2018 - Jan/Feb TFDA

LICENSE = LIVELIHOOD! FEB. 28, 2018 IS THE DEADLINE!

VOL. 30, NO. 1 • JANUARY/FEBRUARY 2018

3

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

REASONS YOU NEED AN EMPLOYEE MANUAL

6 TIPS FOR SETTING UP PAYROLL Benefits to Keep Your Employees EMPLOYEE LEASING: PROS & CONS

EDR RISKS

DR. ANDREW CLARK: A PRACTICE TRANSITION

10 ARTICLES THAT TAKE RISK OUT OF RUNNING YOUR PRACTICE

SPECIAL INSERT! X-RAY FACTS FOR YOUR PATIENTS

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HELPING MEMBERS SUCCEED VOL. 30, NO. 1 • JANUARY/FEBRUARY 2018

cover story

PAGE 74

highlights

DR. ANDREW CLARK

A PUBLICATION OF THE FLORIDA DENTAL ASSOCIATION

BENEFITS THAT KEEP YOUR EMPLOYEES

BENEFITS TO KEEP YOUR EMPLOYEES

Surveys show the level of worker appreciation increases with the number of employee benefits, including their intent to stay. However, the kind of benefit valued can vary with your employees’ age and stage of life.

HEALTH SAVINGS ACCOUNTS:* Less likely to use health care services, this group more likely values a high-deductible health plan coupled with a health savings account (HSA) that allows them to save and grow pre-tax or tax-deductible funds.

PET INSURANCE: Thirty-five percent of millennials own a pet, making them the largest pet-owning population in the U.S. Many companies have started offering this benefit.

RETIREMENT PLANS: The rate of contributions to company sponsored retirement savings by this group has almost doubled since 2012.

TRAINING AND MENTORING: Mentoring programs and employee training will help you find and motivate younger staff.

STARTING FAMILIES VALUES STABILITY

TRADITIONAL HEALTH BENEFITS: Medical,* dental* and vision* coverage are important to this age group.

FLEXIBLE WORK ARRANGEMENTS: This can include flexible hours, compressed work weeks and working remotely, which are valued by all age groups. But, this group oftenhas to care for young children or elderly parents, or both. Stress reduction and job satisfaction also have been correlated with a flexible schedule.

RETIREMENT PLANS: Workers in their 50s will stay at or gravitate toward firms with a defined-benefit pension plan and take a hard look at a company’s 401(k) matching contribution.

READY FOR THE NEXT STAGE

TRANSTION TO TALLAHASSEE

FDC2018 SPEAKER HIGHLIGHTS

PAGE 41

30s

20s

60s

STARTING A CAREER

LIFE INSURANCE:* Because they now have families, this group needs to protect assets, such as a home.

DOMESTIC PARTNER AND EXTENDED FAMILY COVERAGE:* Offering benefits to others beyond spouse and children is becoming more common.

SHORT-TERM DISABILITY BENEFITS:* This covers an employee who has to be out of work and runs out of sick days for events such as: accidents, surgery, illness with a long recovery time and pregnancy leave.

GENEROUS PARENTAL LEAVE: Most dental offices have fewer than the 50 employees that trigger The Family and Medical Leave Act. Employees will value a personnel policy that offers unpaid, job-protected leave.

40s 50s

FINANCIAL PRIME TIME

PHASED RETIREMENT: As highly skilled and experienced baby boomers retire in larger numbers, employers will face significant knowledge-transfer issues. You can keep valuable institutional knowledge from walking out the door and make your employees happy by implementing phased-in retirement plans. This can allow an employee to start accessing 401(k) plans and pensions while also working part time.

LONG TERM CARE INSURANCE:* This policy covers costs for home care, assisted living and nursing homes.

In a recent survey performed by Monster, participants were asked to rank benefits by value and importance when considering a prospective job. The results of the survey ranked average importance by benefit: • HEALTH CARE PLAN: 32% • VACATION TIME: 25% • PAY RAISE: 15%

• EMPLOYEE BENEFIT: 10% • PERFORMANCE BONUS: 9% • RETIREMENT PLAN: 8%

* Call FDA Services at 800.877.7597 for a quote on these important employee benefits.

No Phishing Allowed PAGE 60 NSAIDS Are Good, Decadron is Better PAGE 62 Opioid Use Disorder in the Dental Office PAGE 68

RISKS IN ELECTRONIC DENTAL RECORDS PAGE 54 Human Trafficking —

Dr. Glori Enzor A Modern Term for an Age-old Abuse

Page 34

PAGE 44

features Risky Business Features:

Human Trafficking 34 Florida Supreme Court Has Favorable Implications 38 6 Tips for Setting Up Payroll 40 Benefits To Keep Your Employees 41 Three Reasons You Need an Employee Manual 42 Employee Leasing: Pros & Cons 43 Sound Familiar? 6 Real-life Claims from FDA Services 48 My Day at the Zenith 52 Risks in Electronic Dental Records 54 What Does the Tax Cuts and Jobs Acts Mean for You? 57 Dental Therapists: A False Comparison 19 The Root of Quality Dental Care

is Education and Training 20 The Root of Improving Oral Health in Florida ... 21 BOD Meets in Orlando 23 Pathways to Licensure in Florida 30 Exhibitor Marketplace 72 Insurance: Part 2 76

in every issue Staff Roster 3 President's Message 5 Legal Notes 8 Did You Know? 14 Information Bytes 17

Reasons to Call in The Dental Office Lease Negotitation Pros

Legislative Corner 18 news@fda 24 Diagnostic Discussion 79 Classified Listings 82 Off the Cusp 84

TODAY'S FDA ONLINE: floridadental.org

T I E K MA L A C LO

GATHER FOR FUN & CONTINUING EDUCATION IN YOUR DISTRICT.

2018 NWDDA ANNUAL MEETING FRIDAY & SATURDAY, FEB. 2-3, 2018 THE GRAND SANDESTIN www.nwdda.org • 850.391.9310 nwdda@nwdda.org

2018 WCDDA ANNUAL MEETING FRIDAY, FEB. 2, 2018 • CAMLS, TAMPA Speakers: Dr. Stanley Malamed, Emergency Medicine; Larry Guzzardo, Now What Do I Say?; Larry Guzzardo, Unravel the Mystery of Treatment Acceptance: A Dental Team’s Guide www.wcdental.org • 813.654.2500 kelsey@wcdental.org

2018 ACDDA WINTER CONFERENCE FRIDAY, FEB. 23, 2018 EMBASSY SUITES, WEST PALM BEACH Speaker: Dr. Todd Morgan, Teach You Easy, Cost-effective Approach To Implement Sleep Into Your Practice; Pristine Medical Billing, Maximize Your Billing and Coding. www.acdda.org • 561.968.7714 acdda@aol.com

2018 CFDDA ANNUAL MEETING FRIDAY & SATURDAY, MAY 4-5, 2018 HILTON DAYTONA BEACH RESORT Speakers: Dr. Howard Chasolen, The Seamless Integration of Aesthetics, Form, and Function: The Restorative/Periodontal Interface; Dr. Gerard Kugel, Adhesive Dentistry & Bioactive Materials, The Dos and Don’ts of Porcelain Laminate Veneers www.cfdda .org • 407.898.3481 centraldistrictdental@yahoo.com For a complete listing: www.floridadental.org/calendar

2

TODAY'S FDA

JANUARY/FEBRUARY 2018

FLORIDA DENTAL ASSOCIATION JANUARY/FEBRUARY 2018 VOL. 30, NO. 1

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, 545 John Knox Road, Ste. 200, Tallahassee, Fla. 32303 .

FDA membership dues include a $10 subscription to Today’s FDA. Non-member subscriptions are $150 per year; foreign, $188.

Periodical postage paid at Tallahassee, Fla. and additional entry offices. Copyright 2018 Florida Dental Association.

All rights reserved. Today’s FDA is a refereed publication.

POSTMASTER: Please send form 3579 for returns and changes of address to Today’s FDA, 545 John Knox Road, Ste. 202, Tallahassee, Fla. 32303.

EDITORIAL AND ADVERTISING POLICIES Editorial and advertising copy are carefully reviewed, but publication in this journal does not necessarily imply that the Florida Dental Association endorses any products or services that are advertised, unless the advertisement specifically says so. Similarly, views and conclusions expressed in editorials, commentaries and/or news columns or articles that are published in the journal are those of the authors and not necessarily those of the editors, staff, officials, Board of Trustees or members of the Florida Dental Association.

EDITORIAL CONTACT INFORMATION All Today’s FDA editorial correspondence should be sent to Dr. John Paul, Today’s FDA Editor, Florida Dental Association, 545 John Knox Road, Ste 200, Tallahassee, Fla. 32303.

FDA office numbers: 800.877.9922, 850. 681.3629; fax 850.681.0116; email address, fda@floridadental.org; website address, www.floridadental.org.

ADVERTISING INFORMATION For display advertising information, contact: Jill Runyan at jrunyan@floridadental.org or 800.877.9922, Ext. 7113.

For career center advertising information, contact: Jessica Lauria at jlauria@floridadental.org or 800.977.9922, Ext. 7115.

Today’s FDA is a member publication of the American Association of Dental Editors and the Florida Magazine Association.

WWW.FLORIDADENTAL.ORG

CONTACT THE FDA OFFICE 800.877.9922 OR 850.681.3629 545 John Knox Road, Ste. 200 • Tallahassee, FL 32303

EXECUTIVE OFFICE DREW EASON, Executive Director deason@floridadental.org 850.350.7109 GREG GRUBER, Chief Operating Officer/ Chief Financial Officer ggruber@floridadental.org 850.350.7111 GRAHAM NICOL, Chief Legal Officer gnicol@floridadental.org 850.350.7118

AUSTIN MOSER, Coordinator of Foundation Affairs amoser@floridadental.org 850.350.7161

FLORIDA DENTAL CONVENTION (FDC) CRISSY TALLMAN, Director of Conventions and Continuing Education ctallman@floridadental.org 850.350.7105

CASEY STOUTAMIRE, Director of Third Party Payer and Professional Affairs cstoutamire@floridadental.org 850.350.7202

ELIZABETH BASSETT, FDC Exhibits Planner ebassett@floridadental.org 850.350.7108

JUDY STONE, Leadership Affairs Manager jstone@floridadental.org 850.350.7123

KENLEE BRUGGEMANN, FDC Meeting Assistant kbruggemann@floridadental.org 850.350.7162

ALEX LUISI, Leadership Concierge aluisi@floridadental.org 850.350.7114

BROOKE MARTIN, FDC Marketing Coordinator bmartin@floridadental.org 850.350.7103

ACCOUNTING

JENNIFER TEDDER, FDC Program Coordinator jtedder@floridadental.org 850.350.7106

JACK MOORE, Director of Accounting jmoore@floridadental.org 850.350.7137 LEONA BOUTWELL, Finance Services Coordinator Accounts Receivable & Foundation lboutwell@floridadental.org 850.350.7138 DEANNE FOY, Finance Services Coordinator Dues, PAC & Special Projects dfoy@floridadental.org 850.350.7165

GOVERNMENTAL AFFAIRS JOE ANNE HART, Chief Legislative Officer jahart@floridadental.org 850.350.7205 ALEXANDRA ABBOUD, Governmental Affairs Liaison aabboud@floridadental.org 850.350.7204

JAMIE IDOL, Commissions Coordinator jamie.idol@fdaservices.com 850.350.7142

COURTNEY THOMAS, Governmental Affairs Legislative Assistant cthomas@floridadental.org 850.350.7203

ALLEN JOHNSON, Accounting Manager allen.johnson@fdaservices.com 850.350.7140

INFORMATION SYSTEMS

FDA SERVICES 800.877.7597 or 850.681.2996 545 John Knox Road, Ste. 201 Tallahassee, FL 32303 Group & Individual Health • Medicare Supplement • Life Insurance Disability Income • Long-term Care • Annuities • Professional Liability Office Package • Workers’ Compensation • Auto • Boat

SCOTT RUTHSTROM, Chief Operating Officer scott.ruthstrom@fdaservices.com 850.350.7146 CAROL GASKINS, Assistant Manager – Sales & Service carol.gaskins@fdaservices.com 850.350.7159 DEBBIE LANE, Assistant Manager – Service & Technology debbie.lane@fdaservices.com 850.350.7157 ALEX KLINE, FDAS Marketing Coordinator arey@fdaservices.com 850.350.7166 ANGELA ROBINSON, Insurance Clerk angela.robinson@fdaservices.com 850.350.7156 MARCIA DUTTON, Administrative Assistant marcia.dutton@fdaservices.com 850.350.7145 PORSCHIE BIGGINS, North Florida Membership Services Representative pbiggins@fdaservices.com 850-350-7149 MARIA BROOKS, SFDDA Membership Services Representative maria.brooks@fdaservices.com 850.350.7144

MITZI RYE, Fiscal Services Coordinator mrye@floridadental.org 850.350.7139

LARRY DARNELL, Director of Information Systems ldarnell@floridadental.org 850.350.7102

STEPHANIE TAYLOR, Membership Dues Coordinator staylor@floridadental.org 850.350.7119

RACHEL BURCH, Computer Support Technician rburch@floridadental.org 850.350.7153

COMMUNICATIONS AND MARKETING

MEMBER RELATIONS

MELISSA STAGGERS, WCDDA Membership Services Representative melissa.staggers@fdaservices.com 850.350.7154

KERRY GÓMEZ-RÍOS, Director of Member Relations krios@floridadental.org 850.350.7121

TESSA DANIELS, Membership Services Representative tessa.daniels@fdaservices.com 850.350.7158

MARIAH LONG, Member Access Coordinator mlong@floridadental.org 850.350.7100

LIZ RICH, Membership Services Representative liz.rich@fdaservices.com 850.350.7171

JILL RUNYAN, Director of Communications jrunyan@floridadental.org 850.350.7113 LYNNE KNIGHT, Marketing Coordinator lknight@floridadental.org 850.350.7112 JESSICA LAURIA, Communications and Media Coordinator jlauria@floridadental.org 850.350.7115

FLORIDA DENTAL ASSOCIATION FOUNDATION (FDAF) R. JAI GILLUM, Director of Foundation Affairs rjaigillum@floridadental.org 850.350.7117

WWW.FLORIDADENTAL.ORG

ASHLEY MERRILL, Member Relations Coordinator amerrill@floridadental.org 850.350.7110 CHRISTINE TROTTO, Membership Concierge ctrotto@floridadental.org 850.350.7136

EBONI NELSON, CFDDA Membership Services Representative eboni.nelson@fdaservices.com 850.350.7151

CARRIE MILLAR Director of Insurance Operations carrie.millar@fdaservices.com 850.350.7155

YOUR RISK EXPERTS DAN ZOTTOLI Director of Sales — Atlantic Coast 561.791.7744 Cell: 561.601.5363 dan.zottoli@fdaservices.com DENNIS HEAD Director of Sales — Central Florida 877.843.0921 (toll free) Cell: 407.927.5472 dennis.head@fdaservices.com MIKE TROUT Director of Sales — North Florida 904.249.6985 Cell: 904.254.8927 mike.trout@fdaservices.com JOSEPH PERRETTI Director of Sales — South Florida 305.665.0455 Cell: 305.721.9196 joe.perretti@fdaservices.com RICK D’ANGELO Director of Sales — West Coast 813.475.6948 Cell: 813.267.2572 rick.dangelo@fdaservices.com

To contact an FDA Board member, use the first letter of their first name, then their last name, followed by @bot.floridadental.org.

For example, Dr. John Paul: jpaul@bot.floridadental.org.

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

TODAY'S FDA JANUARY/FEBRUARY 2018

3

NEW FDA MEMBER BENEFIT! FDA Career Center

careers.floridadental.org

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Mentorship WHAT IS THE FDA MENTORSHIP PROGRAM? The Florida Dental Association (FDA) Mentorship Program was developed by the FDA Council on the New Dentist as a resource to help dental students gain a practical and professional perspective of dentistry from established member dentists in an effort to facilitate the transition from dental student to practicing dentist.

WHO PARTICIPATES? The mentors are member dentists from the FDA who volunteer their time and experience to provide professional guidance to dental students. All member dentists are encouraged to participate as mentors. A select number of dental students (depending on the number of mentors available) from each of the three Florida dental schools: LECOM, Nova and UFCD will be able to participate as protégés.

HOW CAN I BECOME MENTOR? Volunteering is easy! Complete and submit a profile by visiting careers.floridadental.org/ementor.

For additional information, please contact Kerry Gómez-Ríos at membership@floridadental.org.

THE FDA'S NUMBERS TELL THEIR OWN STORY As we look back on the challenges of 2017, we should be proud of our successes during a volatile year! Among the highlights of the Florida Dental Association’s (FDA) accomplishments in 2017 is winning the Association of the Year Award from the Florida Society of Association Executives (FSAE). This prestigious award is bestowed upon the best association from all industries in Florida — not just the dental industry! Additionally, FDA Director of Conventions and Continuing Education Crissy Tallman was elected to the FSAE Board of Directors. Congratulations to our FDA staff, you have made us proud!

In March, the FDA Foundation held its signature event, the Florida Mission of Mercy (FLAMOM), in Pensacola and 1,556 volunteers treated 1,767 patients and provided 12,058 procedures worth $1.69 million to the public.

Thank you to the Northwest District Dental Association for hosting and executing a successful FLA-MOM! Please consider participating in the Foundation’s next FLA-MOM event, held March 9-10, 2018 in Fort Myers.

In June, the FDA sold its long-time headquarters and bought a new building that has been renovated with the latest open workflow design and technology to create improved staff synergies to serve our association well into the future. Director of Information Systems Larry Darnell, who earned his MBA this year, and Computer Support Technician Rachel Burch redesigned and improved the FDA website with many enhancements to make it simple for everyone to use. It’s now much easier to navigate and access all the information we have available for you. We moved into our new headquarters the first week of December and we can already see an increase in morale and productivity. A special thank you to ExWWW.FLORIDADENTAL.ORG

LEADERSHIP

ecutive Director Drew Eason and Chief Operating Officer/Chief Financial Officer Greg Gruber for planning, navigating and negotiating the various aspects and contracts to make this three-year project a reality. Please visit the FDA headquarters to see our new home — I know you will be proud.

We had a successful 2017 Legislative Session.

Our priority issues were passed and signed by the governor. They included $200,000 to continue fluoridation efforts in 2017-2018 and $100,000 to support the Donated Dental Services (DDS) program. To learn more about what the FDA is doing for you, the profession and the public, please read “Florida’s Action for Dental Health Two-year Progress Report” in the July/August issue of Today’s FDA online or the hard copy of the report that was mailed to you in September. It’s packed with great information about what the FDA is doing to serve the public and the profession.

PRESIDENT’S MESSAGE MIKE EGGNATZ, DDS

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

While we achieved a lot in 2017, we have significant challenges to overcome in 2018. Most important among them is our advocacy during the 2018 Legislative Session, which began on Jan. 9. It’s your opportunity and responsibility to educate your local legislators on the issues that affect you, dentistry and the public we treat. Dentist’s Day on the Hill (DDOH) is the best and most direct way for you to speak to your legislators in Tallahassee during session. It’s the FDA’s largest single event to advocate on behalf of dentistry and the public.

We highlight the Foundation’s most successful programs, including the FLA-MOM, Project: Dentists Care clinics all over the state and our DDS efforts on behalf of those in need. This year, DDOH takes place in Tallahassee on Feb. 6, with a legislative briefing the evening SEE PAGE 7 TODAY'S FDA JANUARY/FEBRUARY 2018

5

Renew now at floridasdentistry.gov/renewals

DENTAL LICENSE RENEWAL DEADLINE

NEW! MANDATORY SURVEY Complete the surveys!  Telehealth Survey — Mandatory: No License will be issued without it!  Dental Workforce Survey — Voluntary: Provides valuable information

about the state’s dental workforce.

QUESTIONS? CONTACT THE FDA AT 800.877.9922 OR FDA@FLORIDADENTAL.ORG.

WE MOVED! NEW OFFICE NOW OPEN NEW ADDRESS

SAME PHONE NUMBERS

NEW ADDRESS FDA Services 545 John Knox Road, Ste. 201 Tallahassee, FL 32303 800.877.7597

NEW ADDRESS Florida Dental Association Headquarters & FDA Foundation 545 John Knox Road, Ste. 200 Tallahassee, FL 32303

SAME ADDRESS Florida Dental Association Governmental Affairs 118 E. Jefferson St. Tallahassee, FL 32303 800.326.0051

800.877.9922

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TODAY'S FDA

JANUARY/FEBRUARY 2018

WWW.FLORIDADENTAL.ORG

FROM PAGE 5

before. Please make your reservations to attend. We need to educate our legislators on all the great work our profession provides for the public with the care, skill and judgement only our education can offer.

To help improve oral health and increase access to dental care in underserved areas of Florida, the FDA has filed House Bill 369 and Senate Bill 764 to create the dental student loan repayment program. This legislation would encourage dentists to work in rural and underserved areas as full-time Medicaid providers. They would be eligible to receive no less than $50,000 a year in financial assistance, up to five years maximum, to treat our most vulnerable citizens, who all deserve the highest quality of care from a fully trained and qualified doctor and to establish a true dental home.

The addition of community dental health coordinators (CDHC), developed by the American Dental Association (ADA), who act as case managers to help patients in their local community navigate the health care system, would leverage the effectiveness of this program. It would allow patients to receive the dentistry they already qualify for. This current workforce is already in place and could be activated within six months if passed by the Legislature and signed into law by the governor.

This is the type of comprehensive solution to the long-standing complex societal access problem that requires multifaceted answers and political leadership and courage, from both sides of the aisle, to prioritize our resources in the most efficient manner. This will bring together public and private resources and partnerships for adequate funding with the efficiency and safeguards of a private business model.

This would solve the maldistribution of dentists in our state caused by the heavy debt burden students incur to become educated doctors who will treat our most medically compromised patients with the most complex dental diseases. Patients will receive the care they need by qualified practitioners who will use the judgement only their scientific education can provide. These doctors also will provide an economic engine in those communities on an ongoing basis — as local small business employers — who pay local taxes to improve the communities they serve.

WWW.FLORIDADENTAL.ORG

LEADERSHIP The FDA will continue to support the legislation referenced above in 2018, which includes $200,000 to assist local communities to start, maintain or update their systems to supply fluoride in their water to prevent caries and the need for further treatment at higher costs. The FDA also will continue to support legislation for $100,000 funding to support the DDS program, which has provided more than 1,700 patients in need with more than $7 million worth of care since 1997.

All parties agree: Prevention and education are better and less expensive than waiting to treat disease. And all parties also agree that we cannot drill our way out of dental disease! We did not try to solve smoking by creating another practitioner or procedure. It was a comprehensive and proactive approach of ongoing education and prevention, which dentistry already knows how to do. This is what the CDHC is fully trained to excel in — assisting the patients to navigate and access the existing health care system. The workforce in Florida has the untapped capacity to solve this pressing issue.

Finally, I encourage you to learn more about the controversial national issue of dental therapists by reading an article in the ADA News issue from Oct. 16, 2017 entitled, “Access: Only One Part of the Solution.” The author, who is a retiring dental director of a large Medicaid clinic in the Pacific Northwest, has treated children for the last 30 years, and has been on the front lines of the access issue. He writes, “The time has come to reach out beyond the walls of the dental clinic to deliver preventive care and utilize case management, which has brought greater success to our medical colleagues when treating chronic diseases ... Dental caries is probably the only chronic disease where case management has not been used to combat it ... The dental profession has been beaten up over the years on the access issue. It’s time we turned the argument around to enable states to concentrate on solutions that give us better tools to fight our chronic diseases instead of continuing to repeat those that offer dubious access.”

I look forward to supporting solutions together in 2018 that help our profession and the FDA to continue to be the oral health care experts in Florida.

TODAY'S FDA JANUARY/FEBRUARY 2018

7

HOW WELL DO YOU KNOW THE BOARD OF DENTISTRY DISCIPLINARY PROCESS? PART 8

LEGAL NOTES

This is the conclusion of the series.

Proposed Recommended Orders After the hearing, section 120.57(1)(b), Fla. Stats., gives both parties the right to submit a proposed recommended order. Obviously, each is diametrically opposed to the other and the administrative law judge (ALJ) chooses bits and pieces from both.

GRAHAM NICOL, ESQ., HEALTH CARE RISK MANAGER, BOARD CERTIFIED SPECIALIST (HEALTH LAW)

Graham Nicol is the FDA chief legal officer.

TIP: The proposed order must be separated into findings of fact and legal argument. If argument is mixed in with the proposed findings of fact, it can be stricken from the record.

TIP: A final hearing means that there are material issues of fact, so expect the same testimony to be interpreted differently. Proposed findings of fact must be supported by a citation to the record. A persuasive proposed order will deal with opposing evidence as well and convince the ALJ, the finder of fact, who is more believable between the opposing testimony.

A poorly written proposed order will merely reiterate evidence you introduced and not attack the other sides.

The Recommended Order and Exceptions 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.

FDA Members Only!

Expires 4/1/19

8

TODAY'S FDA

The ALJ will submit to all parties a Recommended Order consisting of findings of fact, conclusions of law, and a recommended disposition or penalty, if applicable. The end of each Recommended Order from the Division of Administrative Hearings (DOAH) has a paragraph entitled “Notice of Right to Submit Exceptions.” The paragraph states that “[a]ll parties have the right to submit written exceptions within 15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.”

If you won the DOAH hearing, and the ALJ’s Recommended Order is to your liking, then there is no need to file exceptions.

JANUARY/FEBRUARY 2018

TIP: Always exercise your right to file an exception to an unfavorable finding of fact.

Also, recognize that the opposing party may file objections and you have the right to respond to their exceptions.

In the majority of cases, the DOAH acts as a finder of fact and issues a Recommended Order that an agency often adopts as its Final Order. “Exceptions” are how you argue to the Department of Health (DOH)/Board of Dentistry (BOD) (and on appeal) that the facts determined by the ALJ are incorrect. Exceptions are not seen in civil or criminal litigation. They are unique to administrative law.

Exceptions are essential if you intend to appeal a Final Order that adopted an unfavorable Recommended Order. In administrative law, exceptions are the only means by which a party preserves arguments for appellate review, and the failure to do so can waive the issue on appeal. The leading case, Rosenzweig v.

Department of Transportation, 979 So. 2d 1050, (Fla. 1st DCA, 2008) states: “It is well established that a claim of error, even in the administrative law context, cannot be raised for the first time on appeal.” See also, Worster, DDS v. Department of Health, 767 So. 2d 1239, (Fla. 1st DCA, 2000), in “an appeal from an administrative proceeding, a party cannot argue on appeal matters that were not properly objected to or challenged before the agency.”

WWW.FLORIDADENTAL.ORG

Even pro se parties must file exceptions in administrative litigation. In Stueber v. Gallagher, 812 So. 2d 454, (Fla. 5th DCA, 2002), the court rejected the argument made by a non-lawyer representing himself before an administrative agency that he was not aware of the legal requirements relating to the preservation of error and therefore, should not have been required to file exceptions.

The court ruled “in Florida, pro se litigants are bound by the same rules that apply to counsel.”

TIP: Your lawyer should file exceptions if proposed findings of fact are unsupported based on “competent substantial evidence” in the record or if the proceedings on which the findings were based did not comply with “essential requirements of law.”

DeGroot v. Sheffield, 95 So. 2d 912, (Fla., 1957), defines competent substantial evidence as being “sufficiently relevant and material that a reasonable mind would accept it as adequate to support the conclusion reached” and that “will establish a substantial basis of fact from which the fact at issue can be reasonably inferred.” Under Degroot, ALJs have broad discretion when it comes to findings of fact in the Recommended Order.

TIP: You will not necessarily win the DOAH case simply because the quality and quantity of evidence supporting your position outweighs the evidence relied on by the ALJ for an unfavorable finding of fact. See, for example, Heifetz v. Department of Business Regulation, Division of Alcoholic Beverages & Tobacco, 475 So. 2d 1277 (Fla. 1st DCA, 1985):

It is the (ALJ’s) function to consider all the evidence presented, resolve conflicts, judge credibility of witnesses, draw permissible inferences from the evidence and reach ultimate findings of fact based on competent, substantial evidence. If, as is often the case, the evidence presented supports two inconsistent findings, it is the (ALJ’s) role to decide the

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issue one way or the other. The (DOH/ BOD) may not reject the (ALJ’s) finding unless there is no competent, substantial evidence from which the finding could reasonably be inferred. The DOH/BOD is not authorized to weigh the evidence presented, judge credibility of witnesses, or otherwise interpret the evidence to fit its desired ultimate conclusion.

substantial evidence or that the proceedings did not meet essential requirements of law.

TIP: The ALJ has no medical background, so he or she must rely on expert witnesses. There will always be an expert witness that opposes your expert witness, or else you wouldn’t be going to trial in the first place. Standard of care cases always pivot on “the battle of the experts.”

TIP: Although nothing in the statutes or rules requires a transcript of the final hearing in order to file exceptions, as a practical matter, you must have a transcript. If you don’t have the transcript of the trial, how can you show that the ALJ made an error?

TIP: The ALJ determines the credibility of witnesses and knows, just as well as the lawyers who hired the experts, which ones are prodefendant and which are pro-plaintiff. Goldsmith v. Agency for Health Care Administration, 957 So. 2d 18, (Fla. 1st DCA, 2007), makes it clear that the “determination of a witness’s qualifications to express an expert opinion is within the discretion of the ALJ and will not be reversed absent a showing of clear error.”

TIP: You can have the world-renowned leading doctor who has literally written a book on the procedure testify that you did everything right and be opposed by an expert who didn’t graduate from an accredited school and just passed the board exam yesterday. This is not an example of the lack of “competent substantial evidence.” Realistically, the only example of lack of competent substantial evidence is where opposing counsel introduced no expert at all.

TIP: Exceptions get filed with the clerk of the DOH/BOD not the DOAH. If you file exceptions with the DOAH, there is no guarantee they will make it over to the BOD and you could waive them on appeal. The Final Order issued by the DOH/BOD must include a specific ruling on each exception. The written exceptions are how you argue to the DOH/BOD that there were errors committed by the ALJ, meaning the Final Order should be modified.

In its Final Order, the DOH/BOD may not reject or modify the findings of fact unless it first determines from a review of the entire record, and states with particularity in the order, that the findings of fact were not based upon competent

TIP: An agency need not rule on an exception that does not clearly identify the disputed portion of the Recommended Order by page number or paragraph, that does not identify the legal basis for the exception, or that does not include appropriate and specific citations to the record.

DOH/BOD Final Order In administrative law, unlike civil litigation, the ALJ does not issue the Final Order. Rather, the ALJ files the Recommended Order with the DOH/BOD and the DOH/BOD issues the Final Order.

The BOD has authority to adopt, reject or modify the Recommended Order.

In issuing its Final Order, the DOH takes over from the ALJ and rules on conclusions of law independent of what the ALJ recommendations were. The conclusion of law, sometimes referred to as the “ultimate finding of fact,” is “guilty or not guilty” — i.e., whether you violated the BOD rules or not.

Under section 456.073(5), Fla. Stats., health care regulatory boards in Florida (not the ALJ or the DOAH) decide whether or not a licensee has violated the laws and rules regulating the profession, including a determination of the reasonable standard of care. This is a conclusion of law to be determined by the board and is not a finding of fact to be determined by the ALJ.

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LEGAL NOTES FROM PAGE 9

If rejecting or modifying a conclusion of law made by the ALJ in the Recommended Order, the DOH/BOD must state with particularity its reasons in the Final Order and must further make a finding that its substituted conclusion of law is as, or more, reasonable than that which was rejected or modified.

The DOH/BOD may accept the recommended penalty in a Recommended Order, but may not reduce or increase it without a review of the complete record and without stating with particularity its reasoning in the Final Order, by citing to the record in justifying the action.

Under subsection 456.079(5), Fla. Stats., the ALJ must consider the range of designated penalties and must further “state in writing the mitigating and aggravating circumstances upon which the recommended penalty is based.”

TIP: By knowing where you fall on the sentencing guidelines and which aggravating and mitigating factors are being considered, your lawyer should have an easier job predicting what the BOD’s Final Order will be and whether you should prepare to appeal.

The BOD Hearing As the respondent, you could simply wait until exceptions and responses are sorted and you get the Final Order from the BOD. TIP: Never take this “wait and see” approach when your license is at stake. Realize that the prosecuting attorney will appear in person at the BOD hearing where the Final Order is determined. So, you better have your lawyer attend the BOD hearing as well.

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Many times, the BOD will “rubberstamp” the ALJ’s Recommended Order, but not always. It is not uncommon to see the BOD reject even a stipulated settlement that both parties agreed to so as to dismiss the DOAH case. The BOD has the right, for example, to impose greater penalties, and they often do.

Doctors who have a lawyer appearing before the BOD typically have better success than those who do not.

TIP: Even if the Recommended Order from the DOAH is completely in your favor, make sure your lawyer attends the BOD hearing where the Final Order will be discussed. For example, the DOH/BOD may have filed exceptions and even though your attorney has responded, there is no guarantee that the Final Order will follow the Recommended Order lockstep. Exceptions as well as aggravating circumstances may be completely without merit; however, the BOD may agree with the prosecuting attorney if your attorney is not present to advocate on your behalf.

TIP: If your lawyer anticipates appealing the Final Order, make sure they bring their own court reporter. Agency meetings are obviously “on the record,” but even the best court reporter starts to glaze over after the 18th disciplinary case. Make sure you get an accurate transcript of your hearing for the appeal. See, Esaw v. Esaw, 965 So. 2d 1261 (Fla. 2nd DCA, 2007): “The most salient impediment to meaningful review of a trial court’s decision is not the absence of findings, but the absence of a transcript.”

STEP 16: Appealing an Adverse Final Order If the BOD Final Order completely exonerates you, celebrate and start settlement negotiations on any companion civil or criminal litigation. On the other hand, if the BOD Final Order doesn’t go your way, this last and final step tells you what to do to keep practicing.

Procedure (FRAP), not DOAH rules. Second, section 120.68, Fla. Stats., controls the appeal process compared to section 120.569, Fla. Stats., which controlled the informal hearing, and section 120.57, Fla. Stats, which controlled the formal hearing. Third, an appeal is filed with a district court of appeal (DCA), not the DOAH or circuit court. Fourth, you are no longer referred to as the Respondent but will be called the Appellant, and the DOH/BOD will no longer be called the Petitioner but will be called the Appellee.

TIP: If you thought the DOAH trial was expensive and drawn out, then you are in for an even bigger shock when you appeal to a DCA. An appeal is literally the “end of the road” and the last thing you can do to protect your license.

Motion for Rehearing and/or Reconsideration Some lawyers will automatically file a motion with the agency for rehearing or reconsideration trying to get a “second bite of the apple.” That’s routine in civil litigation, but there are unique risks to taking this step in administrative litigation.

TIP: The BOD doesn’t meet every month, so your motion for rehearing will not always be heard before your time for filing a notice of appeal runs out. Missing the deadline to file a notice of appeal is substantive and means that the case is over, you’ve waived your right to appeal and you’re done. Like civil litigation, a notice of appeal in an administrative law case must be filed within 30 days from the day the final order at issue was rendered.

TIP: Further, unlike civil litigation, in administrative law a motion for rehearing does not stay the effect of the Final Order.

TIP: In civil litigation, the original notice of appeal and one copy have to be filed with the lower court. In administrative litigation, the appellant must file the original notice of appeal with the agency clerk and a copy with the appropriate DCA.

TIP: After the Final Order is entered, the rules of the game change again. First, appeals are conducted under the Florida Rules of Appellate

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Motion to Stay Regardless of whether you file a motion for reconsideration or a notice of appeal, you also will want to file a motion for stay to delay paying the fine, to remain in practice as long as possible or to delay the companion civil lawsuit from moving forward.

TIP: Civil litigators unfamiliar with administrative law may think that filing a notice of appeal results in an automatic stay of the Final Order. It does in civil litigation, but it does not in administrative litigation. FRAP rules state, in general, that the “filing of a notice of administrative appeal or a petition seeking review of administrative action shall not operate as a stay.” So, plan on filing the motion for stay simultaneous with the notice of appeal and/or the motion for rehearing.

TIP: The motion for stay is filed with the DCA you have chosen for the appeal. It is not filed with the agency or the DOAH. FRAP rules state: “When an agency has suspended or revoked a license other than on an emergency basis, a licensee may file with the court a motion for stay on an expedited basis.”

TIP: You have an excellent chance of winning the motion for stay. FRAP rules state: “Unless the agency files a timely response demonstrating that a stay would constitute a probable danger to the health, safety or welfare of the state, the court shall grant the motion and issue a stay.” To like effect is subsection 120.68(3), Fla. Stats:

The filing of the petition does not itself stay enforcement of the agency decision, but if the agency decision has the effect of suspending or revoking a license, (a stay) shall be granted as a matter of right upon such conditions as are reasonable, unless the court, upon petition of the agency, determines that a (stay) would constitute a probable danger to the health, safety or welfare of the state. The agency also may grant a stay upon appropriate terms, but, whether or not the action has the effect of suspending or revoking a license, a petition to the agency for a stay is not a prerequisite WWW.FLORIDADENTAL.ORG

to a petition to the court for a (stay).

In any event the court shall specify the conditions, if any, upon which the stay … is granted.

Will You Win the Appeal?

Subsection 120.68(7), Fla. Stats., lists the grounds upon which a DCA must “remand a case to the agency for further proceedings consistent with the court’s decision or set aside agency action, as appropriate.” There are five different ways to win your appeal: 1. If there has been no hearing prior to agency action and the DCA finds that the validity of the action depends upon disputed facts.

TIP: This is a hard argument to win because you’re basically saying that you should have elected a formal hearing under section 120.57, Fla. Stats., but for some reason, you did not.

2. The Final Order depends on a finding of fact that is not supported by competent, substantial evidence in the record of the informal or formal hearing.

TIP: This is a hard argument to win. Earlier in this series we walked through the steps of competent substantial evidence and concluded that the ALJ generally has very broad discretion in deciding which expert medical witness to believe regarding standard of care, informed consent or scope of practice. Section 120.58, Fla. Stats., states the DCA “shall not substitute its judgment for that of the agency as to the weight of the evidence on any disputed finding of fact.”

(Emphasis added.)

3. The DCA will reverse the Final Order if “the fairness of the proceedings or the correctness of the action may have been impaired by a material error in procedure or a failure to follow prescribed procedure.”

TIP: This is a much easier argument to win than the two previously listed. But remember that a good lawyer will have already argued these points through written exceptions (unique to administrative law) so anticipate the agency

to argue that you have procedurally waived your right to make this argument on appeal because you did not raise it earlier, as discussed previously in this series. In other words, the DCA may not even hear the substantive argument unless you have a good reason why it wasn’t brought up before.

4. The DCA will reverse a Final Order when “the agency has erroneously interpreted a provision of law and a correct interpretation compels a particular action.”

TIP: This is the easiest argument to win if the ALJ or the DOH/BOD hasn’t followed the proper procedural rules for the particular formal or informal hearing. Again, you should have already moved to dismiss the case on this basis long before you get to an appeal, but this is where it makes sense to have a lawyer familiar with administrative litigation review the record and the hearings. As said in the beginning of this series, there are many excellent civil litigators who don’t know administrative law and vice versa.

5. The DCA will reverse a Final Order when it determines the agency has abused its “exercise of discretion.”

TIP: This is the most common argument made on appeal and the one most likely to succeed.

You will prove “abuse of discretion” if you can prove one of four things:

1. The agency acted outside the range of discretion delegated to the agency by law. In other words, if the agency relied on an unwritten policy that should have been promulgated as a formal rule, then you have an excellent chance of winning at the DCA level.

2. The agency acted inconsistent with agency rule. For example, if the agency violated its own sentencing guidelines or should have issued a citation instead of a formal Administrative Complaint, then you have an excellent chance of winning at the DCA level.

3. The agency’s Final Order was inconsistent with officially stated agency SEE PAGE 12

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TIP: An administrative agency like the DOH/ BOD or an ALJ under the DOAH lack subject matter jurisdiction to rule on constitutional questions. If you have a constitutional argument (e.g., the process was served improperly, was overbroad, etc.) then you stand an excellent chance of winning a DCA appeal.

LEGAL NOTES FROM PAGE 11

policy or a prior agency practice, if deviation therefrom is not explained by the agency. For example, if you have researched the subject matter index for the agency and found a similar fact pattern where the prior licensee was given a six-month suspension but you have been given a revocation of licensure, you have an excellent chance of winning.

Similarly, review the agency’s prior rulings on exceptions and waivers of their own administrative rules. If you can find a case similar to yours where the BOD granted the licensee a waiver of the same rule under which you got prosecuted, you have an excellent chance of winning on appeal.

4. The agency acted in violation of a constitutional or statutory provision.

Previous articles in this series have talked about your rights under the Federal and Florida Constitutions in connection with subpoenas and warrants; as well as your rights under the “statute of limitations” for disciplinary proceedings, emergency suspension orders and the equitable doctrine of “laches.” We’ve also discussed how peer review records are protected from both discovery and introduction as evidence in either a civil or a disciplinary proceeding.

TIP: In general, we’ve seen how the burden is on you and your lawyer to file exceptions and challenge evidence before you get to the DCA level. However, constitutionality of an agency’s actions is one of the few issues that can be argued on appeal even if it was not raised in the prior proceedings.

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TIP: Winning at an informal or formal hearing is all about the findings of fact and whether competent substantial evidence and the relevant burden of proof has been met. You will not be allowed to reargue findings of fact at the DCA level unless you can prove that the DOH/ BOD or the DOAH “grossly abused their discretion.” Winning at the appellate level is not about rearguing the facts or trying to introduce new evidence; rather, it is about identifying a meaningful error of law. Just like civil litigators may not be adept at administrative law; an attorney who specializes in appeals may have insight that trial counsel did not.

Three Strikes and You’re Out (Not!) Throughout the steps in this series, we’ve seen how the Florida Dental Association (FDA) Peer Review program helps you succeed. One of the ways mentioned was that peer review settlements do not count as a strike against your license under the “three strikes and you’re out” law. This law came about because of a legislative fight between the trial lawyers and the physicians. It is a perfect example of why you want the FDA lobbying and advocating for you.

Section 456.50, Fla. Stats., and Article X, Section 26 of the Florida Constitution says that “three or more incidents of medical malpractice (in or out of the State of Florida) … occurring on or after Nov. 2, 2004 … (requires that) the board shall not license or continue to license a medical doctor.”

This law applies only if “the malpractice has been found in a final judgment of a court of law, final administrative agency decision, or decision of binding arbitration,” so the FDA modified its

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peer review procedures to ensure that peer review settlements do not count as strikes against your license. Even better, the FDA helped to limit “three strikes and you’re out” to only osteopathic and allopathic physicians. Even though chapter 766, Fla. Stats., on medical malpractice litigation applies to dentists as well as physicians, I’m proud that the three strikes law exempts dentists. Let that sink in.

Conclusion If you have made it this far, you probably know as much about administrative law as some practicing lawyers.

The point of this series was not to teach you how to be a lawyer. We’ve already decided that practicing law is not a do-it-yourself project any more than practicing dentistry.

Rather, this series was to educate you on what is going on at every step in the process so you can make informed decisions in circumstances that are completely unfamiliar to most doctors.

Hopefully, you have seen that no other health care association protects its members like the FDA does and plan to use Peer Review. But if you can’t avoid licensure discipline, my desire is that you know what is going on every step of the way and how to fight for your license and help your attorney win!

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.

Find the entire series at: www.floridadental. org/discipline.

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benefit

NUMBER

11

YOUR FDA STAFF IS “HELPING MEMBERS SUCCEED” EVERY DAY!

PROFESSIONAL STAFF I help members succeed by coordinating meetings with members of the Florida Legislature, which assists our team in advancing our legislative agenda. The FDA works diligently to build and foster relationships with elected officials to support issues that are important to you and the dental profession in Florida.

— Courtney Thomas, Legislative Assistant

Have a question about Capitol Visits?

800.326.0051 • 850.350.7203 • cthomas@floridadental.org www.floridadental.org

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

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

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DIDYOU

ANESTHESIA

?

INFORMATION ABOUT THE FLORIDA BOARD OF DENTISTRY

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

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

The Florida Board of Dentistry’s rules on anesthesia were recently updated to change the terminology from “conscious sedation” or “pediatric conscious sedation” to “moderate sedation” or “pediatric moderate sedation.”

This update was to made to ensure that the terminology more adequately describes the type of anesthesia being performed. If you currently hold a “conscious sedation” or “pediatric conscious sedation” permit, you will be receiving an updated permit to indicate this change to “moderate sedation” or “pediatric moderate sedation.” No substantive changes were made to the definition or scope of the level of permit. To view the complete anesthesia rules with the requirements for all of the varying permit types, please go to http://bit.ly/2i7IME5.

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 352.787.4748.

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X-RAYS The X-ray fact sheet also is available as an Acrobat file on the FDA website.

To download the file go to: floridadental.org/x-ray.

PROVIDED BY

YOUR COLLEAGUES ARE “HELPING MEMBERS SUCCEED” EVERY DAY! YOU are NUMBER

1

DEDICATED VOLUNTEERS HELP YOU SUCCEED A successful dental practice is one of the most fulfilling things you can do. If you’re also working to raise kids and manage your young family, balancing the two can be a great challenge. However, it is important to remember to contribute to organized dentistry in order for the aforementioned things to be possible.

As president-elect of the South Florida District Dental Association, my top priorities are constantly finding new members and helping them succeed. During my term as North Dade-Miami Beach Dental Society president, I made sure we provided new hot topics and streamlined our social media presence in order to attract new young grassroots members. I have been a member of the House of Delegates since 2015 to stay up to date on the current issues we face, as well as contribute to their resolution. I also currently serve on the FDA’s Leadership Development Committee to help find and form our future leaders. Previously, I served in the New Dentist Committee with the same objective.

Many FDA benefits and services help me streamline my business so I can spend more time with my family and be successful in both. Help us spread the word and recruit new members to keep growing our affiliates, districts and every level of organized dentistry.

— Enrique Muller, DMD, MSD enrique@mullerdmd.com

ENRIQUE MULLER, DMD, MSD MIAMI

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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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MOVING YOUR TECHNOLOGY: PLANNING, PATIENCE & LATE NIGHTS

TECHNOLOGY

The Florida Dental Association (FDA) moved its headquarters to a new building in December. The FDA IT Department transferred and upgraded the FDA’s technology — a new phone system, a network of new printers accessible to every staff member, a new security system and new network servers. It took a lot of work and planning!

TIPS FOR A SMOOTH MOVE 1. Plan well in advance (six to nine months if possible). You will need a list of all vendors, phone companies, cable providers, etc. There are more than you think.

2. Evaluate existing technology. If you are using outdated technology, now is the time to replace it. We updated our phone system, which was nine years old.

3. Assess your technology needs at the new location. Those needs may be different and require changes. We now have a fiber connection for the internet, with higher speeds for the same cost. We also eliminated every desktop printer and now use three workgroup printers for the whole company. That will be an enormous saving in the future.

4. Have your vendors identified in No. 1 do walk-throughs at the new office site. They will see things you have not thought of yet. We did several walk-throughs to make sure we didn’t miss anything.

5. Get professional moving assistance for your technology. We used a company that specializes in moving servers, computers and technology. Clem and his pickup truck is not a good idea.

6. Protect your patient data. It is your most valuable asset.

We have a redundant backup system. When moving, accidents can happen. Computers can be damaged.

Use precaution and backup that valuable asset often.

It’s going to be an all-nighter, can I get some more Diet Coke?

7. Be flexible and plan for things to not work. We had contingencies in place and it took a concerted effort to close on Thursday, move everything and be up and running on Monday.

Part of the new FDA network (in progress)

Have you met the guy who invented the cordless phone?

Neither have we…

Going the extra mile to make sure we can help members succeed by phone, email and the web. Technology can be intimidating — we recommend patience and cable ties!

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INFORMATION BYTES LARRY DARNELL, MBA, CAE

MR. DARNELL IS THE FDA DIRECTOR OF INFORMATION SYSTEMS AND CAN BE REACHED AT LDARNELL@ FLORIDADENTAL.ORG.

Larry Darnell makes a point during one of many tech calls.

It took a lot of phone calls to guarantee we never miss a member’s phone call! Standard for technology projects — allow twice the time you think it will take to accomplish the task!

Does this wire look blue or green?

Larry said to use the blue one.

Rachel Burch, FDA Computer Support Technician

Staying connected to our members one wire at a time!

A technology move can involve outside vendors.

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LEGISLATIVE CORNER

LEGISLATIVE CORNER JOE ANNE HART

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

#FDA #ORGANIZEDDENTISTRY #QUALITYDENTALCARE — WHAT’S YOUR HASHTAG? As we celebrate the beginning of a new year, we also embrace the opportunity for new experiences. Many of us create New Year’s resolutions or life goals to help guide us down the road for what we hope is a productive year. We look at new products that could potentially bring more efficiencies in the dental office and improve the overall experience for patients. We venture to new cities, states and countries to create lifelong memories and new hashtag moments: #YouOnlyLiveOnce, #GreatAdventures, #FoodForDays!

The 2018 Legislative Session startedin January and it will be a busy year for organized dentistry. Not only will we fight off legislative efforts to create a new licensed dental provider in Florida, but also advocate for good public policy that promotes incentivizing dentists to work in rural and underserved areas and in return, receive assistance in repaying their dental student loans.

I caution you: you will hear and read things on social media from individuals who will question the ethics of organized dentistry, saying that the Florida Dental Association (FDA) doesn’t want to help people in certain areas of the state access dental care. This is far from the truth! #FLAMOM, #PDCClinics, #DonatedDentalServices, #GiveKidsASmile, #ProBono, #DentistsCare — just to name a few! And by the way, everyone who receives care through these programs and initiatives receives quality dental care from dentists who are trained in comprehensive dentistry.

Earlier this year, I heard someone say — and I’m paraphrasing — that, “Dentists are the most overtrained health care professionals for the most basic dental needs.” I was shocked to hear this person say this considering their background in dentistry. I expect for a dentist to be trained and experienced to identify certain conditions that could potentially impact my overall health. Dentists are doctors who have the responsibility of helping their patients attain optimal health, not just tend to basic needs. #ILoveMyOvertrainedDentist!

As the FDA works to pursue legislative policies that maintain the high standard of dental care in Florida, let your voice be heard and post your hashtag for quality dental care for all Floridians!

“The Root of ” campaign is a legislative initiative to inform stakeholders, including legislators, of the importance of all Floridians receiving quality dental care from dentists who are trained in providing comprehensive care.

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DENTAL THERAPISTS: FALSE

A

Comparison to Other Health Practice Models

WHILE SUPPORTERS OF DENTAL THERAPIST PROPOSALS MAY COMPARE THIS PROPOSED PROVIDER MODEL TO NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS, THAT IS A FALSE COMPARISON. Nurse practitioners and physician assistants have higher requirements for education, training and licensure.

ADVANCED REGISTERED NURSE PRACTITIONER (ARNP) •

•

Four-year undergraduate degree, Bachelor of Science in Nursing (BSN) and successful completion of registered nurse licensing exam

•

Three-year master’s degree (MSN) or Doctor of Nursing Practice (DNP) degree from accredited program

•

Successful completion of nursing practitioner licensing requirements

1-2 years or more of registered nursing practice

•

SERVICES INCLUDE: performing physical assessments, diagnosing illnesses, ordering and analyzing diagnostic tests and procedures, prescribe medications, managing patient treatment, and providing education and counseling.

•

SERVICES INCLUDE: ordering diagnostic tests, performing physical exams, creating treatment plans, counseling for preventive care, assisting in surgery, and prescribing medications.

PHYSICIAN ASSISTANT (PA) •

Four-year undergraduate degree

•

•

Many PA programs also require prior health care experience with hands-on patient care

Three-year master’s degree from accredited PA program

•

Successful completion of the Physician Assistant National Certifying Exam

While dental therapists have a lower requirement for education, training and licensure, they have a larger scope of responsibilities and services, including performing irreversible surgical procedures with limited to no supervision.

DENTAL THERAPIST •

Three-year dental therapy program

THE ROOT OF QUALITY DENTAL CARE IS EDUCATION AND TRAINING

•

SERVICES INCLUDE: Filling cavities, placing temporary crowns, and performing irreversible surgical procedures, including drilling and extracting teeth, with limited to no supervision.

The FDA believes every Floridian deserves the highest level of care to ensure the integrity of their oral health and overall health. We urge opposition to any proposal for a new licensed dental provider that would lower the standard of dental care for Floridians by allowing irreversible surgical procedures to be performed by anyone who is not a dentist.

For additional information, please contact Joe Anne Hart at jahart@floridadental.org or 850-224-1089.

Every Floridian deserves the highest level of care to ensure the integrity of their oral health and overall health.

THE ROOT OF QUALITY DENTAL CARE is Education and Training Floridians deserve to receive the best quality of care from a licensed dentist with the full body of knowledge and experience to provide the highest level of diagnosis and treatment.

FLORIDA DENTISTS COMPLETE 8+ YEARS OF EXTENSIVE EDUCATION AND TRAINING: •

Four-year bachelor degree

•

Four years at a U.S. accredited dental school

•

1-6 years additional training for specialty or state requirements

•

Completion of three national and state-level licensing examinations

The Mouth Affects the Body, The Body Affects the Mouth Dentists’ areas of care include not only patients’ teeth and gums, but also the muscles of the head, neck and jaw, the tongue, salivary glands, the nervous system of the head and neck and other areas.

Your Mouth, Body and Health are Unique to You There is no simple or one-size-fits-all procedure. X-rays give a good picture of what is happening below the surface, but often the extent of a dental condition can only be determined by a dentist during a dental procedure.

DENTISTS ARE TRAINED TO KNOW: •

The chemistry of anesthesia and medications and how they interact with your mouth and body.

•

All the facets of your mouth, including teeth, jaw, bones, tendons, gums, nerves and functionality, how they impact procedures, and vice versa.

•

How medical conditions, such as heart disease, kidney disease, gum disease, lung disease and cancer, and treatment medications affect your mouth and teeth, and vice versa.

•

How to identify undiagnosed conditions such as oral cancer, kidney disease or human papillomavirus (HPV).

•

How to manage potentially life-threatening medical emergencies that may occur during or following a procedure.

DENTISTS ARE TRAINED TO KNOW: •

How to diagnose and treat the underlying cause of the dental condition, such as infection or root damage.

•

Which teeth are integral to the structure of the mouth and how to ensure that structure is supported — particularly for children with developing teeth and mouths.

•

The full spectrum of treatment options and potential ramifications, such as nerve damage, loss of bite function, infection, tooth loss and how these options provide the best treatment course for the best patient outcome.

•

How to effectively communicate to patients the recommended course of action to empower them to be their own best oral health advocate.

THE ROOT OF Improving Oral Health in Florida is Maximizing Current Dental Workforce to Promote Education, Prevention and Relief

In 2015, the Florida Dental Association (FDA) launched Florida’s Action for Dental Health, a comprehensive initiative to improve the oral health and overall health of all Floridians.

A core objective of this initiative is to maximize the use of Florida’s dental workforce to provide Floridians with oral health education, preventive care and relief from dental pain. The FDA supports two key efforts to achieve this objective, particularly in our rural and underserved communities.

Support HB 369 and SB 764 to establish and adequately fund a dental student loan repayment program to encourage dentists to practice as Medicaid providers in rural or underserved areas.

Dental Student Loan Repayment Program

The challenge isn’t that there aren’t enough dentists.

It is critical that Florida’s most vulnerable communities have access to a qualified dentist to provide preventive care, offer relief from dental disease and pain, diagnose oral cancers, treat the underlying causes and educate patients on a recommended course of action to support ongoing oral health.

Develop Community Dental Health Coordinator (CDHC) education programs at dental, dental assisting and dental hygiene schools in Florida and further incorporate CDHCs into the dental team.

Community Dental Health Coordinators

The CDHC program trains qualified dental professionals to provide oral health education, preventive services and assistance in navigating the health care system to help individuals in pain access relief and establish a dental home. CDHCs lead outreach in their own communities as patient navigators to help bridge cultural and language barriers to oral health, such as poverty, language and a lack of understanding of oral hygiene.

For additional information, please contact Joe Anne Hart at jahart@floridadental.org or 850-224-1089.

3RENEW WAYS TO

1 2 3

ONLINE CREDIT CARD PAYMENT

Lee Civic Center Fort Myers, FL

Visit floridadental.org/dues to pay your dues in full or set up a dues installment plan with a credit card.

CREDIT CARD PAYMENT VIA PHONE OR MAIL Call the member relations team at 800.877.9922 to make a credit card payment in full over the phone or use the self-addressed yellow envelope to submit your payment in full, or enroll in the dues installment plan by submitting your dues statement with your credit card information.

Don’t forget your signature!

CHECK BY MAIL Use the self-addressed yellow envelope for a onetime payment in full by check. Make your check payable to the Florida Dental Association.

HAVE QUESTIONS ABOUT YOUR DUES STATEMENT? Go to www.floridadental.org/dues for answers to frequently asked questions!

NEED MORE HELP? Our FDA Member Relations Department is always ready to help with any questions.

Call 800.877.9922 or email membership@floridadental.org.

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2018 FLORIDA MISSION OF MERCY March 9-10, 2018

TODAY'S FDA

JANUARY/FEBRUARY 2018

YOU CAN MAKE A DIFFERENCE! � � � �

dentists, hygienists, dental assistants lab techicians physicians, nurses, pharmacists, EMTs general community volunteers

REGISTER TO VOLUNTEER AT WWW.FLAMOM.ORG QUESTIONS: 800.877.9922 OR FLAMOM@FLORIDADENTAL.ORG

WWW.FLORIDADENTAL.ORG

BOD MEETS IN ORLANDO The Florida Board of Dentistry (BOD) met on Friday, Nov. 17 in Orlando. The FDA was represented by FDA BOD Liaison Dr. Don Ilkka and Director of Third Party Payer and Professional Affairs Casey Stoutamire. Other FDA members in attendance included: Drs. Jim Antoon, Chris Berdy, Tom Biasteros, Andy Brown, Mike Eggnatz (FDA president), Oscar Morejon and Jolene Paramore (FDA president-elect).

BOARD OF DENTISTRY

All of the BOD members were present, which included: Ms. Cathy Cabanzon, chair; Drs. Joe Calderone, Naved Fatmi, Nick Kavouklis, Bill Kochenour, Claudio Miro, Robert Perdomo and T.J. Tejera; Ms. Angie Sissine, hygiene member; and, consumer member, Mr. Fabio Andrade. This was the first meeting for Dr. Kavouklis and Mr. Andrade, and the FDA looks forward to working with them. There is one dentist position and one consumer position open on the board that the governor has not yet filled.

The BOD heard a presentation on periodontal laser therapy by Dr. Sam Low. The presentation was timely since the board was considering a proposal later in the day to allow for the use of lasers by hygienists in periodontal therapy. Dr. Guy Shampaine also gave a presentation on the use of live patients in the dental licensing exam.

The board considered three rule proposals from the Council on Dental Hygiene. First, the BOD unanimously approved the council’s recommendation to add a dental hygienist to the probable cause panel when there is an investigation report of a dental hygienist or dental radiographer, but only if there is a hygienist (current of former board member) who is willing to serve. The hygienist will only be on the panel for the case involving the dental hygienist or dental radiographer. Second, the BOD unanimously approved the Hygiene Council’s recommendation to add the use of adjunctive oral cancer screening medical devices approved by the U.S. Food and Drug Administration to the list of remediable tasks delegable to a dental hygienist. Third, the BOD discussed a proposal allowing hygienists to use lasers in periodontal therapy. This item was sent back to the Hygiene Council for further deliberation and revision. The FDA was opposed to the proposed language because it was vague, broad and did not specify a supervision level or limit the type of laser that could be used.

A group of dentists from South Florida and their attorney discussed their proposal for a dental sedation center. Basically, they would like to have an ambulatory surgical center without going through the formal process with the Agency for Health Care Administration. The BOD did not look favorably upon this proposal and stated they could “fix” the issue under the current BOD anesthesia rules by having the other dentists in their practice get their pediatric conscious sedation permits.

There were eight disciplinary cases, one recommended order and one voluntary relinquishment that dealt with failure to meet the standard of care, anesthesia, substance abuse and failing to keep proper dental records. If you have not yet attended a BOD meeting, it’s suggested that you take the opportunity to attend and see the work of the BOD. It’s much better to be a spectator than a participant in BOD disciplinary cases.

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.

NEXT BOD MEETING The next BOD meeting is scheduled for Friday, Feb. 16, 2018 at 7:30 a.m. EST in Gainesville.

The FDA would like to congratulate Dr. Tejera on his election as chair and Dr. Fatmi on his election as vice chair of the BOD for 2018. The FDA looks forward to working with them in the upcoming year.

WWW.FLORIDADENTAL.ORG

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

Are You Renewal Ready?

Check out Beyond the Bite for the Florida Dental Association’s (FDA) blog, “Are You Renewal Ready?” at http://bit. ly/2CVvXF9 for helpful information on renewing your license by the biennium deadline of Feb. 28. Need additional continuing education (CE) hours to renew your license? Go to http://bit. ly/2mjDLao to take advantage of the FDA’s online CE!

A Friendly Dues Reminder!

To renew your membership for 2018, please visit www.floridadental.org/ dues using your ADA/FDA number as your username and your established password. To establish or to reset your password, please go to http://bit. ly/2DgzImB. **BONUS** Renew today to receive a 10 percent discount on your next order from FDASupplies.com!

Join us in Fort Myers for the 2018 FLA-MOM! The Florida Mission of Mercy (FLAMOM) will be held in Fort Myers on March 9-10, 2018. Please join us and bring your whole team! To register or make a donation to support the event, go to: flamom.org.

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FDAS Alert: Florida Approves 9.8 Percent Workers’ Comp.

Rate Decrease Florida Insurance Commissioner David Altmaier issued a final order approving a statewide 9.8 percent workers’ compensation rate decrease in November 2017, a greater decrease than the National Council on Compensation Insurance filed earlier that year. This rate decrease took effect on Jan. 1, 2018.

What you need to know: n The dental rate will go down to 43 cents for $100 in payroll and the expense constant will decrease from $200 to $160. n The rate decrease will become effective on Jan. 1, 2018 for new and renewal business. n No action is need by policyholders.

Go to http://bit.ly/2A37IBg to learn more about the rate decrease.

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.

JANUARY/FEBRUARY 2018

Medicare Just Got a Little Easier: Three Things to Know After significant advocacy efforts from the American Dental Association (ADA), the Centers for Medicare and Medicaid Services (CMS) has announced a proposed rule to rescind certain Medicare Part D and C requirements for providers. CMS recently published this information in a proposed rule, which is set to be finalized in 2018.

Here are three things you need to know about the proposed Medicare changes: n Dentists no longer need to enroll in or opt out of Medicare to continue to provide dental care and prescriptions for Part C (also known as Medicare Advantage plans) and Part D drug plan beneficiaries. (Read more in ADA News at http://bit.ly/2DfRnuA.) n Dentists no longer need to be enrolled in Medicare to provide supplemental services to patients enrolled in Medicare Advantage plans. n The ADA believes these changes remove duplicative paperwork and are good for both patients and dentists.

The ADA’s advocacy team has been working on these issues for more than three years, and we look forward to CMS finalizing this proposed rule in 2018. However, the agency has not rescinded the two-year opt-out period for providers. Dentists who have already

WWW.FLORIDADENTAL.ORG

opted out cannot accept payments for services covered by Medicare Part B or Medicare Advantage plans. Learn more in this ADA News article at http://bit. ly/2CX4oLJ.) If you have any questions, please contact Director of Third Party Payer and Professional Affairs Casey Stoutamire at cstoutamire@floridadental.org or 850.681.3629.

Books on the Shelf Take advantage of this FDA memberonly benefit! Review the latest scientific and clinical information for us and keep the book at no charge! If you are interested in reviewing a book, go to floridadental.org/member-center/publications/books-on-the-shelf to see what’s on our shelf.

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 Arwa Alwehaib, Boca Raton Kerry Aston, Port Saint Lucie Diego Azar, Coral Springs Ezra Brown, Fort Lauderdale Nilesh Dalal, Coral Springs Jacqueline Fonseca, Fort Lauderdale Ross Hauer, Parkland Charles Lalane, Boynton Beach Alexander Margolis, Boca Raton Jairo Mestre, Lake Worth Shiva Salehi, West Palm Beach Daniel Shimansky, Boca Raton Michael Wiernicki, Boca Raton Tahira Williams, Margate

WWW.FLORIDADENTAL.ORG

Central Florida District Dental Association

In Memoriam

Carlos Alvarez, Winter Garden Matthew Brinker, Gainesville Danene Charlton, Lauderhill Elizabeth Clay, Gainesville Chanelle Commedore, Oxford David Gemmell, Gainesville Toni-Anne Gordon, Orlando Sukhvinder Guram, Gainesville Melissa King, Rockledge Erica Queiroz, Winter Springs Daniel Sanovich, Gainesville Steven Smith, Deltona Lara Thalji, Leesburg Huy Tran, Orlando Farzana Uddin, Winter Garden Robert Wrable, Deland

The FDA honors the memory and passing of the following members:

Northeast District Dental Association

Frederick E. Busch Houston, TX Died: 10/1/17 Age: 94

Daniel Plank Clermont, FL Died: 12/8/17 Age: 38

Charles T. Phillips Belleair, FL Died: 10/11/17 Age: 94

Stephen Young Winter Haven, FL Died: 12/9/17 Age: 79

Mark Webman South Miami, FL Died: 10/25/17 Age: 69

Donald Sherwin Bradenton, FL Died: 12/11/17 Age: 77

Liliem Socarras Diaz, Miami Antony Thomas, Miami Aladino Valiente, Miami Sarah Vargas, Sunny Isles Beach Gerard Wasselle, Lauderdale by the Sea

Devin Burns, Jacksonville Alexandra Erbesti, Jacksonville Noah Fixelle, Jacksonville Joana Halilaj, Jacksonville Robert Lombardo, Gainesville Nathan Nakano, Jacksonville Luke Navarro, Jacksonville

West Coast District Dental Association

Northwest District Dental Association Zachary Flink, Panama City Beach Caylin Slavin, Eglin AFB

South Florida District Dental Association Dana Al Hashimi, Pembroke Pines Juan Buitrago, Miami Paul Byun, Weston Laura Cabrera, Miami Laura Calvo, Miami Richard Coba, Miami Amanda Colonneaux, Miramar Raul Davila, Miami Camila Di Giorgio, Miami Jessica Du, Weston Laura Herschdorfer, N. Miami Beach

Sean Bates, Osprey John Constantine, Palm Harbor Yamila Garber, Riverview Elizabeth Ho, Palm Harbor Brooke Howard, Fort Myers Christopher Karapasha, Tampa Kristen Krotec, Sarasota Larisa Kushnir, Tampa Reinaldo Lasanta-Garcia, Naples Sara Lee, St. Petersburg Andrew Levine, Weston Alexa Moccia, Madeira Beach Alexander Null, Bradenton Matthew Rasmussen, Tampa Ryan Rubino, Bradenton Amy Sakowitz, Longwood Christina Suarez-Watkins, Sarasota Kathlyn Tran, St. Petersburg

TODAY'S FDA JANUARY/FEBRUARY 2018

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2018 AWARDS LUNCHEON Join in the recognition of your colleagues.

FRIDAY • JUNE 22, 2018 11:30 AM-1 PM FLORIDA DENTAL CONVENTION Gaylord Palms Resort & Convention Center Orlando, Florida

2018 AWARD RECIPIENTS PRESIDENT’S AWARD Dr. Michael Eggnatz

NEW DENTAL LEADER AWARD Dr. Jordan Harper

FDA DENTIST OF THE YEAR Dr. Irene Marron-Tarrazzi

DENTAL TEAM MEMBER AWARD Ms. Elizabeth Martinez

J. LEON SCHWARTZ LIFETIME SERVICE AWARD Dr. Jim Antoon

FDA PUBLIC SERVICE AWARDS Dr. Stephen Krist Dr. Harley Richards

FDA LEADERSHIP AWARDS Dr. Chris Bulnes Dr. Bert Hughes

DANIEL J. BUKER SPECIAL RECOGNITION AWARD Ms. Casey Stoutamire

Individual tickets are $40 or table of 10 for $350 Deadline to purchase: June 1st.

Purchase your tickets with your FDC2018 registration beginning March 1

DISABILITY INSURANCE YOU WORK HARD, NOW PROTECT YOUR HARD WORK What would happen if you were to become disabled?

Your ability to earn an income is your most valuable asset and it should be protected! Disability insurance replaces a part of your regular income if you are sick or injured and can’t work.

This coverage will put your mind at ease and help you protect you and your family in the event of a disability.

FDA Services offers the best policies from the best providers available on the market today. Be sure to ask about available discounts. Discounts are available to students in dental school or up to 60 days after graduation.

Just over 1 in 4 of today’s 20-year-olds will become disabled before they retire.

SOURCE: The Guardian Life Insurance Company of America

SO WHAT ARE YOUR GOALS? Do you want to buy a house, a car, start your own pracrice? Your

income and ability to make money are the foundation for all your goals.

You need to protect that foundation. You insure your house and your vehicles, don’t you? Then why wouldn’t you protect against the very thing that affords you these same items — your ability to produce an income?

BULDING BLOCKS OF YOUR FINANCIAL LIFE: INVESTMENTS BUSINESS INTERESTS

EDUCATION

HOME

CARS

PERSONAL ASSETS

INCOME SOURCE: The Guardian Life Insurance Company of America

CALL US AT 800.877.7597 FOR A DISABILITY INSURANCE QUOTE.

LICENSURE

PATHWAYS TO LICENSURE IN FLORIDA Due to Hurricane Irma, the Florida Dental Association (FDA) has received numerous calls from Puerto Rican dentists about how to become licensed in Florida. Unfortunately, there is no easy answer to this. But it does give us the opportunity to remind all our members of the various pathways to licensure in this state.

Traditional Path 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.

1. See, Section 466.006(6) Florida Statutes for definitions and requirements.

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This is the “normal” way a dentist can become licensed in Florida. An applicant must be at least 18 years old and a graduate from a dental school accredited by the American Dental Association Commission on Dental Accreditation (CODA) or its successor entity, if any, or any other dental accrediting entity recognized by the United States Department of Education. Florida will allow a graduate from a non-CODA approved school to apply for licensure, but they must first successfully complete at least two consecutive academic years at a full-time supplemental general dentistry program accredited by CODA. Furthermore, an applicant must successfully complete the Dental National Board Exam, the Florida Laws and Rules Exam, and the ADEX Dental Licensing Exam administered by the Commission on Dental Competency Assessments (CDCA) or the Council of Interstate Testing Agencies Inc. (CITA).

While Florida does not have reciprocity with any state and does not issue licenses by credentials or endorsement, an applicant can successfully become licensed in Florida if

JANUARY/FEBRUARY 2018

they have taken the ADEX exam (in Florida or any other state) after Oct. 2, 2011. If the exam scores are less than 365 days old, then they must show they have been engaged in the full-time practice of dentistry in the state within one year of receiving such licensure in this state.1 If the exam scores are more than 365 days old, then they must submit proof of having been consecutively engaged in the full-time practice of dentistry in another state or territory of the United States, the District of Columbia or Puerto Rico. “Full-time practice” is defined in statute, but includes active clinical practice of dentistry providing direct patient care, full-time practice as a faculty member or full-time practice as a student at a postgraduate dental education program.

Health Access Dental License This license restricts a dentist to only practicing in a health access setting, which is defined as a program or an institution of: s the Department of Children and Family Services s the Department of Health s the Department of Juvenile Justice s a nonprofit community health center s a Head Start center s a federally qualified health center or lookalike as defined by federal law

WWW.FLORIDADENTAL.ORG

s a school-based prevention program s a clinic operated by an accredited college of dentistry s an accredited dental hygiene program in this state The requirements for this type of license are: s Never been convicted of or pled nolo contendere to, regardless of adjudication, any felony or misdemeanor related to the practice of a health care profession. s Graduate of a CODA-approved dental school. s Completion of continuing education (CE) requirements. s Completion of parts I and II of the National Board of Dental Examiners Examination and a state or regional clinical dental licensing examination that the board has determined effectively measures the applicant’s ability to safely practice. s Currently holds a valid, active, dental license in good standing, which has not been revoked, suspended, restricted or otherwise disciplined from another of these United States, the District of Columbia or a United States territory. s Never had a license revoked from another of these United States, the District of Columbia or a United States territory.

While this list is extensive, it is not exhaustive. Plus, under each type of licensure pathway there are more specific details based on Florida statutes and rules.

s Never failed the ADEX licensure examination, unless the applicant was re-examined pursuant to statute and received a license to practice dentistry in this state. s Has not been reported to the National Practitioner Data Bank (NPDB), unless the applicant successfully appealed to have his or her name removed from the data bank. s Submits proof that he or she has been engaged in the active, clinical practice of dentistry providing direct patient care for five years immediately preceding the date of application, or in instances when the applicant has graduated from an accredited dental school within the preceding five years, submits proof of continuous clinical practice providing direct patient care since graduation. s Has passed the Florida Laws and Rules exam.

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FROM PAGE 31

Limited License Under this license, a dentist may practice only if they are employed by a public agency or nonprofit agency or institution that meet the requirements of s. 501(c)(3) of the Internal Revenue Code that are permitted under rule 64B5-7.006, Florida Administrative Code, and which provide professional liability coverage for acts or omissions of the dentist. Limited licensees must provide services only to the indigent or critical need populations within the state. Further requirements for this type of license are: s The applicant has retired or intends to retire, and intends to practice only pursuant to the restrictions of the limited license.

who applies for one. The certificate holder can only work in a state or county government facility, which must provide the BOD office with the name(s) and license number(s) of the licensed dentist(s) under whose supervision the certificate holder shall work. Each facility at which an unlicensed dentist practices dentistry must inform the BOD office when the certificate holder is terminated or transferred. Prior to issuance of a temporary certificate, the unlicensed dentist must submit proof of current CPR certification. Plus, each certificate holder shall complete, no later than upon first renewal, a board-approved course on HIV and acquired immune deficiency syndrome AIDS pertinent to the practice of dentistry and dental hygiene in addition to complying with all CE requirements.

Teaching Permit

s The applicant was licensed to practice in any jurisdiction in the U.S. for at least 10 years.

A teaching permit must be issued by the BOD to a full-time dental instructor at a CODA-approved dental school. The dentist must have a degree in dentistry, or is:

In addition, each limited licensee must complete the same CE requirements that are applicable to regular, actively licensed dentists.

s eligible to take the Florida dental licensure examination and has not failed the examination on three occasions.

Temporary License for Military Spouses

s has successfully completed a post doctoral training program of at least two years in duration and accredited by CODA.

The spouse of an active duty member of the U.S. Armed Forces may practice in Florida under this license. However, they must practice under the indirect supervision of a Florida-licensed dentist. Further requirements for this type of license include: s Proof of marriage to a member of the U.S. Armed Forces who is on active duty in Florida. s An active dental license issued by another state, District of Columbia, or possession or territory of the United States with a clear disciplinary history. s A copy of military orders showing the spouse is assigned to an active duty station in Florida. s Background check submitted to the Board of Dentistry (BOD) office from an approved Livescan provider. s A copy of a self-query to the NPDB.

s was at one time eligible to take the Florida examination.

s obtained a dental degree from a foreign dental education program and agrees to practice dentistry only under the general supervision of a Florida-licensed dentist.

Before the certificate is issued, the applicant must pass the Florida Laws and Rules exam and hold a current CPR certification. While holding a teaching permit, the dentist must be a full-time dental instructor and not engage in the practice of dentistry, except at the teaching facilities under the accredited dental program.

While this list is extensive, it is not exhaustive. Plus, under each type of licensure pathway there are more specific details based on Florida statutes and rules. However, this should give you a 50,000-foot view of the various ways a dentist can become licensed and/or practice dentistry in Florida.

Dental Temporary Certificate The BOD must issue a temporary certificate to any unlicensed dentist who is a graduate of a CODA-approved dental school

WWW.FLORIDADENTAL.ORG

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HUMAN TRAFFICKING

HUMAN TRAFFICKING:

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WWW.FLORIDADENTAL.ORG

Human trafficking is a form of slavery, and is a widespread global issue of human rights, as well as a moral, ethical, social, financial and health care problem, which has only recently begun to be addressed by government and health care professionals.

The U.S. government and the state of Florida defines human trafficking as, “sex trafficking, in which a commercial sex act is induced by force, fraud or coercion, or in which the person induced to perform such act has not attained 18 years of age, and the recruitment, harboring, transportation, provision or obtaining of a person for labor or services, through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery,”1 and although transportation often is used as a form of control over its victims, the defining characteristic is the exploitation for profit.2 Florida follows only California and Texas in the prevalence of trafficked persons,3 and human trafficking is estimated to be a $32 billion industry, second only to drug trafficking.4 Sex trafficking accounts for 82 percent of U.S. victims, with labor trafficking victims representing 11 percent.5 Dental professionals are in a unique position to recognize these victims, provide appropriate treatment and connect these victims with resources and referrals.

Nearly 30 percent of victims will visit a health care professional during their captivity, and virtually none will be identified.6 Because of the nature and conditions of their servitude, these individuals may suffer malnutrition,

WWW.FLORIDADENTAL.ORG

abuse and medical neglect. Inflicted injuries often are to the head and neck region, involving jaw fractures/dislocations, broken teeth, untreated caries and abscesses, as well as indicators of sexually transmitted diseases or addictions. Bruises, burns, ligature marks and identifying tattoos or brands are frequently in areas visible to the oral health care provider. Individuals also may present for cosmetic procedures to enhance their salability.

The ADA Code of Conduct, Section 3.E, Abuse and Neglect, states that, “Dentists shall be obliged to become familiar with the signs of abuse and neglect, and to report suspected cases to the proper authorities, consistent with state laws.”7 In Florida, all dental professionals are mandated by law to report the suspicion of abuse or neglect of a child or a vulnerable adult.8 Furthermore, the failure to report carries both civil and criminal liabilities. Florida Statute 39.205 states that any person who is required to report and who fails to do so is guilty of a third-degree felony. If further injuries result, a civil suit may be brought against the mandated reporter who should have recognized the possibility of abuse and failed to report as required by law. In addition, malpractice insurance does not cover criminal acts; therefore, injuries resulting from a failure to report may expose a health care professional to uninsured professional liability.

More importantly, however, is our moral and ethical responsibility to act. “The suspicion of abuse or neglect provides us with the opportunity to interrupt the chain of

BY DR. GLORI ENZOR

Dr. Glori Enzor graduated from the University of Maryland Baltimore College of Dental Surgery and maintains a private general practice in Sarasota.

Dr. Enzor has been involved in forensic odontology extensively since 1999 and is an active member of several professional organizations, including the American Academy of Forensic Sciences, American Society of Forensic Odontology, National Missing and Unidentified Persons System, local Child Abuse Death Review Team, Child Abduction Response Team and the Florida Emergency Mortuary Operations Response team. She has received advanced training at the Armed Forces Institute of Pathology in Bethesda, and is certified by the FBI in NCIC Coding. She serves as a consultant to seven medical examiner districts and numerous law enforcement agencies in Florida, provides expert witness testimony and lectures throughout the United States on forensic odontology, as well as the recognition and reporting of abuse.

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HUMAN TRAFFICKING

n Do you owe money to someone? Are you in debt to someone, and how are you paying off the debt?

FROM PAGE 35

events that threaten the life and the well-being of our patients.

By learning the signs and symptoms of abuse, knowing how to document what is seen, and by fulfilling our legal duty to report suspected abuse or neglect, dental teams may help to mend a family in distress or to save the life of a helpless child or adult.”9 Some of the red flags of human trafficking that may be observed by the clinician or staff include a patient who: n appears to be under the control of someone who never leaves them alone. n has someone else speaking for them, regardless of their command of English. n does not appear to be their stated age. n lacks identification, a wallet or spending money. n shows signs of malnutrition, dehydration, poor general health, poor hygiene, physical abuse or neglect, untreated illnesses or injuries, or drug abuse/addiction. n appears frightened, anxious or depressed. n does not appear to be aware of their location.10 The clinician should try to separate the patient from their companion to ask screening questions. This can be done by invoking a clinic “rule” for privacy, for example. Remember that these individuals are victims of trauma, and proceed non-judgmentally and sensitively; your words of kindness and validation may bring them strength and dignity. Confidentiality, of course, is key. Some assessment questions include: n Are you living and working in a safe place? Where and when do you sleep? n Have you ever been pressured to do something that you didn’t want to do or were uncomfortable doing? n Have you ever been threatened or intimidated by someone?

If so, what did this person say would happen to you? n Are you able to come and go freely at home and work? n What happens if you leave or talk about leaving home or work?

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n Do you have access to any money or the money you earn?

Has anyone taken some or all of your money, or held your money with promises to keep it safe?

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n Has your communication with others been restricted or cut off? Do you have a phone or computer? What happened to those items? n Do you have days off from work and what do you do on your days off? Are you allowed to take breaks at work? If you are not feeling well, are you able to take time off from work? n Has someone ever controlled your access to food and drink, health care, and/or medication? n Has someone ever taken your identification papers, passport or other personal documents?11 Document any injuries thoroughly, and treat any needs as definitively as possible in one appointment, as they may not be permitted to return. Your records and the answers noted from the questions above constitute legal evidence.

Just as we prepare for any other emergency, it’s not a matter of “if ” you will see these patients, but “when.” Be prepared for abused and trafficked individuals by locating your area’s resources in advance for child protection centers, domestic violence shelters and legal assistance, and be ready to provide these referrals (many centers have free contact cards you can make available in your restrooms, for instance). Your first contact may be local law enforcement — have the contact information for your county sheriff ’s office and city police department handy. In the event of a person who is frightened to return to the controlling companion, dialing 911 for immediate intervention for safety is appropriate. Although we are all mandated reporters for the suspected abuse of a child or vulnerable adult, remember to respect an adult’s decision whether or not to report or to allow a report; however, they may accept your helpful resources.

National resources include: National Human Trafficking Hotline, 888.373.7888 Polaris Project, Text HELP or INFO to BeFree (233733) National Center for Missing and Exploited Children, 800.THE.LOST (800.843.5678) WWW.FLORIDADENTAL.ORG

Dental professionals often are critical first responders in addressing human trafficking, and for setting in motion the path not only to health, but to freedom.

Ortho Assist

Grow your practice

References: 1. UN Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, summary web page at http://www. unodc.org/unodc/en/treaties/CTOC/index.html.

2. Syme S, Camardese S, Mehlman-Orozco K. Identifying Victims of Human Trafficking. Dimensions of Dental Hygiene, August 2017.

3. U. S. Department of State. 2015 Trafficking in Persons Report.

4. Polaris Project. Combating Human Trafficking and Modern-Day Slavery.

5. Polaris Project. Human Trafficking, the Victims and Traffickers.

6. Doctors at War. Human Trafficking Facts – Tragic Truths, 2009.

7. American Dental Association. American Dental Association Principles of Ethics and Code of Professional Conduct, 2011.

8. Florida Statutes, Chapters 39 and 415, www.leg.state.fl.us

 Expert orthodontic help from case diagnosis to retention

9. American Board of Forensic Odontology. Diplomates Reference Manual.

 Invisalign® set up and support throughout treatment

10. U. S. Department of Health and Human Services, Administration for Children and Families. Look Beneath the Surface: Healthcare Providers.

 Interact with your dedicated orthodontist through our secure online software

11. Polaris Project. Human Trafficking: Recognize the Signs 2017.

 Convenient monthly subscription

12. Adelson, W. Human Trafficking; Health Care Providers Could Help Stop Human Trafficking. Florida Board of Medicine, December 2012.

WWW.FLORIDADENTAL.ORG

 Interceptive, fixed and aligner mechanics

www.myorthoassist.com • 866.646.7846

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REFERRAL SOURCES FLORIDA SUPREME COURT DECISION HAS FAVORABLE IMPLICATIONS FOR FLORIDA DENTAL PRACTICES In a recent Florida Supreme Court decision, the Court opined that in certain circumstances referral sources are protectable legitimate business interests under Florida’s restrictive covenant statute. The case has favorable implications for Florida dental practices.

BY LANI M. DORNFELD, ESQ.

Lani M. Dornfeld, Esq. is a member of the law firm of Brach Eichler LLC and practices in the firm’s health law practice group.

She services clients in the firm’s Florida and New Jersey offices.

Lani’s practice is focused on handling regulatory, corporate and transactional matters for her clients, including dental providers. She can be reached at ldornfeld@bracheichler.com.

Reference: 1. White v. Mederi Caretenders Visiting Services of Southeast Florida, LLC, 226 So3d 774 (Fla. 2017).

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The Florida Supreme Court consolidated and reviewed two appellate decisions together, both of which addressed violations of restrictive covenants by home health marketers.1 The issue for the Florida Supreme Court’s review was whether home health service referral sources can be a protected legitimate business interest under Florida’s restrictive covenant statute, Florida Statutes § 542.335. In determining that such referral sources can be protectable interests in non-compete agreements, the Court also addressed referral sources more generally, which is good news for other provider types who rely upon and want to protect referral sources, including dentists.

Florida Law Regarding Restrictive Covenants Under the Florida restrictive covenant statute, restrictive covenant or “non-compete” agreements may be enforceable if they are in a signed writing and the restrictions in such contracts are reasonable in time, area and line of business. If an individual or business seeks to enforce a restrictive covenant, it must prove the existence of one or more “legitimate business interests.”

If a legitimate business interest is not proven, the covenant is unenforceable. The person seeking to overturn the restriction may argue the restraint is overbroad, overlong or otherwise not reasonably necessary to protect the established legitimate business interest(s). A court may rule a covenant to be unenforceable, or it may modify the restraint as the court deems appropriate.

Under the statute, “legitimate business interest” includes, but is not limited to, (1) trade secrets, (2) confidential information, (3) substantial relationships with specific prospective or existing customers, patients or clients, (4) customer, patient or client goodwill associated with an ongoing business or professional practice by way of trade name, trademark, service mark or trade dress, a specific geographic location or a specific marketing or trade area, and (5) extraordinary or specialized training.

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Impact of Supreme Court Decision The Florida Supreme Court acknowledged that Florida’s restrictive covenant statute does not, by its plain terms, list referral sources as a legitimate business interest. However, the use of the words “but is not limited to” leads to the conclusion that the list of interests in the statute was never intended to be an exhaustive list. In short, the Court concluded that the list in the statute does not preclude recognizing referral sources as a protectable legitimate business interest.

The Court’s decision essentially abrogates the Florida Fifth District Court of Appeals’ decision in Florida Hematology and Oncology, etc., et al. v. Tummala, 927 So.2d 135 (2006). That court discussed the importance of referral sources to surgeons and other medical specialists who receive a significant share of their new patients from referring physicians. The court noted that such physicians “expend effort, money and energy to cultivate referral relationships.” Notwithstanding such acknowledgment by the court, the court ruled that the “express language” of Florida’s restrictive covenant statute did not recognize “prospective patients” as a recognized legitimate business interest. Therefore, the court concluded there was no way to recognize referring physicians as a legitimate business interest protected under the restrictive covenant statute.

The Florida Supreme Court’s recent decision is good news for dental practices. The Court made it clear that the words “but is not limited to” in Florida’s restrictive covenant statute must be interpreted expansively, not narrowly. This will make it easier for dental practices and other providers to enforce restrictive covenants in which the business interest to be protected is not specifically included in the list of “legitimate business interests” set forth in the statute.

How to Protect Your Dental Practice Florida’s restrictive covenant statute contains several important provisions concerning the content and enforceability of restrictive covenant agreements. Although the Florida Supreme Court has concluded that referral sources “can be counted” as legitimate business interests protectable in restrictive covenant agreements, enforceability will be determined on a case-by-case basis and will be fact-dependent based on “the context and proof adduced.” By way of example, an oral surgeon who relies heavily on referrals from general dentists and other specialists could make a strong case that each such referral source, if the source provides regular referrals to the oral surgeon, is a protectable interest. However, if one such referral source only refers one or two patients to the oral surgeon per year, the argument that such a referral source is protectable is harder to make. Dental practices should consult with competent health care legal counsel to best position themselves to have enforceable agreements.

The opinions expressed are those of the author and do not reflect the views of the firm or its clients.

This article is for general information purposes and is not intended to be and should not be taken as legal advice.

WWW.FLORIDADENTAL.ORG

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PAYROLL

6 TIPS FOR SETTING UP PAYROLL

BY SUREPAYROLL

If you are getting ready to open or take over a practice, knowing how payroll works is crucial.

Don’t know the first thing about setting up a payroll? Here are six general tips to help you get started.

1.

2.

Request or find your employer identification number (EIN).

You will need your EIN number when it comes time to set up payroll. Generally, practices need a new EIN when ownership changes. You can contact the IRS to get an employment identification number. Go to http://bit.ly/1P1f7jS to apply for an EIN online.

Check state and local tax laws. Do you know if your state and/ or local government require an ID number to process taxes? If you cannot dig up this information on your own, don’t be shy about contacting your tax professional for assistance or coordinating with the previous practice owner. Remember though, you’ll need your own ID number — don’t use the previous practice owner’s.

3.

Don’t overlook the importance of employee paperwork. If you are hiring full- or part-time employees, they must fill out a W-4 form. This will ensure that you are withholding the appropriate amount of federal income tax during each pay period. Employees also should complete a new W-4 form when they get married or divorced, have a baby or want to change their withholding amounts for any other reason.

4.

Choose a pay period. There are many options, including monthly and bimonthly. If you are purchasing an existing practice, check with current employees to find out their current method and if it is working. Before you establish a pay period, check with your state for specific requirements.

Payroll frequency is an important decision. Are you paying your employees monthly, semi-monthly, biweekly or weekly?

The number of times you run payroll sets the stage for the amount of time and energy processing payroll will require. For example, being paid twice a month makes it easy for employ-

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ees to budget personal expenses, but this can impact monthly budgets as some months will call for three paychecks. Paying your employees once a month reduces the time of payrolls processing, but it can put a financial strain on employees.

5.

Decide how payroll will be processed. It is possible to process payroll with nothing more complicated than a pen, paper, checkbook and an informational pamphlet you get for free from the IRS. You also will want a few forms for supplying reports to the IRS — W-2s and 1099 forms (http://bit. ly/2Bb62nW and http://bit.ly/2FO7L6k, respectively) among others. This might make sense if you have few employees.

There also are computer programs that can make the calculations for you. You pay for the program and regular updates to the IRS tables and input the employees’ information. The program will print tax worksheets, IRS report forms and the checks. It also may provide direct deposit so you never have to sign a check. It ultimately will be your responsibility to make sure payroll and taxes are processed in a timely manner and that the numbers are accurate.

6.

Decide who will process payroll. If the answer is NOT ME! Consider items 1-5 and start talking to payroll providers. Hiring a payroll professional may relieve you of some, or all, of the risk involved in IRS filing and audits. A payroll provider also will save you the time of processing things yourself. When choosing a payroll provider, make sure you discuss how all of these things will be handled, what your responsibility will be and what the provider will charge for their services. Running your business is your responsibility whether or not you contract out some of the chores. *If you receive a notice from the IRS, or any other tax agency, based on a filing that SurePayroll made, we’ll work with the agency to help resolve the issue on your behalf. And, if we’re at fault, we’ll pay all the associated penalties and fines.

This article was provided by SurePayroll, the only endorsed payroll provider from the American Dental Association’s (ADA) Business Resources. ADA members receive special member pricing. For more information, visit www.

SurePayroll.com/ADA or call 866.535.3592.

WWW.FLORIDADENTAL.ORG

BENEFITS TO KEEP YOUR EMPLOYEES

Surveys show the level of worker appreciation increases with the number of employee benefits, including their intent to stay. However, the kind of benefit valued can vary with your employees’ age and stage of life.

HEALTH SAVINGS ACCOUNTS:* Less likely to use health care services, this group more likely values a high-deductible health plan coupled with a health savings account (HSA) that allows them to save and grow pre-tax or tax-deductible funds.

PET INSURANCE: Thirty-five percent of millennials own a pet, making them the largest pet-owning population in the U.S. Many companies have started offering this benefit.

RETIREMENT PLANS: The rate of contributions to company sponsored retirement savings by this group has almost doubled since 2012.

TRAINING AND MENTORING: Mentoring programs and employee training will help you find and motivate younger staff.

STARTING FAMILIES VALUES STABILITY

30s

20s

LIFE INSURANCE:* Because they now have families, this group needs to protect assets, such as a home.

DOMESTIC PARTNER AND EXTENDED FAMILY COVERAGE:* Offering benefits to others beyond spouse and children is becoming more common.

SHORT-TERM DISABILITY BENEFITS:* This covers an employee who has to be out of work and runs out of sick days for events such as: accidents, surgery, illness with a long recovery time and pregnancy leave.

GENEROUS PARENTAL LEAVE: Most dental offices have fewer than the 50 employees that trigger The Family and Medical Leave Act. Employees will value a personnel policy that offers unpaid, job-protected leave.

TRADITIONAL HEALTH BENEFITS: Medical,* dental* and vision* coverage are important to this age group.

FLEXIBLE WORK ARRANGEMENTS: This can include flexible hours, compressed work weeks and working remotely, which are valued by all age groups. But, this group oftenhas to care for young children or elderly parents, or both. Stress reduction and job satisfaction also have been correlated with a flexible schedule.

RETIREMENT PLANS: Workers in their 50s will stay at or gravitate toward firms with a defined-benefit pension plan and take a hard look at a company’s 401(k) matching contribution.

READY FOR THE NEXT STAGE

60s

STARTING A CAREER

40s 50s

FINANCIAL PRIME TIME

PHASED RETIREMENT: As highly skilled and experienced baby boomers retire in larger numbers, employers will face significant knowledge-transfer issues. You can keep valuable institutional knowledge from walking out the door and make your employees happy by implementing phased-in retirement plans. This can allow an employee to start accessing 401(k) plans and pensions while also working part time.

LONG TERM CARE INSURANCE:* This policy covers costs for home care, assisted living and nursing homes.

In a recent survey performed by Monster, participants were asked to rank benefits by value and importance when considering a prospective job. The results of the survey ranked average importance by benefit: • HEALTH CARE PLAN: 32% • VACATION TIME: 25% • PAY RAISE: 15%

* Call FDA Services at 800.877.7597 for a quote on these important employee benefits.

• EMPLOYEE BENEFIT: 10% • PERFORMANCE BONUS: 9% • RETIREMENT PLAN: 8%

EMPLOYEE MANUAL THREE REASONS YOU NEED AN EMPLOYEE MANUAL

1

First, a written employee manual (aka handbook) protects your business against employees’ legal claims. In Florida, employment is “at will,” which means both the employer and employee may lawfully end the employment any time, without prior notice and without cause. Your handbook should explicitly state employment is at will and that no contract or term of employment exists between you and the employee.

2

Second and equally important, your employee handbook is your best risk management against sexual harassment claims. Last year marked the highest number of sexual harassment claims filed with the U.S. Equal Employment Opportunity Commission. Next year the rate promises to be even higher. The “Faragher/Ellerth” defense is your best tool to avoid liability for alleged unlawful harassment. The United States Supreme Court first set forth the defense in the companion cases of Faragher v. Boca Raton, 524 U.S. 775 (1998), and Burlington Industries, Inc. v. Ellerth, 524 U.S. 742 (1998). The defense is available for claims of harassment under Title VII of the Civil Rights Act of 1964, provided:

GRAHAM NICOL, ESQ.,

n the employer exercised reasonable care to prevent and promptly correct any sexually harassing behavior.

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

n the employee unreasonably failed to take advantage of any preventive or corrective opportunities provided by the employer. n you are defensible if you have a written policy prohibiting harassment and your employee unreasonably fails to report harassment under the policy. The easiest way to accomplish this is by having a written employee handbook.

Graham Nicol is the FDA chief legal officer.

3

Third, your employee handbook describes your expectations and the duties and responsibilities of your employees. Unless you have written standards, you are unable to effectively discipline employees for violations. You also want your handbook to prominently describe how employees are to address problems so that they take their concerns to you — not a governmental enforcement agency or a lawyer.

The American Dental Association has excellent resources available through its Center for Professional Success. Search for “Creating the Policy Manual” and you’ll be on your way.

Also, check with your business liability carrier for manuals and, while you’re at it, verify that you have adequate employment practices liability coverage — $10,000 of coverage with a $1,000 deductible is insufficient for Florida dentists, who pay high wages and practice in a highly litigious state.

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EMPLOYEE LEASING: PROS & CONS PRO

PREDICTABLE COST FOR SERVICES Employee leasing offers help in every industry and field that exists presently for a flat rate, which allows a practice owner to better calculate their yearly expenditures.

LEGAL PROTECTIONS Most PEO agencies offer legal solutions like employment liability insurance, civil defense and more.

The PEO also ensures that they do not hire any wrong candidates or unprofessional employees.

CON

LIMITS FREEDOM IN HIRING PROCESS The employer only sets the standards for employee hiring. The PEO typically hires new employees based on those standards This lack of control can be enough for some employers to avoid this type of relationship.

CON

LACK OF COMMUNICATION When employees ask questions related to benefits, payroll or other HR-related functions, they communicate with the leasing agency and not the business. If the agency and company do not have a strong working relationship, it can cause a lot of confusion.

CON

BETTER BENEFITS FOR EMPLOYEES The leasing agency typically has access to a better pool of benefit resources for employees.

This can be a recruiting tool to bring in more experienced people and retain them.

EMPLOYEE LACKS MOTIVATION AND LOYALTY Leased employees may lack loyalty and motivation, or feel that they are not truly involved or an active member of the practice. There also can be conflict between leased and regular employees that reduces productivity.

CON

PRO

PRO

REDUCED LIABILITIES Hiring a new employee requires some routine tasks: HR management, workers’ compensation, paying taxes, benefits administration and payroll, etc. The PEO organization completes these tasks and assumes the liabilities.

PRO

Leased employees have been attained from a professional employer organization (PEO). The PEO is the official employer of the leased workers and handles payroll, tax reporting and benefits. However, the employees complete the work for the leasing company or business owner. Some company owners find this to be a more beneficial way of completing projects without the added responsibility of human resource management.

EMPLOYEE HEALTH CARE INSTABILITY PEOs always search for the best deal on employee health care. They may change health care providers on a continuous basis, which can be frustrating for the employees. You may use PEOs for administrative tasks and then offer health insurance to the employees.

Sources: https://content.wisestep.com/top-advantages-disadvantages-employee-leasing/• http://www.businessdictionary.com/definition/leased-employees.html

LEASE NEGOTIATONS

REASONS TO CALL IN THE DENTAL OFFICE LEASE NEGOTIATION PROS 44

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BY CIRRUS CONSULTING GROUP

There’s an old saying that goes, “Leave it to the professionals.” When you need a haircut, go to a barber. When you need your car fixed, see a mechanic. Seems obvious when you put it in these terms, but in today’s do-it-yourself (DIY) culture, business owners are increasingly circumventing professional services to go it alone. In the world of dentistry, negotiating a risk-free dental office lease with fair and reasonable economic terms is an essential component to mitigating risk and running a successful practice — and yet — it’s not always obvious to practitioners why they should consult a professional dental office lease negotiator.

Signing your lease is one of the most important, expensive and significant commitments you’ll ever make as a dentist, and going in blind or ill-prepared can have lasting implications. Here are a few reasons to leave your lease negotiations to the pros.

1. The Doomed DIYer The obvious upside in not hiring a professional dental office lease negotiator is that you won’t have to pay their fees. Often, this is the single biggest motivator for dentists who view the task as one they can easily tackle themselves. Of course, as with many such tasks, you get what you pay for.

lease permeates every aspect of a practice, this is one area where an investment today can save big bucks tomorrow.

If you sidestep the experts, you won’t be getting their professional guidance and advice, that exposes you to significant financial repercussions and the unnecessary risks that come with a poorly negotiated lease agreement. Every time you renegotiate or renew your lease, you are committing to another $500,000 to Consider the amateur handyman who decides to build his own $1 million contract. Spending a fraction of this contract value furniture; he can save money by building his own bookcase, to ensure that your future is protected just makes good business but what happens one month later when the shelves give out sense. The value that a professional dental office lease negotiator because it was poorly constructed? The bookcase collapses; brings — both economically and in terms of risk reduction — is the objects on the shelves end up broken; it creates a mess worth far more than the initial investment of their fee, not to and leaves the “handyman” right back where he started — no mention the substantial, long-term savings that can be achieved bookcase, plus one mess and minus several treasured objects. with proper representation.

Because poor planning and mismanagement of a dental office

2. More Time to Dedicate to Your Practice The most immediate benefit to working with a professional lease negotiator is the amount of time saved. Spending more time chairside is critical to the practice’s success. When you decided to open a dental clinic, you probably didn’t realize you were signing up for all the administrative burdens required to run a successful practice. Whether you’re just starting out or are growing an established practice, taking chairside time away to review the lease, research market rental rates, negotiate with your landlord and understand tenant rights is a time-consuming nuisance.

Don’t be fooled into thinking that the only step in lease negotiations is the initial review and signing of the contract, or that your landlord has prepared a fair lease that will see you through your career. Lease negotiations are a dynamic and potentially lengthy, ongoing process that require a dedicated time investment — if you’re doing it right. A reactive tenant acts only when prompted, or upon finding themselves up against a deadline. Often, this means it’s too late to get a favorable outcome, i.e., when your lease is about to expire and you’re at the mercy of your landlord. A smart dental tenant is proactive, and by working with a professional negotiator, you will ensure that you have both the leverage and knowledge to be successful in securing a favorable lease agreement for the practice.

practice. Lease negotiation is a core function, but there is a wide spectrum of services that a lease negotiation firm provides, including insight from market research and data analysts, inWorking with a professional dental office lease negotiation house brokers, attorneys and ex-landlords. Whether designing firm is an eye-opener for most practitioners because they don’t asset protection terms, or leveraging emerging market trends to realize how much more they can be doing to optimize their help you map out practice goals, your lease negotiator is backed practice. Professionals will not only identify landlord-set lease by a team of experts who put all the pieces together, and deliver traps and try to negotiate the best deal for you, but also provide a results-focused business solution for your peace of mind. a wealth of business acumen and resources to improve your SEE PAGE 46

3. Reap the Benefits of Comprehensive Services and Support

FROM PAGE 45

4. Your Future Self Will Thank You for Strategy-Planning Now Most dentists are naturally eager to build out the practice and open their doors. However, in their haste, they often fail to consider their mid-range and long-term goals. The details in your office lease dictate key aspects of your business, such as the ability to bring in associates or specialists, the conditions

5. Relax! Someone Else Will Fight Your Battles Lease negotiations with a current or prospective landlord sometimes means playing hardball, and some individuals are simply not comfortable with, or capable of, getting tough and asking for what they want and deserve. But it’s not just about being assertive; you also have to know what the stakes are, and how to best achieve the desired results. A lease negotiator acts as your own personal advocate to represent your best interests, and ensures that your leasing needs are being met. For example, as a dental tenant, you may not immediately appreciate the importance of addressing “relocation language” that prevents your landlord from moving your clinic, or the amendment of

under which you sell the practice, obligations and restrictions for remodeling or expanding, etc. — which is why the details within the lease should not be taken lightly. A skilled dental office lease negotiator will outline a comprehensive negotiation strategy that aligns with both your short- and long-term goals, and takes the big picture into account — so your lease doesn’t hinder you as you progress in your career. the “assignment” clause, preventing your landlord from taking 50 percent or more of your practice sale proceeds at transition time. Your negotiator, however, knows that strategic tactics today will certainly pay off later, and that every word in your lease agreement can have major implications down the road.

Keep in mind that your landlord will draft a lease that benefits them, not you. In their hands, the lease is a tool towards achieving financial flexibility and power. Your lease negotiator can convert a bad lease into armor to protect your assets, family and estate, and optimize the lease in your favor. They will negotiate the best terms and rental rates possible so that you, not your landlord, are in control of your financial future.

intentionally buried or obscured by your landlord. The negotiator will use their skills to revise the lease to work in your favor Dental office lease agreements can be complex and lengthy, full — something that an untrained professional simply cannot do. of technical legal jargon and contain terms that aren’t tenantThis is one of the key differences between a professional dental friendly for the average business owner. Navigating the tricky office lease negotiator and a general commercial lawyer/atand complex language is just one challenge. The bigger obstacle torney. While lawyers can be experts in contract management is identifying expensive traps and risks, and understanding and negotiation, they often lack dental industry and real estate what must be done to reduce or eliminate them. Most leases experience to produce a lease agreement that both protects leave the tenant vulnerable to expensive penalties and inconand enhances the value of a dental practice. If you’ve retained venient pitfalls that can have devastating effects on their career an attorney, ask them how many dental office leases they’ve or practice. Before signing, it’s your responsibility to review the negotiated. Dental lease negotiators have specialized expertise proposed terms. But how will you know what to look for? A in contract negotiation, dental tenant rights, practice optimizaseemingly innocuous statement may harm you down the road, tion — and, they understand the industry inside and out. and similarly, the absence of a key clause can leave you, your Would you go to a mechanic to get your haircut, or a barber to assets, your family and your practice exposed. fix your car? If the answer is “no” to both, why would you, as a For example, did you know that you can be held financially dentist, handle your own lease negotiation? Gambling with the responsible for the practice even after a sale or transfer of the fate of your entire practice hardly seems worthwhile when you lease? Or that you could be forced to bear the financial burhave a team of specialists just a phone call away. Some things den of a forced relocation? Dental office leasing professionals are just better left to the experts! For more information, go to will review your lease and identify risky terms that have been www.cirrusconsultinggroup.com.

6. Do You Speak Legalese? We Do!

This article was originally posted on the FDA’s blog, Beyond the Bite on Nov. 30, 2017.

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CLAIM SCENARIOS

SOUND FAMILIAR? 6 REAL LIFE CLAIMS FROM FDA SERVICES

BY FDA SERVICES STAFF

Total Paid: $5,000 in IT services put in by the Beazley team.

These are a collection of real claim scenarios from FDA Services (FDAS) staff.

Professional tip: Every professional liability policy with The Doctors Company includes a $50,000 Cyberguard policy. You can increase that to $1,000,000, starting at $600 annually for a solo-practitioner.

Hurricane Irma Claim Recently, I worked with a member who had purchased a Business Owner’s Package Policy Extension, providing additional coverage for their business. The policy was purchased through Liberty Mutual and it had excellent “civil authority” coverage.

When Hurricane Irma came through Florida and this dentist was unable to return to his office, this extension ended up paying out lost income due to city authorities not allowing residents back into the city, even though there was no building damage.

Total paid: $31,000 for three days of office closure.

Professional tip: Make sure your office insurance policy includes civil authority coverage!

Hurricane Irma Claim This past hurricane season, two different clients of mine reached out regarding a similar coverage question, “My sign was damaged due to the hurricane [or complications from the hurricane]. Do I have coverage to replace the sign?” Most of the business owners’ policies that FDAS sells contain some type of property coverage (whether that’s building coverage, business personal property coverage or both), general liability coverage and a bunch of extra coverages that I like to call the “bells and whistles.” Sign coverage is one of those little “bells and whistles” coverages for consideration.

Total paid: $10,000 for sign replacement.

Cyberliability Claim An insured called me to discuss his professional liability and mentioned that his computer system had been hacked. He told me that he had hired a third-party administrator to try and restore his system and get him up and running. The hackers were demanding a ransom, but the third-party thought they could restore him from backups. The cost of the third party was about $5,000 and the ransom was $2,500. I advised him to call The Doctors Company right away, as all professional liability policies have $50,000 in coverage under the professional liability policy for Cyberliability. This includes coverage for cyber extortion. Beazley, the administrator of the insurance, was able to get the insured fully functional at no out-of-pocket cost.

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Professional tip: Here are a few details to help understand what your policy may cover if your sign is damaged: n Was my sign damaged due to a covered cause of loss? For example: If your sign was struck by an object during the hurricane, one of your first items for consideration should be if you have wind coverage on your policy or not. n Is there a limit on my sign coverage? Is that enough? n Is there a separate deductible for my sign? n Is my sign attached or detached from the building? Policy verbiage may vary based on this information, so it is best to refer to your policy for additional details.

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Employers Practices Liability Claim Dr. XYZ had a discrimination claim. A female dentist owner had a current female employee file a discrimination suit against her because the employee felt she was being pushed out for being pregnant and could not work as much. This is the second time we have had a female employer be sued by a female employee for discrimination related to pregnancy.

Total Paid: $0. The claim was reviewed and denied again.

Why? The insured’s policy provides windstorm coverage for location No. 2, but not for location No. 1. Since the cause of loss was due to a tropical storm, the claim was denied.

Professional tip: All employers should have employers’ practices liability coverage in place in the amount of at least $100,000 and higher if there are more than five employees.

Practices of all sizes experience discrimination suits.

Professional tip: In Florida, many business owners are located in coastal areas, and as a result, windstorm coverage is typically excluded on a business owner’s policy. A separate windstorm policy can be purchased; however, windstorm policies only provide coverage for direct physical loss to the building.

Currently, windstorm policies do not provide the extra coverage you would find in a business owner’s policy. As a result, business owners who live in coastal areas in which windstorm coverage is excluded risk the loss of business income and other valuable coverage.

Hurricane Irma Claim

Employers Practices Liability Claim

During this hurricane season, I received many claims for business income from power outages due to a named storm. Many of the policyholders did not suffer direct damage, but rather power outages from damage off premises. Each policy is different in how this coverage will pay and therefore, it is important to look at the coverages, exclusions and endorsements.

Our insured was contacted by a former employee’s legal representative demanding $50,000 in unpaid wages the employee felt they were owed. The employee had alternated weekly work schedules, working 45 hours and 30 hours. They were stating that they were not paid overtime for the five years they had worked this schedule.

We received a claim from an insured for business income loss as a result of a tropical storm. The insured has two locations on his policy and filed a claim for location No. 1 that did not have any power for a period of 10 days. The loss was a result of power failure from downed power lines down the street caused by the windstorm.

Unfortunately, the insured did not have a separate employers’ liability policy. They did have an office insurance policy that offered up to $10,000 in coverage and filed a claim. The claim is still pending, but the insured had to hire their own labor attorney and will be responsible for defending the claim and any additional costs.

Initially the claim was denied, citing that there is an exclusion on the policy that specifically denies coverage for power outage if the outage occurs away from the premises. The insured argued that he has the Ultra PLUS endorsement, which provides business income coverage from a covered cause of loss to electric power transmission lines not located at the described premises.

Total paid: $10,000 lump sum paid out by carrier to insured.

This might cover the cost of legal fees, but that will depend on the outcome of the suit.

Total paid: Pending, but employer liability coverage is in place up to $150,000.

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Professional tip: HR360 is a great resource for state labor laws and other employee resources. If you are insured with The Zenith (worker’s comp company), you get this service for free.

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E P L I

WHY DO YOU NEED IT?

MPLOYMENT RACTICES

Employment practices liability insurance (EPLI) is a type of liability insurance covering wrongful acts arising from the employment process. The most frequent types of claims covered under such policies include: wrongful termination, discrimination, sexual harassment and retaliation.

LEGAL COUNCIL “From my perspective, employment practices liability presents an equivalent, if not greater, risk to Florida doctors than malpractice. Dentists are well-trained on patient care responsibilities, but there is no similar education on rapidly changing employment law.”

IABILITY

NSURANCE

– Graham Nicol, FDA Chief Legal Counsel

EPLI COVERAGE PREMIUM ESTIMATES (Coverage w/ 3rd Party)* Option 1

Option 2

Limit: $250,000 Retention: $5,000 Estimated Premium: $814

Option 3

Limit: $500,000 Retention: $5,000 Estimated Premium: $949

Limit: $1,000,000 Retention: $5,000 Estimated Premium: $1,356

* Premium estimates are non-binding and are based on dental practices with 10 or fewer employees in your mailing zip code.

CLAIM EXAMPLE The call comes in… “I am being sued! Help! An employee quit and they now allege that I systematically campaigned to force them to resign. Am I covered?”

Agent’s Perspective… These situations are hit and miss, and can come down to “he said, she said.”

Unfortunately, this scenario is quite common. An employee is terminated or quits. They are unhappy.

They sue. Who’s right? Who’s wrong? Most importantly, can you prove it? These claims are significant and very costly to defend. In the example above, the following amounts were paid: $150,000 Defense | $100,000 Lost Income to Plaintiff | $110,000 Mental Anguish to Plaintiff

Call us at 800.877.7597 to learn more and apply for coverage.

WORKER'S COMP

MY DAY AT THE ZENITH A WORKERS’ COMPENSATION CARRIER

First, let me begin by stating that our FDA Services’ (FDAS) team is constantly striving for outstanding customer service. We are always surveying our member clients on how well we are doing and how we can improve. On top of that, we are looking for insurance and service partners that also strive for superior customer service.

FDAS has been partnered with The Zenith, a workers’ compensation carrier, for more than five years and I have always been impressed with the service their underwriting staff provides our team. Their management consistently reaches out to make sure that we are happy. Recently, they invited me to visit their offices to sit in on a staffing meeting, and I took them up on their offer.

BY CARRIE MILLAR, FDA SERVICES DIRECTOR OF INSURANCE OPERATIONS

Ms. Millar can be reached at 850.350.7155 or carrie.millar@ fdaservices.com.

What is a staffing meeting?

This was my first question when I arrived at their headquarters in Sarasota, Fla. I had assumed that the meeting would show me how they rallied their troops and boosted company morale. I pictured a room full of underwriters, sales reps and other employees shouting out sales numbers and celebrating profit. I was wrong! A staffing meeting is how the company reviews unique claims and all coverage declinations.

How does it work?

A team meets twice a week to review regional claims, and consists of a staff physician, staff lawyer, claims vice president, special investigation unit rep and rotating claims adjusters. This occurs at the Sarasota office on Tuesdays and Thursdays, and the Orlando office on Mondays and Wednesdays. They collaborate on the claims presented that day and determine if, based on standardized industry language of DWC-12 compensability for the state of Florida, they will be paid.

Why is this unique?

In my 15 years working in the insurance industry, I have never heard of this. Typically, with other carriers, workers’ compensation insurance claims are assigned to an adjuster and the adjuster makes the decision. If you do not agree with the decision, then you complain to their manager and must work your way up the management ladder. Some carriers do have a formal appeals process, but they tend to be closed-door and held monthly. This is the first time I have seen a collaborative approach to insurance claims besides medical malpractice claims.

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What I experienced?

Claim #3

I sat down in the office of Lori Sikorski, assistant vice president of claims, along with Dr. Jill Rosenthal, the chief medical examiner, Georgia Higgins, a senior trial attorney, a fraud investigator and several claims examiners (adjusters). I was given a scrubbed list (to protect client information) of the claims that were to be discussed. I also was given a sheet of the 21 standard DWC-12 notice of denial statements for the state of Florida.

Employee Jose is employed at dairy farm. Jose is 43 and has worked at the dairy farm for 16 years, first as a milker and now parlor manager. He reported hand/finger pain but did not know the cause. He went to the doctor for treatment and was told it was from repetitive motion. The initial decision was to pay the claim in full. The insured employer asked that the claim be staffed because they felt it should be declined. He has a total of nine prior claims, but he has been there for 16 years.

Claim #1 Employee Amy, employed by an insured restaurant, was touched by a co-worker with latex gloves. She had an allergic reaction to the gloves, was treated at an outpatient facility and returned to work.

Discussion: Did she know of her allergy? Yes. Did the restaurant know? Yes. Could an accident have been avoided? No. Decision: The team decided to cover her initial medical bills from the initial touch but declined any additional claims, as latex allergy is a pre-existing condition.

Claim #2 Employee Erika, employed by an insured restaurant, went to a laser tag event that was paid for by the restaurant. She fell, chipped her tooth and had to have a crown put on.

Discussion: Was she paid to attend? No. Was it strongly encouraged? No. Did it produce benefit to employer other than goodwill and employee morale? No. Decision: This was declined because the accident was not sustained in the course and scope of employment. This was a two-pronged declination because the event was optional and the employer did not directly benefit from attendance.

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Discussion: What were the other claims? They were minor accidents from farm work, all medical only treatment. Did he return to work? Yes. Does the dairy use mechanical machinery to milk cows? Yes, but the cows must be cleaned prior to the machinery being put on. Technology has advanced in the last 16 years, but he worked as a milker for more than eight.

Decision: Fully covered.

Claim #4 Employee Maria has been employed for two years at an insured farm. She was driving a utility truck and struck a tree.

She sustained a stomach area injury and was treated by a primary care physician (PCP). She had an MRI of the lumbar and metastatic disease was discovered — and it may have spread to bone and spine. A treatment plan for cancer has begun.

Discussion: Was this known? No. She had an MRI two years ago and clear. Was she supposed to be driving? Yes. Decision: Initial PCP visit covered. The rest of the claim is declined for the major contributing cause of the need for treatment or disability is no longer the industrial accident. They will offer a settlement on a denial basis.

At the end of my experience, I went away feeling even stronger and more assured in offering The Zenith to FDAS clients.

Policyholders and their employees are not a number and all claims are taken seriously. I thank The Zenith for sharing their process with me.

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DENTAL RECORDS

RISKS IN ELECTRONIC DENTAL RECORDS SYSTEM AND USER ERRORS RESULT IN MANY EHR-RELATED DENTAL CLAIMS. Electronic health records (EHRs) are a collection of health records that present a comprehensive picture of an individual’s health. Records that are a part of that collection include electronic dental records (EDRs) and electronic medical records (EMRs). The end goal for EHRs is to have all of a patient’s information available for use by any health care provider or, in an aggregated form, for use in population health.

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

For questions regarding this article, please contact David Hester, Director, Patient Safety and Risk Management at The Doctors Company, at 800.

421.2358, ext. 3658 or dhester@ thedoctors.com.

Reference: 1. Mendonca, E. Clinical Decision Support Systems: Perspectives in Dentistry, J Dental Education 2004; 68:6, 589-597. http://www.jdentaled.org/content/68/6/589. full.pdf.

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While many see the interaction between computers and health care as something that occurred in the past 25 to 30 years, but it actually started in the 1950s. Robert Ledley, DDS, and Lee Lusted, MD, co-authored the paper, “Reasoning Foundations of Medical Diagnosis,” which attempted to leverage computer power to make a diagnosis.1 From these early beginnings, the clinical decision support system has evolved into an integral part of the EDR and EHR. While hospitals and medical offices have adopted EMRs at rates of greater than 80 percent, the dental community does not have the financial incentives to adopt electronic records that have been extended to the medical profession. These financial incentives are made available for eligible providers who can demonstrate that they have made meaningful use of the records through a validation

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process administered by the Centers for Medicare and Medicaid Services (CMS). Recently, the medical community was informed

by CMS that there will be financial penalties for those who do not switch to electronic records; however, the mandate does not apply to dentists.

A review of dental closed claims by The Doctors Company in which electronic records were listed as a contributing factor showed that system and user factors resulted in most of those EHR-related claims. Userrelated issues were present in 60 percent of the claims reviewed. Those were problems primarily associated with hybrid records/ conversion from paper records, training and education, and use of copy-and-paste techniques. System-related issues contributed to the remaining 40 percent — mainly due to fragmented EDRs and other technology and design issues.

Case Example: Conversion from Paper Records A practice was in the process of migrating from a paper record system to an EDR system. During the transition, a patient missed his follow-up appointment after a procedure the previous week. Due to the ongoing WWW.FLORIDADENTAL.ORG

BE CYBERSECURE. TAKE THE NECESSARY ADMINISTRATIVE, TECHNICAL, AND PHYSICAL STEPS TO MAINTAIN THE SECURITY AND PRIVACY OF YOUR EDR SYSTEM.

conversion process, the missed appointment was not noted.

Several days later, the patient sought emergency treatment for a developing complication. If the missed appointment had been noted, appropriate contact could have been made with the patient to bring him in for the necessary follow-up care.

Case Example: Fragmented EDRs A patient was referred to a dental specialist who reviewed the digital X-rays that were sent to the office. With the patient’s consent, the dentist decided to immediately proceed with a procedure. After beginning the procedure, the dentist noticed that the dental features of the patient did not match what was observed on the X-rays. Further examination revealed that the X-rays that were provided to the specialist belonged to another patient. In this case, a fragmented EDR was a contributing factor. This may occur when several standalone systems are used to deliver dental care. It also can occur when information is imported from one provider to another.

Summary While the total number of dental closed claims that have an EDR system as a contributing factor is small, these claims will become more prevalent as more dentists switch to electronic records. The early trends suggest that the EDR will parallel the EHR in the type of risk to their respective health care providers.

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Risk Management Strategies Research the EDR systems that are available. Speak to other dentists in your area to discuss their positive and negative experiences with their systems.

Ensure that all staff members are adequately trained in how to use the EDR. Consider how you will incorporate training for new hires.

Validate the information entered in the EDR. Verify your patient’s identity before charting. Check to be sure that documents to be scanned and added to the EDR belong to the correct patient.

Be cybersecure. Take the necessary administrative, technical, and physical steps to maintain the security and privacy of your EDR system.

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.

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TAX CUTS AND JOBS ACT WHAT DOES THE TAX CUTS AND JOBS ACTS MEAN FOR YOU?

BY DEBIE LEONARD, DIRECTOR, TAX SERVICES DEPARTMENT, SHAREHOLDER EMERITUS, THOMAS HOWELL FERGUSON P.A. CPAS

The Tax Cuts and Jobs Act (TCJA) passed by Congress and signed into law

by President Trump is a sweeping tax package. Many in the tax profession are calling its passage and enactment the greatest change to the tax code in more than 30 years! Because the TCJA represents a major tax overhaul, it will take time to understand its full effect on your individual tax situation along with what it means for your business. Below is an outline of some of the changes for individual and business tax filers.

Individual Tax Change Highlights Tax Brackets. There are seven tax brackets: 10 percent, 12 percent, 22 percent, 24 percent, 32 percent, 35 percent and 37 percent. Your income and how you file will determine your tax bracket. To see which tax bracket you are in, visit www.thf-cpa.com and view our blog.

Standard Deduction. Increased to $24,000 (joint filers), $18,000 (heads of household), and $12,000 (singles and married taxpayers filing separately).

These figures will be indexed for inflation.

Exemptions. The deduction for personal or dependency exemptions is

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suspended. The rules for withholding income tax on wages will be adjusted to reflect this change.

State and Local Taxes. The itemized deduction for state and local income, sales and property taxes is limited to $10,000.

Child and Family Tax Credit. The credit for qualifying children has been increased to $2,000 and the refundable portion of the credit has been increased to $1,400. It also introduces a new nonrefundable $500 credit for taxpayer’s dependents who are not qualifying children.

Miscellaneous Itemized Deductions.

The deduction is suspended. This category included items such as tax preparation costs, investment expenses, dues and unreimbursed employee expenses.

Mortgage Interest. Mortgage interest on loans used to acquire a principal residence and a second home is now only deductible on debt up to $750,000, starting with loans taken out after Dec. 15, 2017. There is no longer any deduction for interest on home equity loans. This change does not affect home acquisition mortgages taken out under binding contracts in effect before Dec. 16, 2017, as long as the home purchase closes before April 1, 2018.

Education Tax Breaks. The TCJA leaves all the existing education-related tax breaks in place. It now allows you to take tax-free distributions of up to $10,000 per year from a Section 529 plan to cover tuition at a public, private, or religious elementary or secondary school.

“Green” Vehicles. The TCJA retains the tax credit of up to $7,500 for new qualified plug-in electric vehicles.

Kiddie Tax Repealed. Income for children will now be taxed at single tax rates rather than a portion of it being taxed at the parent’s rate, which is significant for children working for a family business.

Unearned income will now be taxed at the rate for estates and trusts.

Health Care “Individual Mandate.” Starting in 2019, there will be no penalty for individuals who fail to obtain minimum essential health coverage.

Casualty and Theft Losses. This deduction is suspended except for losses incurred in a federally declared disaster.

Moving Expenses. The deduction for job-related moving expenses has been eliminated, except for certain military personnel. The exclusion from income for moving expense reimbursements also is suspended.

Alimony. For post-2018 divorce decrees and separation agreements, alimony will not be deductible for the paying spouse and will not be taxable to the receiving spouse.

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TAX CUTS AND JOBS ACT FROM PAGE 57

Estate and Gift Tax Exemption. Effective for decedents and gifts made starting in 2018, the exemption has been increased to $11.2 million ($22.4 million for married couples).

Alternative Minimum Tax (AMT) Exemption. Retained for individuals with expanded exemption amounts of $500,000 (single) and $1 million (married filing joint).

ROTH Conversion Recharacterization. You can no longer reverse the conversion of a traditional IRA into a ROTH account.

Expiration date of the above individual provisions is 2025.

Business Tax Change Highlights Pass-through Income. Pass-through entities such as S-Corporations, Partnerships and Schedule C Businesses will receive a 20 percent deduction on their “qualified business income.”

However, it only applies to a specific set of businesses. A new tax code section has been added for this provision. The calculations will relate to income for the pass-through entities and will have limitations for the maximum deduction allowed.

Service Industries and Pass-through Income. The 20 percent deduction does not apply to “service businesses” unless the owner’s income is lower than $207,500 (single) or $415,000 (married filing joint). Income from the following trades or businesses is phased out (above the income threshold) of qualified business income: health, law, consulting, athletics, financial, brokerage services, or where the principal asset is the reputation of skill of one or more employees or owners. To receive the deduction, businesses must either pay W-2 wages equal to 40 percent of income to get the full deduction or limit deduction to 2.5 percent of original cost of depreciable, tangible property plus 25 percent of wages.

Meals and Entertainment Expenses. Entertainment expenses are no longer deductible. Meal expenses (including meals for employees) are 50 percent deductible.

Charitable Contributions. Charitable donations for amounts paid in exchange for the right to purchase tickets to an athletic event or for priority seating are no longer deductible.

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C-Corporations. The new tax rate is a flat 21 percent and the business AMT has been repealed.

Paid Family Leave Credit. A new credit for businesses paying employees while on leave under the Family and Medical Leave Act (FMLA) has been established.

Net Operating Losses (NOL). Losses are now limited to 80 percent of taxable income and can no longer be carried back.

However, for most they may now be carried forward indefinitely.

Luxury Automobile Depreciation. The deduction will increase from $3,160 for the first year to $10,000, increasing the cap to $50,000 with a sliding scale across years.

Bonus Depreciation. Increased to 100 percent deduction for assets both new and used when acquired and placed in service.

Business Interest. Interest paid on business debt will only be deductible up to 30 percent of your business’ “adjusted taxable income.” For pass-through entities, the deduction will be calculated at the entity level. Any interest disallowed will be carried forward indefinitely.

Like-kind Exchange Treatment Limited. The rule allowing the deferral of gain on like-kind exchanges of property held for productive use in a taxpayer’s trade, business or for investment purposes is limited to cover only like-kind exchanges of property not held primarily for sale. Excludes tangible property.

One area of concern for membership organizations, like the Florida Dental Association, is the tax deductibility of membership dues. At this point, it is the opinion of the American Dental Association (ADA) and the American Society of Association Executives (ASAE) that dues will remain tax deductible if paid by the practice/corporation as an expense in the normal course of business. However, if those dues are paid by the individual, then they will not be tax deductible due to the suspension of Miscellaneous Itemized Tax Deductions under the TCJA noted above. The dues question has not yet been finalized, but the ADA and ASAE continue to seek final guidance from the IRS. The TCJA affects many areas of taxation. If you wish to discuss how the law impacts your particular situation, you can contact me at 850.668.8100 or dleonard@thf-cpa.com. In our next article, we will explore the various factors in entity selection the benefits/drawbacks of converting your business from an S-Corporation or Sole Proprietorship to a C-Corporation.

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SPE

W E I V E R P AKER No Phishing Allowed!

When the internet first gained popularity back in the 1990s, few had the foresight to predict how much it would become intertwined in our everyday lives, both at home and work. The internet has given people all over the world tremendous opportunities to interact and conduct business.

Unfortunately, hackers and scammers also see opportunity, and they are exploiting individuals and businesses at an alarming rate. Privacy is at risk, both for team members and our patients.

Dental team members know quite well how the HIPAA regulations impact our daily professional lives, and for good reason. Dental/medical is now the fastest growing form of identity theft, and the government (i.e., HIPAA) wants to ensure that we do everything reasonably possible to safeguard our patient’s information.

DR. PAT LITTLE

Dr. Pat Little is a certified fraud examiner and the senior fraud examiner for Prosperident. He can be reached at pat@patlittle. com.

Dr. Little will be speaking at FDC2018 and presenting two courses on Thursday, June 21.

“Dental Financial Stewardship: A Total Team Approach” will be at 9 a.m. and “HIPAA Compliance, Data Breaches and Identity Theft: Don’t Get Bitten” will be later that day at 2 p.m.

So, how do scammers and hacker’s steal our private information? In many cases, it’s easy because many of us don’t take enough precautions. We practically give our information away! We tend to think of identity thieves as high-tech computer geeks, but many simply trick us into giving up our (and our patient’s) personal information.

One of the most common methods to gain private information is through a scheme called phishing. When we go fishing, we bait a hook and cast it out hoping to catch a fish. We don’t know how many or what kind of fish we are going to catch, but if we keep casting, we’ll eventually catch something. Internet phishing works on the same principle. Identity thieves send millions of email messages (the bait) designed to trick us into clicking on a link or email attachment (the prized fish). These emails often seem like they are sent by someone familiar, thus we don’t think anything of responding. Unfortunately, by clicking on the link or attachment, we unknowingly expose our data and privacy to these thieves.

Many phishing attempts are simple and are avoided by most. However, more targeted attempts, called spear phishing, appear more legitimate because the sender is supposedly a person or business we know well. Thus, we let our guard down and do as the email instructs. A common example is an email from what appears to be from your bank or credit card company. Since the email appears legitimate, we click on a link or open an attachment, and the damage is done. This can happen to anybody and the scammers know it!

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One simple technique that we all are capable of performing is simply don’t open email attachments without scanning them first.

So, what do we do? First, make sure all your devices are properly secured with the appropriate security software. It is vital to keep this software updated, as well. Second, always back up your data and understand how to restore it when needed. Granted, these take some level of technical understanding and that is why working with a good IT firm is vital for your dental practice.

However, one simple technique that we all are capable of performing is simply don’t open email attachments without scanning them first. Likewise, don’t click on links in emails without exercising extreme caution. For example, if you receive an email from your bank, consider logging in through the bank’s website instead. Yes, that is a little more inconvenient, but how inconvenient will it be if you and/or your patients become victimized?

Can you afford the loss of patient confidence? Can you afford the HIPAA fines? There is no way to eliminate online risk. However, with appropriate safeguards, we can minimize it.

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W E I V E R P AKER

NSAIDS Are Good, Decadron is Better

BY DRS. MARC GOTTLIEB AND JOSEPH KAMELGARD

Dr. Gottlieb is a general dentist with a practice in Levittown, NY, and can be reached at marc@ AnxietyFreeDental.com. He will be speaking at FDC2018 and presenting three courses. On Thursday, June 21, his workshop, “Impression Techniques, Concepts and Materials for the Dental Team” will be at 9 a.m., and “Simple Solutions for Financially $trapped Patients” will be at 2 p.m. On Saturday, June 23, “Game Changers You Never Learned in Dental School” will be at 10:45 a.m.

Dr. Kamelgard is a Board Certified General Surgeon and a Fellow of the American College of Surgeons and can be reached at kamelgard@gmail.com.

Both Drs. Gottlieb and Kamelgard have had no commercial support or conflict of interest in writing this article.

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After years of suffering with episodic acute back pain and medicating myself with nonsteroidal anti-inflammatory drugs (NSAIDs), I had an epiphany. It was December 2010, and my pain was so intense I couldn’t take it any longer and scheduled an appointment with an orthopedic surgeon. During the consultation, we reviewed how often I was taking NSAIDs to manage my distress. As a practicing dentist and dental anesthesiologist, taking a narcotic was not practical for me. The orthopedic surgeon offered me two immediate options: a steroid injection or a steroid dose pack. I decided to try the steroid dose pack. Within 24 hours, I was feeling significantly better. That’s when it hit me. I’ve been treating myself and my patients with NSAIDS, when I could be offering them locally infiltrated steroids. I will refer to locally infiltrated steroids from this point forward as injectable steroid anti-inflammatory drugs (INSAIDs).

After a brief literature review, I realized that — with rare exception — dental pain is acute and inflammatory in nature. Opioid medications only treat pain and do nothing to treat inflammation. NSAIDS administered prior to a procedure or immediately upon completion are effective in managing acute dental pain and swelling.1 However, there are significant side effects and many older patients cannot tolerate this class of medication.2 INSAIDs alone, or in combination with NSAIDs, appear to eliminate the need for addictive medications.

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In January 2011, I started injecting steroids into the buccal fold opposite areas of oral surgery. Within a week, I quickly realized my patients had significantly less pain and swelling compared to a narcotic analgesic or regular doses of 800 mg ibuprofen. Then, I expanded my use of INSAIDs to my endodontic and periodontic procedures with similar results. Six years ago, I wrote approximately 40 Vicodin prescriptions a quarter. This past quarter I wrote two.

Through two case studies, I will demonstrate how effective INSAIDs are in reducing inflammation and swelling with minimal complications. The first case is of a 20-year-old Caucasian man with “Mountain Dew mouth” (sugar-induced rampant decay) that required removal of all his upper teeth. The second case is a 94-year-old Caucasian man on multiple medications with a history of bleeding that required removal of his remaining lower anterior teeth with associated alveoplasty.

In the first case, this young man presented with multiple carious and abscessed teeth. His personal medical history was unremarkable, taking no prescription medications and denied any known drug allergies. All his upper teeth from second molar to second molar were broken down to the gingiva and non-restorable.

The plan for the lower arch was to restore and maintain a lower bicuspid occlusion. A full thickness flap was reflected from second molar to second molar with associated buccal alveo-

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plasty. Upon completion of the surgery, a continuous suture was placed and 6 mg of dexamethasone was infiltrated into the buccal fold evenly around the arch. After weighing the risk benefit ratio of NSAIDs, a single dose of 800 mg ibuprofen was administered before he left the office. He remained asymptomatic and pain-free for the entire recovery period (Figs. 1 and 2).

Aleve, aspirin and potassium. Our dental treatment plan was to remove his remaining five lower anterior teeth and place an immediate lower denture. Medical clearance was obtained from his physician and a pain-management strategy was established. Our plan was to infiltrate 4 mg of dexamethasone evenly in the buccal vestibule opposite the surgery in combination with 500 mg of acetaminophen taken by mouth every four to six hours as needed. The surgery went well with minimal bleeding. A full thickness flap from lower left cuspid (No. 22) to lower right cuspid (No. 27) was reflected with a buccal alveoplasty to remove a significant undercut. Then, the lower denture was inserted with a soft reline material. After 24 hours, he presented for his first follow-up visit with no pain, having never taken the acetaminophen (Figs. 3-6).

Fig. 1: Extraoral photo taken 24 hours after the surgery.

Fig. 3: Extraoral photo 24 hours after surgery

Fig. 2: Intraoral view.

Managing the pain of medically compromised patients can be a real challenge. They often have multiorgan disease and NSAIDs often are contraindicated due to advanced cardiovascular disease or drug interactions with their aspirin or other blood thinners. In the second case study, our 94-year-old man has limited mobility and requires a walker to reach the dental operatory. Clinical exam revealed the classic black-and-blue discoloration on the extremities and posture you would expect of a geriatric patient. His current medications are Atenolol, WWW.FLORIDADENTAL.ORG

Fig. 4: Intraoral view.

The dental literature is full of various levels of scientific evidence that steroids reduce the amount of pain and swelling following third molar surgery or orthognathic surgery.3 I’ve treated the other 28 teeth in the mouth for more than six SEE PAGE 64 TODAY'S FDA JANUARY/FEBRUARY 2018

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binds to specific steroid receptors acting as a corticosteroid hormone receptor agonist.4 The drug was first produced in 19575 and due to its myriad of uses, currently finds itself listed on the World Health Organization’s List of Essential Medicines.6 It can be found in solid form for oral administration as well as a soluble inorganic ester form for intravenous, intramuscular, intra-articular, soft tissue and intralesional injections. Additional preparations exist for use as eye drops and skin lotions. What makes dexamethasone such a valuable drug is its potent anti-inflammatory property in combination with its nearly complete lack of causing sodium retention (as compared to equipotent anti-inflammatory doses of hydrocortisone and closely related hydrocortisone derivatives).

The list of U.S. Food and Drug Administration- (US-FDA) approved uses for dexamethasone is extensive. It has approved label indications in endocrine disorders, rheumatic disorders, collagen diseases, dermatologic diseases, allergic states, ophthalmic diseases, gastrointestinal diseases, respiratory diseases, hematologic disorders, neoplastic diseases, edematous states, miscellaneous other conditions, diagnostic testing of adrenocortical hyper-function, cerebral edema associated with primary or metastatic brain tumor, craniotomy or head injury.

Additional indicated use for intra-articular or soft tissue injection exist, as well as those for intralesional injection.

Figs. 5-6: 48 hours showed increased bruising, but no significant swelling and no pain. Over the next six days, he required one sore spot adjustment and after 10 days, looked perfectly normal.

FROM PAGE 63

years with amazing success. I currently inject approximately 50 doses of Decadron (dexamethasone) every month for a variety of dental indications with inflammation. I use steroids cautiously when treating diabetics and haven’t used the medication on any patients under the age of 18. Diabetics will experience a temporary 24-hour increase in their blood glucose.

Dexamethasone appears to be a potent anti-inflammatory drug with minimal side effects (Fig. 7). My patients appreciate managing their discomfort without having to take opioid medications.

More about Dexamethasone Dexamethasone is a synthetic adrenal glucocorticoid, which

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Despite the long history of safety and extensive usage that is dexamethasone’s pedigree, there have been some newer uses that have been scientifically studied over the years for which there are no specific label indications. In general surgery, a single IV dosage at the end of a procedure was found to reduce the postoperative nausea experienced by patients, in addition to reduced pain scores reported. In dentistry, a single IV perioperative dose of dexamethasone had statistically significant analgesic benefits.7 Still others have found that a submucosal dexamethasone 4 mg injection is an effective therapeutic strategy for swift and comfortable improvement after surgical procedure, and has a significant effect on reducing postoperative pain and swelling.8 This last point can not be stressed enough. In the current environment of excessive opioid usage and addiction, having a protocol in one’s arsenal of pain management where narcotic medications are almost never needed is a powerful tool every dentist should be aware of. To be clear, however, despite the US-FDA label indications for acceptable uses of soft tissue injections of dexamethasone, treatment of acute dental procedure pain and prevention of postoperative opioid requirements is NOT a specified indication (but should be)!

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SPEAKER PREVIEW

References: 1. O’Neil, Michael The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell pg. 42 2. Weighing the Risk Benefit Ratio of NSAIDS personal communication with FDA 3/2017 3. Chen, Qian et al. Submucosal injection of Dexamethasone reduces postoperative discomfort after third-molar extraction. A systematic review and meta-analysis. JADA 2017:148(2):81-91 4. National Center for Biotechnology Information. PubChem Compound Database; CID=5743, https://pubchem.ncbi.nlm.nih.gov/compound/5743 (accessed Oct. 10, 2017).

WWW.FLORIDADENTAL.ORG

5. Rankovic, Zoran; Hargreaves, Richard; Bingham, Matilda (2012). Drug discovery and medicinal chemistry for psychiatric disorders. Cambridge: Royal Society of Chemistry. p. 286. ISBN 9781849733656. Archived from the original on 2016-03-05.

6. “WHO Model List of Essential Medicines (19th List)”(PDF). World Health Organization. April 2015. Archived(PDF) from the original on 13 December 2016.

Retrieved 8 December 2016.

7. Waldron, N. H., Jones, C. A., Gan, T. J., Allen, T. K., & Habib, A. S. (2013).

Impact of perioperative dexamethasone on postoperative analgesia and sideeffects: systematic review and meta-analysis. BJA: British Journal of Anaesthesia, 110(2), 191–200. http://doi.org/10.1093/bja/aes431 8. Shah, S. A., Khan, I., & Shah, H. S. (2011). Effectiveness of Submucosal Dexamethasone to Control Postoperative Pain & Swelling in Apicectomy of Maxillary Anterior Teeth. International Journal of Health Sciences, 5(2), 156–165.

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Bank of America is a registered 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 | flyer-0715-den-rep2 | ARVYXDWV | Rev. 11/17

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12/21/16 10:41 AM

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Opioid Use Disorder in the Dental Office:

Identifying Patients and Engaging Them in Conversation

BY JASON E. PORTNOF, DMD, MD, FACS; BRYAN NACK, DMD; STEVEN E. HAAS, DMD, JD, MBA; AND, STEVEN I. KALTMAN, DMD, MD, FACS

On Oct. 26, 2017, President Donald Trump declared the ongoing American opioid crisis a “Public Health Emergency.” This decree arrives on the heels of legislation introduced to Congress in April 2017 by Sens. John McCain and Kathy Gillibrand entitled the “Opioid Addiction Prevention Act of 2017.”1 This bill, if passed, will limit prescribing of opioids for acute pain to the lesser of a seven-day supply, or what is permitted by state law. The law excludes opioid prescriptions for chronic pain, cancer, palliative care and hospice.

In 2015, 3,228 Floridians died of a drug overdose, a 22.7 percent increase from 2014.2 This was the fourth-highest gross number of deaths, and the seventh-largest increase in deaths, by state for the year. Collier, Dixie and Monroe counties had the highest number of prescription opioid deaths in 2015.3 With the steadily increasing prevalence of opioid-addicted patients in Florida and the United States alike, it is imperative for the contemporary dental practitioner to be equipped to identify, intervene and refer these patients.

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Spotting a chronic opioid user is not an easy task. It involves excellent physical exam skills and a high level of clinical suspicion. The clinical triad of CNS depression, respiratory depression and pupillary miosis is the pathognomonic feature of acute intoxication.4 Nonspecific signs and symptoms may include constipation, ileus, needle track (if using injectable opioids, such as fentanyl or heroin), seizures, bradycardia, cyanosis, hypothermia, ventricular arrhythmias, orthostatic hypotension, nausea and vomiting. The antidote to opioid overdose is naloxone (Narcan).

The average onset of opioid withdrawal is at four to five days since last use, and may not peak until the 10th day.5 Typically, withdrawal symptoms are the opposite of those seen in intoxication.

Early symptoms of withdrawal may include agitation, anxiety, muscle aches, increased tearing, insomnia, runny nose and sweating. Later, patients may experience abdominal cramping, diarrhea, mydriasis, goosebumps, nausea and vomiting. Withdrawal symptoms can be precipitated in the dental office when giving naloxone to reverse IV sedation with fentanyl or other opiates. The patient must be monitored closely for

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development of these symptoms when using naloxone.

Longo et.al. described four characteristics seen in drug users: escalating use, drug-seeking behavior, doctor shopping and scamming.6 Escalating use is the increase in dose or frequency needed to control the patient’s pain. Drug-seeking behavior is a determined pursuit of additional medication to quench cravings.

For instance, the patient may steal from the medicine cabinets of family and friends, forge prescriptions or obtain illegally on the street. Doctor shopping is a routine of visiting many different doctors with the sole purpose of obtaining more medication. They may visit, for example, the orthopedist, family doctor and dentist, obtaining a prescription from each. Finally, scamming is manipulation of the practitioner in order to coerce them into writing a prescription.

For instance, the patient may threaten to sue, write a bad online review or to find a new dentist.

Prescription drug monitoring programs are online databases that have been created to reduce prescription drug misuse and prevent diversion. In Florida, the program is called E-FORCSE, or the Electronic-Florida Online Reporting WWW.FLORIDADENTAL.ORG

Support self-efficacy by providing encouragement and instilling confidence in the patient that they can conquer their opioid use disorder.

of Controlled Substance Evaluation.7 Upon login, practitioners can access the records of all Schedule II, III and IV prescriptions received by any patient.

The Patient Advisory Report shows date, dosage, number, prescriber and pharmacy for each prescription written. Suspicious practitioners can use this resource to identify opioid users, other substance users and doctor shoppers, and to guide their decisions when prescribing.

Once the practitioner has suspicion that their patient is an opioid user, they must engage them in a conversation about their use. Do not hesitate or be afraid to begin a conversation. At the same time, be calm, nonjudgmental and use openended questions to coax the patient into talking about their habits and goals.

Various strategies can be used to engage patients in conversations about their use. A particularly simple and effective method is the SMART Recovery program,8 which employs five steps to engaging a drug user about their use: develop a discrepancy, express empathy, amplify ambivalence, roll with resistance and support self-efficacy. When developing a discrepancy, the objective is for the patient to reflect on their future goals and realize that their drug WWW.FLORIDADENTAL.ORG

DR. JASON E. PORTNOF

use does not jive with those goals. For example, maybe the patient wants to go back to school or run a marathon, neither of which is feasible for a patient with severe drug use habits. Express empathy by making statements such as, “I know overcoming this addiction will be hard.� Amplify ambivalence by helping the patient to explore the part of themselves that wants to keep using, and the one that wants to quit. Rolling with resistance is possibly the most important step. A resistant patient is an indication that the practitioner must change his or her approach. The patient may not be ready for a change, or they may not want to stop their habit. Instead of becoming judgmental and making accusations, ask the patient whether the topic can be discussed at a future appointment, and change approaches when following up.

Lastly, support self-efficacy by providing encouragement and instilling confidence in the patient that they can conquer their opioid use disorder.

DR. BRYAN NACK

DR. STEVEN I. KALTMAN

With the increasing numbers of these patients presenting to the dental office, dental providers must have a plan in place to care for these patients. Once an opioid user is identified in the dental DR. STEVEN E. HAAS

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TAKING CARE OF RISKY BUSINESS COURSES TO HELP YOUR PRACTICE THRIVE! BENJAMIN DYCHES, DDS, JD  THURSDAY, JUNE 21 ESSENTIAL LEGAL CONCEPTS AND STRATEGIES TO PROTECT TODAY’S HEALTH CARE PROFESSIONALS * MICHAEL DEMEOLA, CPA,CFE  FRIDAY, JUNE 22 THE EPIDEMIC OF DENTAL EMBEZZLEMENT — DIAGNOSIS, TREATMENT AND PREVENTION * ROBERT ANDERTON  MITCH GARDINER JO JAGOR  RYAN DONIHUE  SATURDAY, JUNE 23 EVERYTHING YOU NEVER WANTED TO KNOW ABOUT A MALPRACTICE TRIAL

* THESE COURSES ARE FREE TO FDA MEMBERS! 70

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PLUS 10 MORE COURSES RELATED TO RISK & PRACTICE MANAGEMENT

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FROM PAGE 69

practice, it is time to refer the patient to a provider that specializes in addiction medicine. Dentists are not equipped for treatment of opioid use disorder, so it is imperative to form a referral network, since an increasing number of these patients are presenting to the office. A proper referral team may include a family practice physician, psychiatrist, psychologist, anesthesiologist, pain specialist, addiction specialist and pharmacist.

Practitioners should continue to follow up with the patient’s progress at future dental appointments after referral.

Finally, the Centers for Disease Control and Prevention (CDC) has taken a strong stance when it comes to opioid sales and has published new recommendations for health care practitioners who prescribe these medications. Prescribers should refer to a Guideline for Prescribing Opioids for Chronic Pain-United States 2016,9 information that is “intended to improve communication between clinicians and patients about risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy” (citation).

As of 2012, dentists ranked fourth among medical specialties for their opioid prescribing rate.10 Dentists write 12 percent of prescriptions for immediate release opioids and are by far the major prescribers of opioids for adolescent patients between the ages of 10-19.11 This is of particular importance as adolescent prescribing of opioids has been implicated in the major problem of drug diversion and opioid misuse serving as a gateway to addiction and heroin abuse. Nova Southeastern University College of Dental Medicine is committed to training the next generation of WWW.FLORIDADENTAL.ORG

dentists and specialists in the prevention and management of prescription drug misuse. Through core competencies longitudinally taught throughout the pre- and post-doctoral curriculum, students and residents are provided a solid foundation in prevention, identifying substance misuse disorders, managing complicated patients who require effective pain management and referring patients for appropriate treatment. In addition, interdisciplinary and interprofessional continuing education courses for the dental community on controlled substances abuse and safe prescribing practices are being designed. Similar guidelines should be adapted at other dental schools in Florida and nationwide.

This article briefly discussed how to identify opioid users and how to engage them in conversation about their use.

With the increasing frequency of these patients presenting to the dental office, these are essential skills for the modern dentist. For more information on this topic, please refer to “Opioid Use Disorder in Dental Patients: The Latest on How to Identify, Treat, Refer, and Apply Laws and Regulations in Your Practice” Anesth Prog. Fall 2017;64(3):178-187.

Citations

SPEAKER PREVIEW 5. Opioid withdrawal timelines, symptoms and treatment. American Addiction Centers. <https://americanaddictioncenters.org/withdrawal-timelines-treatments/opiate/> 6. Longo L, Parran Jr T, Johnson B, Kinsey W. Addiction: Part II. Identification and management of the drug-seeking patient. American Family Physician. 2000; 61(8): 2401-2408.

7. E-FORSCE, the Florida Prescription Drug Monitoring Program. <http://www.floridahealth.gov/statistics-and-data/e-forcse/> 8. Braastad J. Using motivational interviewing techniques in SMART Recovery. <http://www. smartrecovery.org/resources/UsingMIinSR.pdf> 9. Dowell, D., Haegerich, T.M., Chou, R. CDC Guideline for Prescribing Opioids for Pain – United States, 2016, MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: <http://dx.doi. org/10.15585/mmwr.rr6501e1> 10. Denisco R, Kenna G, O’Neil M, Kulich R, Moore P, et al. Prevention of Prescription Opioid Abuse. JADA. 2011; 142(7): 800-810.

11. Volkown N, McLellan T, Cotto J, et al.

JAMA.2011; 305(13): 1299-130.

Jason E. Portnof, DMD, MD, FACS is the director of pediatric craniomaxillofacial surgery and an associate professor of oral and maxillofacial surgery at Nova Southeastern University College of Dental Medicine (Nova). He can be reached at jp11@nova. edu.

Bryan Nack, DMD is a resident in the oral and maxillofacial surgery department at Nova, and can be reached at bmn780@gmail.com.

1. Sens. McCain, J and Gillibrand K. “Opioid Prevention Act of 2017.” U.S. Senate Bill 892.

115th Congress. 2017. <https://www.congress. gov/bill/115th-congress/senate-bill/892/text>

Steven A. Haas, DMD, JD, MBA is the associate dean of clinical services at Nova and can be reached at shdmdjd@gmail.com.

2. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015.

Weekly. 2016. 65(50-51): 1445-1452.

Steven I. Kaltman, DMD, MD, FACS is a chair and professor in the department of oral and maxillofacial surgery, and the associate dean of hospital affairs at Nova. He can be reached at skaltman@ nova.edu.

3. Drugs identified in deceased persons by Florida Medical Examiners. 2015 Annual Report.

Florida Department of Law Enforcement. Sept 2016.

4. Fareed A, Stout S, Casarella J, Vayalapall S, Cox J, and Drexler K. Illicit opioid intoxication.: diagnosis and treatment. Substance Abuse: Research and Treatment. 2011: 5.

Dr. Portnof will be speaking at FDC2018 and presenting his course, “Opioid Disorder in Dental Patients,” on Thursday, June 21 at 9:30 a.m.

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EXHIBIT HALL HOURS

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FRIDAY • JUNE 22, 2018 9 a.m. – 6 p.m.

C

SATURDAY • JUNE 23, 2018 9 a.m. – 2 p.m.

Ansell | Microflex Anutra Medical Inc. Aseptico Aspen Dental Atlanta Dental Supply Atlantic Dental Sales Inc.

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AA-dec A. Titan Instruments Accutron Inc. ACTEON North America ADS Florida | Henry Schein Professional Practice Transitions ADS Page Brown and Associates Advantage Technologies Advice Media AFTCO Air Techniques Alexion

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J OF

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9 a.m. – 6 p.m.

3D Diagnostix Inc. 3M Oral Care

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THURSDAY • JUNE 21, 2018

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Bank of America Practice Solutions Banyan Barksdale Dental Lab Belmont Equipment Benco Dental Benevis Practice Services Berryhill, Hoffman, Getsee & DeMeola LLC Bien-Air BioHorizons BIOLASE Biotec Inc. BirdEye Bisco Dental Products BQ Ergonomics LLC Brasseler USA

JANUARY/FEBRUARY 2018

CareCredit Careington International Carestream Dental Carl Zeiss Meditec Inc. Carr Healthcare Realty Certo International LLC ClearCorrect ClearGage Clorox Healthcare Colgate COLTENE Convergent Dental Inc. Cool Jaw

by Medico International Inc. Crest + Oral-B Crown Seating CUTCO Cutlery

D Dansereau Health Products Delta Dental Government Programs Demandforce DenMat Dental Care Alliance Dental Equipment Liquidators Inc. Dental Services Group of Clearwater DentalOne Partners Dentsply Sirona Designs for Vision Inc. DEXIS

Diatech Inc. DigiDent Labs Digital Dental Digital Doc LLC Digital Resource Doctor Multimedia Doctor’s Choice Doctors Disability Specialists DoctorsInternet.com Doral Refining Corporation

E-F Eclipse Loupes Envolve Benefit Options | Envolve Dental Inc. Essential Dental Systems FDA Supplies | SourceOne Dental Inc. First Citizens Bank Florida Combined Life Florida Dairy Farmers Florida Dental Association Florida Dental Association Foundation Florida Dental Association Services Florida Medical Advisors Florida Probe Corp.

Forest Dental Products Inc. Fortress Insurance Company Fortune Management Fotona

G Garfield Refining Company Garrison Dental Solutions GC America Inc. GlaxoSmithKline Glidewell Dental

WWW.FLORIDADENTAL.ORG

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These exhibitors have made a commitment to attend the Florida Dental Convention (FDC). Not only do these companies exhibit the latest in technology, materials and equipment, but many sponsor events and continuing education programs at the FDC.

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Look to see if your supplier is on the list. Make an effort to stop by their booth in the Exhibit Hall in June for exclusive show specials. Support these companies that support the Florida Dental Convention.

GoldenDent Great Expressions Dental Centers Greater New York Dental Meeting Greenberg Dental & Orthodontics GreenSky Patient Solutions LLC

H Hager Worldwide Halyard Health Hartzell Instruments Hawaiian Moon Heartland Dental Henry Schein Dental Henry Schein Practice Solutions HIOSSEN Hu-Friedy Hunza Dental

I i-CAT iCoreConnect Inc. ICW International Implant Direct Implant Educators INOVA Federal Insurance Credentialing Specialist integrated dental systems

K Karl Schumacher Dental KaVo Kerr Kettenbach LP Kuraray America

L Lares Research Legally Mine

WWW.FLORIDADENTAL.ORG

LendingClub Patient Solutions LIBERTY Dental Plan Lighthouse by Web.com LumaDent Inc.

M MacPractice Medidenta Microcopy Midmark Corporation Millennium Dental Technologies Inc. Modular & Custom Cabinets Ltd.

N-O National Dental Pulp Laboratory Inc. Neoss New Image Dental Laboratory Nobel Biocare NSK America Officite Orascoptic Ortho-Tain | HealthyStart

P Pacific Dental Services Patient News Patterson Dental PDT Inc. | Paradise Dental Technologies Pelton & Crane Perio Protect PerioChip By Dexcel Technologies PeriOptix Peter J. Freuler Jr., PA, CPA Philips Sonicare & Zoom Whitening Planmeca USA Inc. Porter Instrument Co. Inc.

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Power Dental USA Prestige Products Direct Professional Sales Associates Inc. Proma Inc. Prophy Magic Pulpdent Corporation

R-S RF America IDS RGP Dental Rose Micro Solutions Royal Dental Manufacturing Sage Dental SciCan Inc. SDI (North America) Inc. Serve First Solutions Inc. Shamrock Dental Co. Inc. Shofu Dental Corporation Sierra Dental Products Snap On Optics Solmetex LLC Sonendo Inc. Straumann Sunset Dental Lab Superior Dental Design Services & Upholstery SurgiTel

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V-W Vatech America VivioSites VOCO America Inc. Wand Dental Inc. (Milestone Scientific) Water Pik Inc. Wells Fargo Practice Finance

Z Zimmer Biomet Dental

Exhibitors in red are FDAS Crown Savings Merchants.

T-U The Doctors Company Thommen Medical U.S. Jaclean Inc. Ultradent Products Inc. Ultralight Optics Inc.

FDA SERVICES INC. IS A MAJOR SPONSOR OF THE FLORIDA DENTAL CONVENTION.

TODAY'S FDA JANUARY/FEBRUARY 2018

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TRANSITIONING

2.

1.

3.

Dr. Andrew Clark:

A Time For Transition 74

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DR. ANDREW CLARK completed his orthodontic residency at the University of Florida College of Dentistry in Gainesville, where Dr. Lucas Stevens served as a visiting professor. They often spoke about his practice in Tallahassee and Dr. Clark shadowed him several times during his residency to observe and learn how to run a practice. Dr. Clark admired Dr. Stevens’ work as a doctor and quickly learned that he was well-loved and respected in the community.

Shortly after Dr. Clark graduated from the residency program, Dr. Stevens’ sudden death took the Tallahassee community by surprise. While Dr. Clark spent the summer working with a corporate company, he stepped in to cover Dr. Stevens’ office a few days a week to keep the practice up and running. Ultimately, Dr. Clark and his wife, Langley, bought the practice in Tallahassee and fell in love with the city and its residents. The staff was wonderful during the transition and everyone worked hard to maintain relationships with all of Dr. Stevens’ patients during an emotional and sad time. The Clarks have been in Tallahassee for four and a half years, and in that time, have maintained minimal staff turnover while growing the practice. Dr. Clark is making Clark Orthodontics his own while continuing the vision Dr. Stevens created.

TFDA: How did this practice transition work?

AC: I felt that the transition went extremely smooth considering the difficult nature involved. Full credit goes to the staff and the current patients for entrusting me with their care and making it possible. Unfortunately, there was a threemonth lag before I was able to become the permanent orthodontist, which could have drastically compromised the practice, but the staff was amazing in being able to keep it afloat.

TFDA: What do you feel you did right during the transition?

AC: The most important part was putting current patients first. We made sure that their treatment was interrupted the least amount possible. Obviously, orthodontics is a business; but initially, I wasn’t focused on getting new patients. I wanted all current patients to get to know me, so I spent extra time at each appointment to make sure we developed a trusting relationship and they were comfortable with their treatment. Ultimately, that is what I felt we, as a team, did the best job on.

TFDA: Can you tell us about something you would do differently?

AC: During that three-month period, I was really pushing myself to my limits. I was working two days in Tallahassee and four days in Jacksonville — all while living in Gainesville with a two-year-old baby. I was driving two to three hours per day on top of a full day of work, and I wish that I had committed earlier and made the jump in sooner. It was a big decision for my family, and we took the time we needed to make the best decision. But in hindsight, if we had jumped in a little earlier it would have made everything easier for all involved.

TFDA: What is the best part of your day at the practice?

AC: Without a doubt, it’s when I remove braces/Invisalign and the patient first sees their new smile. I also like to bring up the initial photos so we can see the complete transformation. Orthodontic treatment is more than just teeth, there is improvement in facial structure and self-esteem.

Photos: 1. Enjoying some time on the beach with his family, (l to r) Dr. Clark, his Wife Langley, Daughters Emerson and Leighton.

2. A fish tank graces the operatory area.

3. Surf boards adorn the operatory.

WWW.FLORIDADENTAL.ORG

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COMPLEAT DENTISTRY

Insurance: Part 2 DR. EDWARD HOPWOOD

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

Compleat dentistry is a slower-paced, 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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In Part 1, I wrote about insurance and how it’s best to look at it as a useful tool that we can use to offset risk. I explained that insurance works when it follows three basic rules:

ably less than $400 per year. As dentists, we know how to control our own risk. We just need to get our patients to control their risk like we do.

1. The risk we are covering must be of sufficient size to be catastrophic.

The third rule probably is the one that’s most egregiously violated. Patients often will admit that they don’t do all they can to protect themselves from the risk. And insurance companies often don’t do all they can to help patients prevent problems. As dentists, one of our main roles is to help motivate and encourage our patients to work hard at prevention.

2. The risk must be an uncontrolled risk that both we and the insurance companies hope will never happen.

3. We do all that we can to make sure that it won’t happen or at least we try to protect ourselves from the risk.

I also wrote about how insurance tends to break down as a tool when it doesn’t follow these rules, using maternity insurance as an example. So, now let’s turn our attention to dental insurance.

Dental insurance does not cover catastrophic risk (Rule 1 violation). The normal maximum annual reimbursement for dental insurance is $1,500. So, by definition, it cannot be helpful to defray catastrophic risk.

Because the dental insurance companies have failed to keep pace with inflation, the product they sell no longer resembles insurance.

Dentistry is not an uncontrolled risk (Rule 2 violation) — not with the modern-day knowledge of prevention as well as the outstanding materials available to us. To demonstrate this, how much money does the average dentist spend on their dental care over an average 10-year period? It’s prob-

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Since dental insurance doesn’t follow the basic rules of insurance, we really shouldn’t call it insurance at all. It’s important to recognize that even the insurance companies have stopped looking at it as insurance.

That’s why they are trying to negotiate lower fees — touting that as the chief benefit to their clients — and why they haven’t even tried to keep up with inflation with their annual maximum reimbursements. That’s also why we are seeing all the shenanigans going on in Washington state.

In the 1970s, some practice management companies believed they could build a million-dollar practice by streamlining systems and introducing practice efficiencies to win at the insurance game. The math was simple: Get 1,000 patients with $1,000 yearly benefit, and make sure they get their full benefit. That was a quick way to a million-dollar practice.

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The problem with that approach is that it quickly becomes a game pitting the dentists vs. the insurance companies, with the insurance companies pushing to keep the dentists’ fees low and the dentists pushing to improve efficiency. And then, it becomes a “race to the bottom” (as Seth Godin so accurately describes it) in a quest for cheaper, faster, more efficient. This is like what we are witnessing with Uber drivers agreeing to ridiculously low fees, then complaining about low pay.

As I proceeded with my practice career, I found that I wasn’t that good at competing in the race to the bottom. So, I continued down my path toward compleat dentistry. Then, further along on my practice path, I found that I don’t hate insurance companies. I realized that they are simply selling a tool that has been misapplied for so long, it has morphed into something far different than what it was when it started.

I’ve also realized that dental insurance is not some benevolent big brother that comes in and helps us out when we are in trouble. When patients are presented with the need to have some dental work, they often ask, “Should I get insurance?”

I take the time to respond to them and explain how it is not appropriate to get insurance for a tooth that needs a root canal and crown (approximately double the annual maximum), just like you can’t go get homeowner’s insurance when your house is on fire. But for those patients who already have some sort of plan, we work to help them get their maximum benefit.

I now look at reimbursement schedules with the same dispassionate, actuarial mindset that the insurance companies use.

If the reimbursement is the same as our current fees, then it would be appropriate to be a provider for that plan — but, why bother? The insurance will get reimbursed just the same. If the reimbursement is less than our current fees, then it is not appropriate to sign up as a provider. There should be no emotion in that decision. It’s a business decision, and reducing your fees to be on some list is a poor business decision. I honestly don’t believe that the insurance companies are working hard so their preferred providers can grow their practices. Further, different fees for patients based on what type of plan they have is simply not fair.

Rather than working to increase speed and efficiency while decreasing costs, I no longer participate in the race to the bottom. I use an entirely different approach: We work to build a relationship with the patient first and foremost, then try to establish health and look for ways to make it affordable for our

WWW.FLORIDADENTAL.ORG

SINCE DENTAL INSURANCE DOESN’T FOLLOW THE BASIC RULES OF INSURANCE, WE REALLY SHOULDN’T CALL IT INSURANCE AT ALL. IT’S IMPORTANT TO RECOGNIZE THAT EVEN THE INSURANCE COMPANIES HAVE STOPPED LOOKING AT IT AS INSURANCE.

patients. Often, treatment can be phased over many years to help our patients affordably receive exceptional care. But the most important point is this: Over the course of a lifetime, I honestly believe it is cheaper to pay for compleat dentistry, regardless of insurance.

So, when a patient asks, “Do you take my insurance?” I am comfortable to answer, “Yes, as long as it isn’t one of those plans that tells you that you aren’t allowed to come to our office.” I’m not on any lists, but we always work hard to help our patients receive their maximum reimbursement for any procedure we complete. We have one fee schedule that is the same for all our patients. Interesting enough, our current fees are always well within the norms for the published fees for our area. And I don’t have a love/hate relationship with insurance companies — just like I don’t have a love/hate relationship with any of the tools in my workshop.

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Contact us us Contact

MM ain Office • 1101 DOuglas avenue • altaMOnte springs, fl 32714 ain Office • 1101 DOuglas avenue • altaMOnte springs, fl 32714 telephOne : :(407) 439-1001 ••ttelefax elefax (407)331-3030 331-3030 telephOne (407)331-6620 331-6620 •• (850) (850) 439-1001 : :(407) By ppOintMent ve., ., sste te.. 500 500••OOrlanDO rlanDO , lfl32801 32801 Byaa ppOintMent••37 37n. n. O Orange range a ave ,f By a ppOintMent • 201 e. g OvernMent s treet • p ensacOla , f l 32502 By appOintMent • 201 e. gOvernMent street • pensacOla, fl 32502 ByBa ppOintMent • 155 e.

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424 • f Ort c Ollins ,c 80525 y appOintMent • 155 e. BOarDwalk rive, ste. 424 • fOrt cOllins, c OO 80525 ww eBsites .t cOM •• www www.h .health ealth ttOrneys .cOM eBsites• •www www .the heh health ealthl law awfirM.cOM aa ttOrneys .cOM

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REPRESENTATION OF REPRESENTATION OF DENTISTS DENTISTS Werepresent representdentists, dentists, dental dental practices practices and We anddental dentalpersonnel. personnel.

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BY DRS. FARAJ AL OTAIBY, JASBIR UPADHYAYA, RESIDENTS IN ORAL AND MAXILLOFACIAL PATHOLOGY; NADIM M. ISLAM; NEEL BHATTACHARYYA; AND, DONALD M. COHEN

A 69-year old female presented to Dr. Daniel Convey, an oral and maxillofacial surgeon in Norfolk, Neb., for evaluation of a painful, erythematous and ulcerative lesion in the facial and palatal alveolar mucosa posterior to teeth Nos. 2-3 area (Fig. 1). The lesion extended from the molar area to the maxillary tuberosity and posteriorly to the right side of junction of hard and soft palate. Areas of erythema and ulceration covered by yellowish fibrinous exudate and necrotic tissue were present.

The patient reported that the lesion was present for the last two months and was painful. No significant medical history was provided. Dr. Convey’s clinical impression was a squamous cell carcinoma. He performed an incisional biopsy and submitted the tissue to the University of Florida College of Dentistry Oral Pathology Biopsy Service for histopathologic examination and interpretation.

Fig. 1: Lesion in the palatal and alveolar mucosa demonstrating ill-defined erythema with ulceration and focal necrosis.

Question: Based on the clinical findings, what is the most likely diagnosis?

A. Squamous cell carcinoma B. Malignant salivary gland neoplasm C. Lymphoma D. Necrotizing sialometaplasia E. Histoplasmosis

Fig. 2: Scattered epithelioid macrophages, admixed with lymphocytes and plasma cells, containing multiple round “dot-like” organisms of Histoplasma capsulatum (shown with green arrows).

SEE PAGE 80 WWW.FLORIDADENTAL.ORG

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DIAGNOSTICS FROM PAGE 79

Diagnostic Discussion A. Squamous cell carcinoma Incorrect, but an excellent choice.

Squamous cell carcinoma (SCC) is consistently a major concern if non-healing ulcerations exist in the oral cavity, especially in the elderly. The palatal (hard palate) involvement is not as common as other intraoral sites, such as lateral sides of the tongue, ventral tongue and floor of the mouth. Squamous cell carcinoma is well-known for its ability to mimic a variety of conditions and show different clinical presentations such as swelling, induration, erosion and specifically, surface ulceration. However, in most cases SCC presents as an asymptomatic lesion with leukoplakic or erythroplakic changes in the surrounding mucosa. In contrast, the ulcerated lesion present in our patient was painful and not indurated. Furthermore, the histologic feature was pathognomonic for the condition and could not be confused with the diagnosis of a SCC (Fig. 2). However, it is prudent to include carcinoma in the differential diagnosis of any nonhealing ulcer in the elderly, and a biopsy is necessary to rule out this potentially life-threatening disease.

B. Malignant Salivary Gland Neoplasms Incorrect, but a good differential. The most common location for malignant salivary gland tumors is the palatal mucosa. Mucoepidermoid carcinoma (MEC) and adenoid cystic carcinoma (ACC) are the most common malignant salivary gland neoplasms, which occur

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in patients with a wide age range (from the third to the seventh decades). These can present as a raised area with painful ulcerations, although pain is a more frequent symptom in ACC. Like any other malignant neoplasm, these lesions also demonstrate erosion and/or perforation of the underlying bone. Alveolar gingiva does not have minor salivary glands and is unlikely to be the origin of the neoplasm unless it is invaded by a salivary gland adenocarcinoma from adjacent sites, such as palate or buccal mucosa.

Most of those malignancies present initially as a mass rather than ulcer, which might develop ulceration in later stages. The lesion noted in our patient manifested as an ulcer initially, not a mass (Fig. 1). Histologically, malignant salivary neoplasms demonstrate cells of ductal and/or myoepithelial origin, which were easily distinguishable from the microscopic findings seen in the presented lesion (Fig. 2).

C. Lymphoma Incorrect, but a good guess. Lymphoma can clinically present as erythema, swelling and even ulceration with a boggy presentation such as our case. It can affect different oral tissues, involving the vestibule, palate, non-healing extraction sockets and gingiva. Diffuse large B-cell lymphoma (DLBCL) is the most common form of non-Hodgkin’s lymphoma, which most commonly affects middle-aged males with an average age of 60 years. Unfortunately, the incidence of lymphomas is increasing each year and these now comprise the second most common malignancy found in the oral cavity after squamous cell carcinoma. Lymphomas are aggressive neoplasms and usually present as a rapidly enlarging mass in the soft tissues or as a vaguely painful destructive process within the bone. Due to the pain, they often are mistaken for a toothache. Most

JANUARY/FEBRUARY 2018

patients with DLBCL have no symptoms and unlike our patient, significant pain is absent in the majority of lymphoma cases. Night sweats, fever, itching and the aforementioned fatigue are common signs of B-cell lymphoma in some patients, and these signs are important clues to the diagnosis. Our patient did not complain of any signs of consistent weight loss, fever or fatigue.

D. Necrotizing sialometaplasia Incorrect. Necrotizing sialometaplasia most frequently occurs in the posterior palatal salivary glands. However, the palatal lesions exist closer to the midline rather than the alveolar ones due to the absence of salivary glands in that area.

Necrotizing sialometaplasia affects adult males nearly twice as often as females.

The condition initially appears as a nonulcerated swelling often associated with pain or paresthesia. Within two to three weeks, the tissue sloughs out leaving an ulcerated area. In addition, most of the lesions appear as a deep ulceration and the patient may complain that a “part of my palate fell out” and the pain often subsides. The lesion typically resolves on its own in five to six weeks. In contrast, the ulcer in this patient — which appeared shallow — was painful and had been there for more than eight weeks (Fig. 1). Necrotizing sialometaplasia most likely is a consequence of ischemia as a result of trauma to the salivary tissue. No history of trauma was reported by our patient.

E. Histoplasmosis Correct. This is an infrequent infection of the oral cavity and usually is associated with disseminated infection caused

by Histoplasma capsulatum, a dimorphic fungal organism. Oral histoplasmosis occurs in individuals with disseminated disease, in which older adults and immunocompromised folks are at risk.

Histoplasmosis was one of our clinical WWW.FLORIDADENTAL.ORG

concerns given the patient’s age along with the necrotic and painful appearing ulcer on the palate and alveolar mucosa.

The clinical presentation of histoplasmosis varies and may manifest as ulcers, raised granulomatous mass, verrucous or thickened plaque-like lesions.

Histoplasmosis is one of the more common infectious diseases in immunocompromised patients. The causing organism is mostly isolated from soil contaminated with bird or bat feces in endemic areas (such as areas drained

by Ohio and Mississippi rivers in the United States). Warm and humid temperature makes a favorable environment for growth of the fungus. The infection occurs mainly by inhalation of fungal spores. The course of histoplasmosis depends on many factors, specifically the host’s immune status, the amount of the inhaled infective spores and probably the strain of H. capsulatum.

Healthy individuals or patients who inhale a small number of spores are typically asymptomatic because their immune system is appropriately able to clear the spores or the spore number is not enough to induce symptoms.

However, nonspecific symptoms such as flu-like illness can be seen. On the other hand, the symptoms might be lethal in severe disseminated conditions in immunocompromised patients.

Many organs can be involved in disseminated histoplasmosis, including the upper aerodigestive tract and oral cavity. Immunosuppression, due to organ transplantation, chronic renal disease, prolonged use of corticosteroids, AIDS or even advanced age, is the most important predisposing factor in the development of disseminated infection.

Intraorally, the most commonly affected sites are the tongue, palate and buccal mucosa. Lesions inside the oral cavity WWW.FLORIDADENTAL.ORG

apparently indicate to the presence of disseminated disease and major immune suppression.

DIAGNOSTICS

The microscopic examination revealed large numbers of fungal organisms distributed sparsely within the biopsy tissue (seen as multiple round structures in Fig. 2). A prominent histiocytic proliferation interspersed by plasma cells and neutrophils is discerned. Special stains used to confirm presence of fungal organisms, namely periodic acidSchiff and Grocott’s methenamine silver were positive for the organism. Interestingly, prominent pseudoepitheliomatous hyperplasia can be seen histologically in association with histoplasmosis.

This feature is crucial because it could be misdiagnosed as a squamous cell carcinoma with subsequent unnecessary resection and significant morbidity.

References: Akin L, Herford AS, Cicciù M. Oral presentation of disseminated histoplasmosis: A case report and literature review. J Oral Maxillofac Surg. 2011 Feb;69(2):535-41.

Antonello VS, Zaltron VF, Vial M, Oliveira FM, Severo LC. Oropharyngeal histoplasmosis: report of eleven cases and review of the literature. Rev Soc Bras Med Trop. 2011 JanFeb;44(1):26-9.

Muñante-Cárdenas JL, de Assis AF, Olate S, Lyrio MC, de Moraes M. Treating oral histoplasmosis in an immunocompetent patient. J Am Dent Assoc. 2009 Nov;140(11):1373-6.

Viswanathan S, Chawla N, D’Cruz A, Kane SV. Head and neck histoplasmosis — a nightmare for clinicians and pathologists! Experience at a tertiary referral cancer centre. Head Neck Pathol. 2007 Dec;1(2):169-72.

Narayana N, Gifford R, Giannini P, Casey J. Oral histoplasmosis: an unusual presentation.

Head Neck. 2009 Feb;31(2):274-7.

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.

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

DR. ISLAM

Clinicians are invited to submit cases from their own practices.

Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter.

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

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 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.

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General Dentist Opening — South Florida and Orlando Markets. Looking for an opportunity with a successful and growing company? Sage Dental currently has opportunities for qualified General Dentists & Specialists at our South and Central Florida practices. Sage Dental offers you: Excellent Earning Potential — Sage Dental operates more efficiently and we share the results with our doctors through a higher compensation model. Ability to Focus on Patient Care — By delegating all the management and administrative stresses to us, our doctors can focus on providing the best patient care possible. State-of-the-Art Facilities — Our dentists enjoy working in state-of-the-art facilities with the latest dental technology and equipment.

Quality of Life — Since you don’t have to worry about insurance claims, payroll, staffing, accounting and marketing, you have the time to enjoy everything Florida life has to offer, including our many golf courses and beautiful beaches. If you are ready to take the next step in your career as a General Dentist or Specialist and want a position with excellent earning potential, Sage Dental has what you are looking for. Apply today! Contact: Bradford Cabibi - Doctor Recruitment, Email: bcabibi@mysagedental.com, careers@mysagedental.com; website: http://www. mysagedental.com/, https://www.mysagedental.com/ career-opportunities/; Phone: 561-999-9650 Ext. 6146, Fax: 561-526-2576.

Endodontist — Supplement your Schedule in Ocala!

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. We are interested in speaking with Endodontists to join our team one day a week. This is a great opportunity to supplement your schedule. Our specialists enjoy a built-in referral system from our general dentists. We are firm believers that the practice of dentistry must always be based on the doctor-patient partnership. That means that our behavior must demonstrate a conviction of honesty and the utmost integrity. Dentists are given full clinical autonomy so they can work with patients in choosing the best course of action for treatment and prevention. Social responsibility is one of Christie Dental’s core values. Whether it is partnering with the Brevard County Schools Supply Zone, participating in the Making Strides against Breast Cancer Walk, sponsoring the local little league team, or being involved with Reach Out and Read book drives, we are proud to support the Marion, Brevard and Osceola communities. DDS/DMD/BDS, Certificate in Endodontics, FL State Dental License or eligibility. kateanderson@ amdpi.com.

Endodontist — Melbourne Supplement your Schedule! 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. We are interested in speaking with Endodontists to join our team one day a week in Melbourne. This is a great opportunity to supplement your schedule. We are firm believers that the practice of dentistry must always be based on the doctor-patient partnership. That means that our behavior must demonstrate a conviction of honesty and the utmost integrity. Dentists are given full clinical autonomy so they can work with patients in choosing the best course of action for treatment and prevention. Social responsibility is one of Christie Dental’s core values. Whether it is partnering with the Brevard County Schools Supply Zone, participating in the Making Strides against Breast Cancer Walk, sponsoring the local little league team, or being involved with Reach Out and Read book drives, we are proud to support the Marion, Brevard and Osceola communities. DDS/ DMD/BDS, Certificate in Endodontics, FL State Dental License or Eligibility. kateanderson@amdpi.com.

JANUARY/FEBRUARY 2018

General Dentist — Sign on Bonus! 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. We are firm believers that the practice of dentistry must always be based on the doctor-patient partnership. That means that our behavior must demonstrate a conviction of honesty and the utmost integrity. Dentists are given full clinical autonomy so they can work with patients in choosing the best course of action for treatment and prevention.

Doctors are supported with a network of resources and support, including mentor programs, leadership opportunities, continuing education and even a clear path to ownership. New dentists are able to shadow and learn from experienced professionals in their field, and seasoned professionals appreciate the camaraderie and collaborative environment. Social responsibility is one of Christie Dental’s core values. Whether it is partnering with the Brevard County Schools Supply Zone, participating in the Making Strides against Breast Cancer Walk, sponsoring the local little league team, or being involved with Reach Out and Read book drives, we are proud to support the Marion, Brevard and Osceola communities. Christie Dental is 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 established mentor programs and leadership opportunities. DDS/DMD/ BDS, FL State Dental License or Eligibility, Min 2 years’ experience. kateanderson@amdpi.com.

General Dentist-Full time in Melbourne! 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. We’re interested in talking with Doctors to join our team in the Melbourne area We are firm believers that the practice of dentistry must always be based on the doctor-patient partnership. That means that our behavior must demonstrate a conviction of honesty and the utmost integrity.

Dentists are given full clinical autonomy so they can work with patients in choosing the best course of action for treatment and prevention. Doctors are supported with a network of resources and support, including mentor programs, leadership opportunities, continuing education and even a clear path to ownership. New dentists are able to shadow and learn from experienced professionals in their field, and seasoned professionals appreciate the camaraderie and collaborative environment. Social responsibility is one of Christie Dental’s core values. Whether it is partnering with the Brevard County Schools Supply Zone, participating in the Making Strides against Breast Cancer Walk, sponsoring the local little league team, or being involved with Reach Out and Read book drives, we are proud to support the Marion, Brevard and Osceola communities. DDS/DMD/BDS, FL State Dental License or eligibility. NOTES: Additional Salary Information: Christie Dental is 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 established mentor programs and leadership opportunities. kateanderson@amdpi.com.

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Associate General Dentist. Pelican Landing Dental located Bonita Springs, FL - (SW FL, basically Naples).

We are a family-owned (my wife and I both practice FT here), high-end, 100% FFS, general practice.

Many of your questions can be answered by going to PelicanLandingDental.com. We are seeking an Associate Dentist - We are very willing to mentor an enthusiastic, but quality driven dr. We are NOT looking for a dr who has “been doing forever and has it all figured out.” My wife and I are continuing education junkies and we put great attention into the quality of our work and the business operations of our practice.

Therefore, our associate will need to: A) look the part and communicate well (most of our pts are retired midwesterners, age 60-85); B) be eager to fit into our high quality driven system; C) care deeply about the quality of their work; D) treat patients like family.

Compensation range from 175k-300k depending on skill set - Assoc Dr. will see in excess of 30 new patients a month, we charge $1670 for a B/U and Cr, and our case acceptance is 80% our better - which we’re planning on teaching patient communication/ case presentation skills to the assoc dr. FT preferred, but 3 days a week is acceptable. At least 1 yr clinical experience or Residency. drrichgilbert@gmail.com.

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 Fax 407-327-1018 or email doctor@newsmiledentistry. net. FL Dental License, DEA, NPI, Malpractice Ins. Ability to start soon.

Pediatric Dentist -Tampa, FL. Available January 2018.

Private Pediatric dental practice - Non-corporate. Two office locations in the Tampa bay area. One office has 8 chairs and is 5 days a week. 2nd office has 6 chairs with potential for growth. An ideal candidate I am seeking is full time, 5 days per week. All PPO and feefor-service patients in both practices. High-income potential approximately 300,000+ for the first year.

Both offices have digital radiographs and charting.

In office IV sedation provided for the larger office location. Fully trained and certified staff in place with orthodontics provide in both locations by an orthodontist. Full autonomy over treatment plans. Position is available starting January 2018. Must have a current Florida dental license, previous experience in private practice is preferred but not necessary. Must have graduated or soon to graduate from a certified pediatric dental residency program. Candidate should have excellent communication skills and enjoy a fast pace, fun work environment. We are now interviewing qualified candidates so if interested please email current CV to, sugarbugdude@gmail.com. Prior to interviewing we ask you to sign a non-disclosure agreement in order to protect our practice information. We are looking forward to speaking further about this amazing opportunity with an interested candidate. CV to sugarbugdude@gmail.com. Requirements: Must have a current Florida dental license. Previous experience in private or corporate offices is preferred. Must be a pediatric dental specialist. No general dentist limited to children. Excellent communication and people skills. Must enjoy a fast-paced work environment.

NOTES: Additional Salary Information: % of Collections and/or Daily minimum guarantee.

GENERAL DENTIST - PRIVATE FFS/PPO, TAMPA AREA. At Apollo Beach Dental Excellence, we boast a team of dental professionals dedicated to creating and maintaining healthy, beautiful smiles. In a safe, comforting environment, we provide meticulous, uncompromising, state-of-the-art dentistry to each and every patient. We are a private PPO/FFS dental office.

We do not accept HMO/Medicaid. We have a wonderful team dedicated to the success of our patients, dentist, and our office. We are a family practice located in APOLLO BEACH FL, 15 mins south of TAMPA in Hillsborough county. Our great team focuses on an outstanding patient experience and convenient patient hours. This is a terrific opportunity for a patient focused, versatile, team oriented Associate Dentist!

We are an outstanding practice looking for a terrific Associate Dentist! Be a dentist that will have clinical freedom and autonomy enjoyed in our traditional private practice without the financial or administrative burdens associated with practice management. Must -Have great communication / people skills. -Perform general dentistry, composite fillings, crown/bridge, dentures/partials, preventive care, surgical extractions, implant restores, and dental emergencies. Earn GREAT pay treating patients on their time!! On your time off enjoy the beautiful Tampa Bay area. Perks of being a dentist at our Practice: Paid CE, 3 weeks paid time off, 401k; 6-hour work day, no weekends or holidays — have that work/life balance we all desire; Guaranteed salary plus bonus; Bonus paid on % of production, NOT collection - concentrate on patient care and not office collections. Essential Job Responsibilities: Diagnose and treat oral health conditions in accordance with the Office Treatment & Diagnosis Policy in the H/R Manual; Examine patients, review medical history, develop and present a preventive and restorative treatment plan; Prescribe medications appropriately; Address clinical issues promptly and accurately; Provide treatment for fillings, broken teeth, replacement of teeth, root canals, extractions and other treatments as necessary; Perform daily Post Op calls to any patients that received surgery or root canals; Available by phone for after hour emergencies; Ensure compliance with OSHA and dental board procedures. admin@apollobeachdental.com.

General Dentist Associate for a Private Office in Orlando FL. An Excellent opportunity for a General Dentist to join an Upscale Private Established Dental Office North of 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% FFS/PPO. - (No HMO/ No Medicaid). 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 plus base salary with a huge potential for the right person, in addition to the on-the-job experience, mentoring

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Endodontist, Dentist. A traditional fee-for-service general practice seeks full- and part-time associates and endodontists. Experience preferred. Offices in the Tampa Bay, FL area include Clearwater, Largo, Pinellas Park, St. Petersburg, and Bradenton. Established in 1981. Immediate income, paid vacation, health insurance, 401k, flexible days. No capitation. Send CV to Corp@FloridaDentalCenters.com, fax: (727) 445-8382 or call: (723) 461-9149.

General Dentist for Private Practice in Port Charlotte, FL. Experienced General dentist needed for a full or part time position in a well-established private practice. Busy practice offers tremendous earning potential. Great community, staff and patients. Please e-mail your resume to familydentistry18400@gmail. com. Valid Florida license, valid DEA number, current malpractice insurance.

General Dentist. As a dentist with an Aspen Dentalbranded practice you are not only making a statement that you are committed to providing quality dental care but you are also becoming a part of a collaborative network of dental professionals. We’re on a mission to give America a healthy mouth. For an estimated 47 million Americans, lack of access to affordable dental care is a real problem and by aligning with Aspen Dental you can be part of the solution. As an Aspen dentist, you can expect to see a steady flow of new patients every day that are ready to get their smile back. Daily procedures include restoration (fillings), crown and bridge and core build-ups (veneers, onlays, inlays), extractions, removable prosthodontics, and providing comprehensive treatment plans. And at the end of the day you’ll find your career is truly rewarding. As a dentist, you’ll have clinical autonomy and be able to focus your entire day on providing quality patient care. You will have the support of highly skilled, trained office staff and the operational and administrative aspects of the practice will be taken care of by Aspen Dental Management, Inc’s (ADMI) business teams. You can enjoy access to free continuing education and training through the Doctor Development Program, as well as the opportunity to own your own practice through the Practice Ownership Program. What Is Offered: Aggressive Compensation Package; Premium Benefits Package; Sign on Bonuses for select locations; Relocation Assistance; State-of-the-Art Practices. About Aspen Dental-branded practices: Aspen Dental-branded practices are independently owned and operated by licensed dentists. The practices receive non-clinical business support services from Aspen Dental Management, Inc., a dental support organization. Educate patients on oral health. Complete comprehensive full mouth exams and diagnose dental conditions. Assess treatment planning options and discuss with patient.

Carry out agreed clinical treatments. Maintain patients’ medical records. Maintain an awareness of the budget and work in conjunction with operations team to attain financial objectives of the office. Keep abreast of new developments in dentistry through structured continuing professional developments. Must be a DDS or DMD from an accredited school. mioconnor@ aspendental.com.

Part Time Pediatric Dentist. Our thriving Orlando, FL private practice office is seeking a part time associate to join our busy practice. We have a modern office, a wonderful patient base, and a loyal and committed team. We are looking for a fun, caring, compassionate individual committed to providing excellence in total oral health care to our little patients (and big ones).

Our office creates an environment that encourages family-centered preventative care and a team approach with our parents and children. Our practice is committed to excellent service that exceeds the expectations of our patients and their parents. Our goal is to build trust with our patients and parents and make each and every visit a positive experience. We are located in a very desirable area of sunny Orlando, FL. This opportunity is perfect for the individual interested in working part time with the potential for full time. We offer a competitive compensation and benefits package including health insurance and 401k.

To become part of our outstanding team, email your C.V. to mlkdentistry@icloud.com.

TODAY'S FDA JANUARY/FEBRUARY 2018

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FEELING THE L VE JOHN PAUL, DMD DR. PAUL IS THE EDITOR OF TODAY’S FDA. HE CAN BE REACHED AT JPAUL@BOT. FLORIDADENTAL.ORG.

Judging by my observations of human kind, most of today’s problems are due to too little or too much love. Our feelings for our fellow man or woman are either so lacking that we are soulless oafs without empathy to care for those who do not enjoy the same fortunes as ourselves, or our feelings are so great they overwhelm us or the focus of these emotions. I don’t make light of the extremes. No one should be the victim of a crime or be ignored and swept aside by society, and anyone in those circumstances has my compassion. Those of us who spend some — if not all — of our time in between those extremes also have my compassion.

Often, there literally aren’t any words to adequately describe our feelings. The ancient Greeks had at least six different words for love that we have distilled down to one word that depends on context and inflection for meaning.

I posit that if we were better able to express ourselves about appropriate positive feelings for each other, we might all spend our lives living with more harmony and less discord. Dante’s “Divine Comedy” had nine levels of hell describing an increasing lack of love for others. I recommend five levels of affirmative caring or love for one another.

LEVEL 1: If I found you lying across my path, I would gently step over you so as not to cause you harm.

LEVEL 2: If I found you lying across my path, I would gently move you from the path so that I and others would cause you no harm.

LEVEL 3: I have a truck and I will help you move to a new home. This describes how most of us see our patients — deserving of the skills we learned in school.

LEVEL 4: You never have any money and I am happy to pay for your meals, your drinks and your movie tickets because life is better when you are around.

LEVEL 5: I will share my toothbrush with you. You don’t have to be a dentist to realize this is the deepest feeling one person can have for another.

JOHN PAUL, DMD EDITOR, TODAY'S FDA

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