has a great reputation. We are expanding!! Professional working environment with fun, friendly, and supportive staff.

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Contact Dr. Spallone (772)532-1260. drtiffanyspallone@gmail.com.

REGISTERED DENTAL HYGIENIST. Kissimmee Dental/ Jenny Narvaez DDS. General Dentistry practice at the same location for over 20 years. We are looking for bi-lingual (Spanish-English) Dental Hygienist. Please contact us at: We are located at 2916 Vineland Road, Kissimmee Fl., 34746 (407) 390-9113. kissimmeedental@live.com.

Associate Dentist - Rockledge, FL. Outstanding FullTime opportunity for an experienced dentist to join our affiliated practice in Rockledge, FL, Rockledge Family Dentistry. Well-established and growing patient base. Excellent compensation, with full benefit package! 2+ years’ experience preferred. Email resume to bames@dentalcarealliance.com. Learn more @ www.dentalcarealliance.net. https://doctorcareersdentalcarealliance.icims.com/jobs/4041/associatedentist/job.

Lead Dentist (Pedo Emphasis) Fort Myers, FL. Join our terrific Dental Team as a lead General Dentist providing care to children ages 1-12! Dr. Amrita Wheeley, is seeking a full-time Dentist treating kids 4 days per week to work in our specialty practice! High Income Opportunity: $175,000 Salary with potential earnings of $300,000 a year; Practice Leadership - Clinical Freedom; Patient Focus - Established and Growing Patient Foundation; Partnership Model - Long Term Doctor Career Path/Investment Opportunities; Full Benefits - Healthcare & Dental Benefits, 401K, Short Term/Long Term Disability, Time Off; Malpractice Coverage Assistance; Continued Education Support: Paid ADA & State Society Dues, Study Clubs and GEDC University Courses; Group Practice Camaraderie - Technique Development Assistance. Please view our Doctor Career Path video: http://www. screencast.com/t/M3xWM5CYN. https://careersclinical-greatexpressions.icims.com/jobs/10400/ lead-dentist-%28pedo-emphasis%29-fort-myers%2c-fl/ job?mode=view.

General Dentist - Melbourne, FL. Heartland Dental supported offices are looking for outgoing and positive Dentists that are seeking career satisfaction and continuing education opportunities. There are 100 reasons to join Heartland Dental, discover yours! For more information, contact kayers@hearland.com or apply today at heartland.com. https://jobs.heartland. com/job/HEDEUS5753/General-Dentist-MelbourneFL. ORAL HEALTH DENTIST * MAKE THE RIGHT MOVE. Tara Griffin, DMD, Diplomate ABDSM, ASBA invites you to come to Panama City Beach, FL to experience the beautiful emerald beaches and tour her new dentistry with the latest in dental technology and equipment. Emerald Coast Dental Spa * Dental Sleep Medicine, a well-established, private dentistry is looking for a Florida Licensed Dentist with treatment planning & implant experience. Offering a competitive salary, health insurance, paid time off, IRA, incentive and bonus plans. Work with a highly-trained team of professionals connecting medicine and dentistry to save lives. JOIN A CATEGORY 1 DENTISTRY > First in: Oral Appliance Therapy, Botox & Juvederm Facial Cosmetics * Pharmaceutical Grade Nutritionals * Integrative & Functional Medicine. 850.624.4212.

Associate Dentist - Bartow, FL. We currently have an outstanding Full-Time Associate Opportunity for a General Dentist to join one of our highly successful affiliated practices in Bartow, FL. State of the art practice facilities. Strong commitment to long-term dental care for the whole family! Be chair side and make money from day one. Highly trained and dedicated staff to support you. No Day-to-Day headaches of Managing a Practice. Excellent compensation pkg. with performance based incentives. Well-established and growing patient base. Full Time Dentist Benefits Package. Requirements: 2+ years’ experience required; Licensed to practice dentistry in the State of

WWW.FLORIDADENTAL.ORG

FL. Email resume to bames@dentalcarealliance.com.

Learn more @ www.dentalcarealliance.net. http:// www.dentalcarealliance.net/doctor-careers/.

have a valid DEA license, and professional liability policy. Send resume to abrooker@dental-partners. com. http://www.dental-partners.com.

Lead Dentist (Full-Time) Dallas, TX. Dr. April Kaneira, Clinical Partner, is seeking a full-time Senior Dentist or Associate to lead our established, digital practice in Dallas, TX. Enjoy a rewarding career with a full office staff, a strong schedule and the ability to focus on quality patient care. High Compensation Opportunity: Potential Annual Earnings of 200K+; Practice Leadership: Clinical Freedom; Patient Focus: Established/ Growing Patient Foundation; Multi-Specialty Office/ Digital; Partnership Model – Investment Opportunities/Long Term Career Path; Full Benefits Offered – Healthcare Benefits, 401K, Short Term/Long Term Disability, Time Off; Malpractice Coverage Assistance; Continuing Education Support: Internal & External Advanced Training, Paid ADA & State Society Dues.

Group Practice Camaraderie– Technique Development Assistance, Chairside Mentoring. Please view our Doctor Career Path: http://www.screencast. com/t/M3xWM5CYN. https://careersclinical-greatexpressions.icims.com/jobs/11288/lead-dentist-%28-fulltime%29-dallas%2c-tx/job?mode=view.

General Dentist -- Port Charlotte, FL $5000 Sign on Bonus. If you’re looking to make your professional mark on a community, this is your chance. Build valuable relationships with patients and get involved with the greater community while providing top-notch dental care. Our talented and dedicated support team will work alongside you to help ensure your success.

You’ll enjoy the following: Base salary with performance incentives to earn more. Sign-on bonus of $5000. Relocation package. Full time benefits include CE allowance, professional liability, 401K and group health/wellness plans. Practice 4-5 days per week with family friendly days/hours. Prefer 3+ years of experience. Candidates must be licensed to practice in the State of Florida with no board reprimands or issues and have a valid DEA license. Send resume to abrooker@dental-partners.com or call 321-574-8003 for a confidential review of the opportunity. www. dental-partners.com.

Lead Dentist- (Full Time)-Fort Myers, FL. Come lead our terrific dental team in Fort Myers, FL! Dr. Amrita Wheeley, Fort Myers Clinical Partner, is seeking a full-time Senior Dentist or Associate to lead our established, digital practice in Fort Myers, FL located at: 9250 College Parkway, Fort Myers, FL 33919. Enjoy a rewarding career with a full office staff (including Hygienist), a strong schedule and the ability to focus on quality patient care. Compensation: High Compensation Opportunity: Potential Annual Earnings of 200K+; Benefits/Perks: Practice Leadership: Clinical Freedom and Treatment Autonomy; Patient Focus: Established and Growing Patient Foundation; MultiSpecialty Office/Digital; Partnership Model – Investment Opportunities/Long Term Doctor Career Path; Full Benefits Offered – Healthcare & Dental Benefits, 401K, Short Term/Long Term Disability, Time Off; Malpractice Coverage Assistance; Continuing Education Support: Internal & External Advanced Training, Paid ADA & State Society Dues. Group Practice Camaraderie– Technique Development Assistance, Study Clubs, Chairside Mentoring, GEDC University Courses.

Please view our Doctor Career Path video: http:// www.screencast.com/t/M3xWM5CYN. Must have a DDS/DMD from an accredited University and active State Dental Board license. Hannan Ayad| Clinical Recruiter | Great Expressions Dental Centers PSCNorth | 29777 Telegraph Road. Suite 3000| Southfield, MI 48034 USA phone 248-598-7256 |Ext. 71178| fax 248-430-5528 | web www.greatexpressions. com. https://careersclinical-greatexpressions.icims. com/jobs/11264/lead-dentist--%28full-time%29-fortmyers%2c-fl/job?mode=view.

General Dentist- Busy Private Practice Office. Private practice, non-corporate office seeking a motivated general dentist. We have a very busy office in Palatka, FL. New facility with 9 ops, 3 full time hygienists, paperless, digital X-rays, and electric handpieces. It’s an amazing place to work! You will be replacing my retiring partner who has been working a full schedule 4 days a week Tuesday-Friday. Start as an associate with buy in potential. $200K+ earnings potential. New and recent grads welcome. Email resume to drm@ sjrdental.com or call 386-325-5467.

General Dentist -- Venice, FL Part Time. If you’re looking to make your professional mark on a community, this is your chance. Build valuable relationships with patients and get involved with the greater community while providing top-notch dental care. Our talented and dedicated support team will work alongside you to help ensure your success. You’ll enjoy the following: Base salary with performance incentives to earn more. Sign-on bonus of $2500. Part time benefits include CE allowance. Practice part time, 1-2 days per week. Candidates must be licensed to practice in the State of Florida with no board reprimands or issues,

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General Dentist -- Gainesville, FL Full Time $5000 Sign on Bonus. If you’re looking to make your professional mark on a community, this is your chance. Build valuable relationships with patients and get involved with the greater community while providing top-notch dental care. Our talented and dedicated support team will work alongside you to help ensure your success.

You’ll enjoy the following: Base salary with performance incentives to earn more. Sign-on bonus of $5000. Relocation package. Full time benefits include CE allowance, professional liability, 401K and group health/wellness plans. Practice 4-5 days per week with family friendly days/hours. 3+ years of experience and licensed to practice in the State of Florida with no board reprimands or issues with a valid DEA license. Send resume to abrooker@dental-partners. com or call 321-574-8003. http://www.dental-partners.com.

Pediatric Dentist (Full-Time) - Fort Myers, FL. Enjoy a rewarding long term career with dedicated staff in this productive environment with an established patient base! Compensation: High Income Opportunity: 200k Salary with potential earnings of 300k plus a year; Benefits/Perks: Practice Leadership - Clinical Freedom and Treatment Autonomy; Patient Focus - Established and Growing Patient Foundation; MultiSpecialty Practices with Dedicated Staffs; Partnership Model - Long Term Doctor Career Path; Full Benefits - Healthcare & Dental Benefits, 401K, Short Term/ Long Term Disability, Time Off; Malpractice Coverage Assistance; Continued Education Support: Internal & External advance training, Paid ADA & State Society Dues, Study Clubs and GEDC University Courses; Group Practice Camaraderie - Technique Development Assistance. Please view our Doctor Career Path: http://www.screencast.com/t/M3xWM5CYN. https://careersclinical-greatexpressions.icims.com/ jobs/10281/pediatric-dentist-%28full---time%29---fortmyers%2c-fl/job?mode=view.

Dentist. American Care, a patient centered physician group, with 18 medical centers, over 60 healthcare providers, and over 30,000 patients, is looking to contract a Dentist to provide dental services to our members. These services will be provided at our medical centers where we have designated areas for treatment. We are open to dentists leasing space at the medical centers. Please visit www.americancare. com for more information.

General Dentist. Broward county/southeast Florida.

Need a General Dentist ASAP. PT/FT in Parkland/Pembroke Pines. Please send resume to: Pearlydentist@ hotmail.com.

Lead Dentist (Full-Time) - Seminole County, FL. Join our terrific dental team in Seminole County, FL! Dr. Rick Woodward, Clinical Partner, is seeking a full time Senior Dentist or Associate for our busy practice

in Central Florida! Enjoy a rewarding role with a dedicated and experienced staff in this productive practice with an established patient base! Compensation: * High Compensation Opportunity: Potential Earnings of 200K+; * Possible Sign on Bonus *for provider who can start immediately. Please note: The Requirements preview below had invalid markup and has been repaired. The original code can still be seen with the toggle view button. Must have a DDS/DMD from an accredited University and active State Dental Board license. Apply Here: http://www.Click2apply. net/8r4k9kyr6ynr5cwg. PI98830446.

ORLANDO - PRIVATE FFS/PPO OFFICE - General Dentist Full Time. An Excellent opportunity to join an Upscale Private Established Dental Office Near Downtown Orlando, providing excellent patient care with the latest State-of-the-Art technology including Digital Paperless records, Digital x-rays, Intraoral Camera, Cerec, Laser, Invisalign. And doing ALL aspects of dentistry including Cosmetic, Ortho, Surgery and Dental Implants. we are 100% PPO/FFS. (No HMO/ No Medicade). Our practice has grown immensely throughout a short period of time and we are looking to continue moving forward. We are a very successful dental health model designed to help our patients and the community achieve a healthy and beautiful smile by providing great dental care and excellent customer service. We offer superior quality and excellent patient care, provide attention to details and our patients love us. Great compensation, with a huge potential for the right person in addition to the on-the-job experience, mentoring and clinical support. If you have GPR-AEGD Residency it is a Plus ...This is a Full-Time position, but willing to discuss Part Time if requested.

Please Fax Resume to 407-327-1018 or E-mail it to Dr. Marouf at: Doctor@NewSmileDentistry.Net. Associate Dentist - Tampa, FL. Our office is seeking a highly motivated and experienced associate dentist to join Dr. Juan F. Prado and his professional staff. We are a family oriented and very busy dental practice located in the Carrollwood neighborhood of Tampa. The associate dentist MUST be friendly and well-rounded in treatment planning as well as possess excellent communication skills. A minimum of three years’ experience is preferred but not required.

Bilingual (English/Spanish) preferred but not required.

Other certifications preferred but not required: Cerec and Invisalign. Please send your resume to pradodds@ tampabay.rr.com or call the office at 813-968-1373.

Requirements: Current and valid Florida Dental License, DDS/DMD from an accredited dental school, CPR and DEA licenses.

Associate Dentist - Tampa, FL. Our office is seeking a highly motivated and experienced associate dentist to join Dr. Juan F. Prado and his professional staff. We are a family oriented and very busy dental practice located in the Carrollwood neighborhood of Tampa. The associate dentist MUST be friendly and well-rounded in treatment planning as well as possess excellent communication skills. A minimum of three years’ experience is preferred but not required.

Bilingual (English/Spanish) preferred but not required.

Other certifications preferred but not required: Cerec and Invisalign. Please send your resume to pradodds@ tampabay.rr.com or call the office at 813-968-1373.

Requirements: Current and valid Florida Dental License, DDS/DMD from an accredited dental school, CPR and DEA licenses.

Oral Surgeon (Million Dollar Opportunity) - Tampa, FL. Come lead our specialty team as a full time Oral & Maxillofacial Surgeon in Tampa, FL! Our Tampa Clinical team has a current, select opening for a full-time (5 days/week) Oral & Maxillofacial Surgeon in Tampa, FL. Aggressive compensation package (avg. $150k/ month in production), full/dedicated/trained staff, consistent schedule with a strong referral network of 30 local offices. High Compensation Opportunity: * Avg. Million Dollar Income; Six-Figures vs. Percent of

TODAY'S FDA

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CLASSIFIED ADVERTISING FROM PAGE 78 Production; * Attractive Sign-On or Relocation possible as well ($$$)! Apply Here: http://www.Click2apply.net/y3cqry86gn2q5bkv. PI98421976.

General Dentist-Sebastian, FL. Since 1997, Christie Dental has grown from our first location in Merritt Island, FL to 17 locations from coast to coast in Central Florida. We are a community based, multi-specialty group committed to the traditional doctor-patient relationship and providing the highest quality care and service to our patients. Our mission is to be Florida’s premier dental provider of choice through fiscal, social and ethical excellence. This is a part time position working Fridays and every other Saturday and can be a great supplement to an existing schedule and may offer future growth opportunity. Christie Dental primarily a fee-for-service and PPO provider.

Interested candidates, please contact Kate Anderson: kateanderson@amdpi.com or 781-213-3312. https:// www.christiedental.com/.

Associate Dentist (Full-Time) - Hillsborough County, FL. Dr. Rick Woodward, Clinical Partner, is seeking a full time (5 days per week) Senior Dentist or Associate for our highly productive multi-specialty dental practice located in Tampa Bay, FL (Hillsborough County). Enjoy a rewarding role with a dedicated and experienced staff in this beautiful practice with an established patient base! Compensation: High Compensation Opportunity: Potential Earnings of 200K+; Benefits/Perks: Practice Leadership: Clinical Freedom and Treatment Autonomy; Patient Focus: Established and Growing Patient Foundation; Multi Doctor/Multi Specialty practice; Partnership Model – Investment Opportunities/Doctor Career Path; Full Benefits Offered – Healthcare & Dental Benefits, 401K, Short Term/ Long Term Disability, Time Off; Malpractice Coverage Assistance; Continued Education Reimbursement, Paid ADA & State Society Dues; Group Practice Camaraderie – Technique Development assistance, Study Clubs, Chairside Mentoring, GEDC University Courses.

Please view our Doctor Career Path video: http:// www.screencast.com/t/M3xWM5CYN. Please apply via this ad for consideration, Molly McVay | Sr. Clinical Recruiter | Great Expressions Dental Centers phone 248-430-5555 |Ext. 72467| fax 248-686-0170 | web www.greatexpressions.com. Must have a DDS/DMD from an accredited University and active State Dental Board license. Apply Here: http://www.Click2apply. net/st495xry9bfvs5xk. PI98746798.

Associate wanted for 7 Operatory Spacecoast Dental Office. WELL ESTABLISHED fast paced 7 operatory Cosmetic and Sedation. Dental Office on the beautiful space coast of Florida. We are successful and busy and in need of a General Dentist who is capable of all aspects of dentistry. Molar Endo a plus. Each operatory is equipped with Patterson EagleSoft and Schick Digital X-rays. Must be focused on quality patient care.

Looking for a motivated DDS or DMD with Florida license. Please email to psjdentalcare@aol.com.

General Dentist- Full-Time FT Myers, FL. We currently have an outstanding Full-Time Associate Opportunity for a General Dentist to join one of our highly successful affiliated practices in the Fort Myers, FL area. State of the art practice facilities. Strong commitment to long-term dental care for the whole family! Be chair side and make money from day one.

Highly trained and dedicated staff to support you.

No Day-to-Day headaches of Managing a Practice.

Excellent compensation pkg. with performance based incentives. Well-established and growing patient base.

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Full Time Dentist Benefits Package. Requirements: 2+ years’ experience preferred. Licensed to practice dentistry in the State of FL. Email resume to bames@ dentalcarealliance.com.

Part-Time (2+ days) Endodontist - Fort Myers, FL. Come lead our specialty team as a part-time Endodontist in Fort Myers, FL! Great Expressions Dental Centers has a current, select opening for a part-time (2-3 days/week) Endodontist to join our Fort Myers, FL multi-specialty practice in Page Field. We offer an aggressive compensation package, dedicated staff, consistent schedule with a strong referral network of local offices. Compensation: Six Figure Annual Base vs. Competitive Percent of Production! Attractive Sign-on or Relocation possible as well. Benefits/ Perks: Leader in the practice: Clinical Freedom and Treatment Autonomy; Patient Focus: Established and Growing Patient Foundation; Multi-Specialty office; Doctor Career Path – Partnership/Investment Opportunities; Full Benefits Offered – Healthcare & Dental Benefits, 401K, Short Term/Long Term Disability, Time Off; Malpractice Coverage Assistance; Continued Education Reimbursement, Paid ADA & State Society Dues; Mentorship – Study Clubs, Chairside Mentoring, GEDC University Courses. Please view our Doctor Career Path video: http://www.screencast.com/t/M3xWM5CYN. Please apply via this ad for consideration!

Hannan Ayad| Clinical Recruiter | Great Expressions Dental Centers PSC-North | 29777 Telegraph Road.

Suite 3000| Southfield, MI 48034 USA phone 248598-7256 |Ext. 71178| fax 248-430-5528 | web www. greatexpressions.com. “Look for the Smile Above Our Name!” Must have a DDS/DMD from an accredited University and active State Dental Board license, Endodontist Dental License and certifications. Apply Here: http://www.Click2apply.net/pqt5vtwd44wwrcwh. PI98720091.

Oral Surgeon (Part-Time) Fort Myers. Join our established and highly productive dental team (2-3 days per week) as a Part-time Oral & Maxillofacial Surgeon in our attractive multispecialty practices located at: 10580 Colonial Boulevard, Unit 103 Fort Myers, Florida 33913, 25195 Chamber of Commerce Drive Bonita Springs, Florida 34135. High Compensation Opportunity: Offering 40% of production vs salary of $2,000 per day; Production range of $7,000 - $10,000 per day. Benefits/Perks: Practice Leadership: Clinical Freedom and Treatment Autonomy; Patient Focus: Established and Growing Patient Foundation; MultiSpecialty Office Setting; Partnership Model – Long Term Doctor Career Path/Investment Opportunities; Malpractice Coverage Assistance; Continued Education Reimbursement, Paid ADA & State Society Dues; Group Practice Camaraderie– Technique Development Assistance, Study Clubs, Chairside Mentoring, GEDC University Courses. Please view our Doctor Career Path video: http://www.screencast.com/t/ M3xWM5CYN. For More Information, Please Contact: Hannan Ayad| Clinical Recruiter | Great Expressions Dental Centers PSC-North | 29777 Telegraph Road.

Suite 3000| Southfield, MI 48034 USA phone 248598-7256 |Ext. 71178| fax 248-430-5528 | web www. greatexpressions.com. Must have a DDS/DMD from an accredited University and active State Dental Board license, Oral Maxillofacial Surgeon License and certifications. Apply Here: http://www.Click2apply.net/ qkvjftbn7w7rd3t9. PI98719976.

Lead Dentist (Full-Time) - Saginaw, TX. Come lead our terrific dental team in Saginaw! Dr. Rick Woodward, Texas Clinical Partner, is seeking a full-time Senior Dentist or Associate to lead our established, digital practice in Saginaw, TX located at: 1453 N Saginaw Blvd, Suite 150 Saginaw, TX 76179. Enjoy a rewarding career with a full office staff (including Hygienist), a strong schedule and the ability to focus on quality patient care. Compensation: High Compensation Opportunity: Potential Annual Earnings of 200K+; Benefits/Perks: Practice Leadership: Clinical Freedom and Treatment Autonomy; Patient Focus: Established and Growing Patient Foundation; Multi-Specialty Office/Digital; Partnership Model – Investment

SEPTEMBER/OCTOBER 2017

Opportunities/Long Term Doctor Career Path; Full Benefits Offered – Healthcare & Dental Benefits, 401K, Short Term/Long Term Disability, Time Off; Malpractice Coverage Assistance; Continuing Education Support: Internal & External Advanced Training, Paid ADA & State Society Dues. Group Practice Camaraderie– Technique Development Assistance, Study Clubs, Chairside Mentoring, GEDC University Courses. Please view our Doctor Career Path video: http://www.screencast.com/t/M3xWM5CYN. Hannan Ayad| Clinical Recruiter | Great Expressions Dental Centers PSC-North | 29777 Telegraph Road. Suite 3000| Southfield, MI 48034 USA phone 248-5987256 |Ext. 71178| fax 248-430-5528 | web www. greatexpressions.com. “Look for the Smile Above Our Name!” Must have a DDS/DMD from an accredited University and active State Dental Board license. Apply Here: http://www.Click2apply.net/tsd9qtc6zfyjpz53.

PI98420779.

Pediatric Dentist (Full - Time) Fort Myers, FL. Join our terrific Dental Team in Florida as a lead Pediatric Dentist! Dr. Raul Rangel, Clinical Partner, is seeking a full time Pediatric Dentist in our highly productive dental practices located at: 5100 S. Cleveland Avenue, Fort Myers, Florida 33907. Enjoy a rewarding long term career path with dedicated staff in this productive practice environment with an established patient base! Hannan Ayad| Clinical Recruiter | Great Expressions Dental Centers PSC-North | 29777 Telegraph Road. Suite 3000| Southfield, MI 48034 USA phone 248-598-7256 |Ext. 71178| fax 248-430-5528 | web www.greatexpressions.com. “Look for the Smile Above Our Name!” Must have a DDS/DMD from an accredited University and active State Dental Board license, Pediatric Dental License and certifications.

Apply Here: http://www.Click2apply.net/d2f5dnz8wz3862q7. PI98720011.

Part-time General Dentist in Sebastian, FL. Christie Dental currently has an opportunity for a Part-time General Dentist at our Sebastian, location. (Fridays, plus Every other Saturday. 2nd Day of Dentistry flexible). Christie Dental is a PPO/Fee for Service dental group practice with 13 locations serving communities across central Florida. We are proud to provide a competitive compensation package, including comprehensive health benefits (Health, Vision, Dental), Life Insurance, Long Term Disability, Professional Liability Insurance, a 401(k) program with employer matching, and more. For more information about this opportunity, please contact Kate Anderson at kateanderson@ amdpi.com.

Dentist. Jacksonville clinic is seeking a Dentist for the Jacksonville Florida office. The applying provider must be credentialed in Medicaid or be willing to apply.

Candidate must also meet the following criteria: be licensed in the state of Florida; Must have malpractice insurance; Must not have any convictions in lawsuits within the last two years; No suspension of license within the past five years. We are a fast paced, office with a wonderful, patient oriented staff and an inhouse lab. We operate within a Christian environment where patient satisfaction is a priority. The hours of operation are Tuesday -- Friday, 8am until completion (normally about 4pm). You choose your scheduled days! 904.683.0415.

General Dentist. Full-Time Associate Dentist needed for a well-established non-corporate practice located in a growing area of Brevard County Florida. Our office is a state of the art facility Specializing in the care patients. Our office is equipped with a surgical suite set up for sedation dentistry (IV and General), and such surgical procedures placement of Implants (including Zygomatic Implants) and full mouth Implant restorations. Our office prides ourselves in providing the best quality care for our patients. Competitive Salary based on experience will be offered send resumes to SadeshDMD@gmail.com.

WWW.FLORIDADENTAL.ORG

FOR SALE/LEASE Office space for specialist- 3 ops. Perfect opportunity for specialist looking to add satellite or start-up location in wonderful SW Florida! Three operatories available within long established busy general dentist office (nearly 30 years at location). Ideal for Endodontist or Periodontist, owner open to other options too. Call today for more information, office space is located in Punta Gorda, FL. 941.628.6827.

Dental Office-Palm Bay. For Lease: 1,000+ SF. Furnished and Equipped. Waiting Room, Private Office, Laboratory, Business Office, 4 Operatories, Bath Room. Lease 1 to 7 days.

Perfect for part time Specialists or full time Dentist. Located in Professional Center on Palm Bay Road, Palm Bay Florida, 32905. Contact Al at DDDOCTORRR@aol.com to negotiate rent. Ample parking.

Office for sale in Panama City, FL. For sale, Panama City, FL. 1933 sqft. Stand-alone building. 4 equipped ops with room for 2 more ops; Lab, etc. Plenty of parking. Superb location in professional office park on major street on best side of town. Does not include practice, already sold that when dentist recently retired. 850-271-5612.

INTRAORAL X-RAY SENSOR REPAIR. We specialize in repairing Kodak/Carestream, Dexis Platinum, Gendex GXS 700 & Schick CDR sensors. Repair & save thousands over replacement cost. We also buy & sell dental sensors. www.RepairSensor.com/919-9248559. http://www.repairsensor.com/.

New 2017 Gendex GXS-700 sensor and New Nomad Pro 2. NEW 2017 Gendex GXS 700 size 2 sensor with full kit. $5250 OBO. Includes the Vixwin software and XCP rings as well.

Also available: New 2017 gendex gxs 700 size 1 sensor and New Nomad Pro 2 $5500.

Please contact me if you have any questions. Thank you, Daryl Brito. dbrito1987@gmail. com. Call/Text me: 973-356-9810.

Schick Digital Dental Sensors for sale. I have Schick Elite and Schick CDR sensors for sale, most are used, some mint demos available. Also Remote Hubs, Schick and Sirona in CDR black hubs and Blue/white Elite and 33 Hubs. Email me for a list. Also have Schick wall holders and Remote Hub wall holders. Schick Software also available. Please request list.

Schick Elite sensors from $3496-$5416. Schick CDR sensors from $1283-$4655. CDR Black Hubs $175. HS Hubs $1000. Elite/33 Hubs $1256. Sensor wall holders generic 3 for $25 4 for $32 5 for $39 6 for $45. Blue Schick holders $54 - $61. White Hub holders also available. ifixmolars@aol.com. 321.626.8624. General Dental Practice for Sale. General Dental Practice For sale in Southwest Florida. No HMO. Digital X-Rays, Eaglesoft paperless office. Well equipped, modern equipment. Owner retiring. Send resume to vimac44@ gmail.com or call (941)204-3121.

Space for Rent/Share. New State-of-the-art Dental Office, with CBCT and Nomad. Ideal for a satellite office for a pediatric dentist (pediatrician’s office next door), endodontist, prosthodontist or general dentist with practice limited to pedo or Oral Surgery. Fast growing area in East Bradenton/Lakewood Ranch. Email attierentals@gmail.com or call Patricia (941)720-9747.

Statement of Ownership

WWW.FLORIDADENTAL.ORG

TODAY'S FDA

SEPTEMBER/OCTOBER 2017

79

Trying to Reason with Hurricane Season

OFF THE CUSP

T JOHN PAUL, DMD Dr. Paul is the editor of Today’s FDA. He can be reached at jpaul@bot.floridadental.org.

here’s a satellite photo of Charlie (the storm, not the dentist) on the wall in my dining room — the first of five hurricanes so far to center on my little house in Lakeland.

I had my then-girlfriend come to my house the day before Charlie hit because it looked like her condo in Tampa would get the worst of the storm. I was wrong — Polk County took the beating. No damage to the house, but the power went out and there were a lot of tree limbs. I got tired of sweating and hauling debris and figured the ideal way to get out of more work that afternoon was to finally get around to asking her to marry me. I was right about that decision — it’s the best decision I have ever made. My immediate workload lightened as I watched her wear out three cell phone batteries while staring at the new shiny thing that kind of fit her finger. The years since have been very, very good to me. Having a family gives you purpose and incentive to succeed.

It’s hard to explain to folks who live outside of the hurricane belt why we don’t evacuate to North Dakota every time the TV fills with spaghetti models. The best explanation I heard was from a sheriff on the west coast, “You run from water, you hide from wind.”

Judging by the gasoline shortage, everyone on the Florida coast did leave. Those of us in the middle of the state boarded up, took in our flamingoes, took in our friends from the coast and waited until it was safe outside.

The Florida Dental Association took a proactive stance as soon as it appeared the state was in danger, and did a great job providing the guides to prepare for the storm (in plenty of time to use them) and getting assistance after the storm. Irma was hardly past when the Texas, New York, Oklahoma, Tennessee and Louisiana dental associations committed financial support to our recovery efforts.

We never asked, it’s just what dentists do for each other.

You can’t be a responsible news reporter and experience a hurricane without writing about it. It’s the way to fame and fortune. Who would know Jim Cantore were it not for his constant presence during foul weather? I don’t know what it is about a hurricane that makes folks crave canned tuna and baked beans, but you still can’t buy either of those items at my Publix. You also can’t buy a 30-amp plug, the big, round twisty one you use to connect a generator to your house, and why don’t those come in the box with the generator, anyway?

I expect there will be some empty chairs in our offices this fall. Recovery will involve more than cleaning up debris and patching up our offices. We will improvise and overcome like we always do. I hope each one of you is fine, and if you’re not fine, please let somebody know. There’s help available and you are not alone.

JOHN PAUL, DMD EDITOR, TODAY'S FDA

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TODAY'S FDA

SEPTEMBER/OCTOBER 2017

WWW.FLORIDADENTAL.ORG

Rewarding the practice of good dentistry...

10937A_Tribute-10th_InfoG-WHITE_PartialOutline_Dental_082917m2.pdf

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1

8/29/17

2:56 PM

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