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F l o r i da

D e n ta l

A sso c i at i o n

TODAY’S FDA

8.5 Tips for Dental Safety Checklists Management of the Anxious Dental Patient Licensure renewal Five Factors to Dramatically Improve the Patient Experience

VOL. 25, NO. 6 SEPTEMBER/OCTOBER 2013


New plans beginning Oct. 1. Find out nOw how to get your health plan. HealtHcare reForm aNd SubSidy iNFormatioN available A Member Benefit Since 1989 800.877.7597 insurance@fdaservices.com www.fdaservices.com

A wholly owned subsidiary of the Florida Dental Association


contents cover story

40

8.5 Tips for Dental Safety Checklists

news

columns

18 Health Care Reform

3

Staff Roster

21 Board of Dentistry

5

President’s Message

35 Licensure Renewal

7 Legal Notes

69 Florida Department of Health Cuts Complaint Response Time

11 Information Bytes 13 news@fda 46 Diagnostic Discussion

features

80 Off the Cusp

22 Florida’s First Mission of Mercy Program 26 Dental Treatment of the Pregnant Patient 39 Leading an Insurance Team that Puts Members First

classifieds 74 Listings

54 Management of the Anxious Dental Patient 62 Five Factors to Dramatically Improve the Patient Experience 78 Your Team’s Personal Appearance

Read this issue on our website at:

www.floridadental.org.

www.floridadental.org

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

September/October 2013

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candidates sought for fda leadership

florida dental assocIation september/october 2013 VOL. 25, NO. 6

editor Dr. John Paul, Lakeland, Editor

staff Jill Runyan, publications manager • Jessica Lauria, publications coordinator Lynne Knight, marketing coordinator

council on communications Dr. Thomas Reinhart, Tampa, chairman Dr. Roger Robinson Jr., Jacksonville, vice chairman Dr. Richard Huot, Vero Beach • Dr. Scott Jackson, Ocala Dr. Marc Anthony Limosani, Miami • Dr. Jeff Ottley, Milton Dr. Jeannette Hall, Miami, trustee liaison • Dr. John Paul, editor

board of trustees

FDA speAker oF the house Deadline: Feb. 28, 2014 Elected by the FDA House of Delegates Duties: preside over all meetings of the House of Delegates; serve as ex officio parliamentarian of the Board of Trustees; and review all proposed resolutions of the Board of Trustees, councils and committees of the House.

FDA eDitor Deadline: Feb. 28, 2014 Appointed by the FDA Board of Trustees Duties: editorial supervision of all FDA publications; appoint volunteer associate editors as needed; and maintain open communications with other entities affiliated with the FDA.

For more information, call Rusty Payton, FDA chief operating officer, at 800.877.9922.

Dr. Terry Buckenheimer, Tampa, president Dr. Richard Stevenson, Jacksonville, president-elect Dr. Ralph Attanasi, Delray Beach, first vice president Dr. William D'Aiuto, Longwood, second vice president Dr. Michael D. Eggnatz, Weston, secretary Dr. Kim Jernigan, Pensacola, immediate past president Drew Eason, Tallahassee, executive director Dr. David Boden, Port St. Lucie • Dr. Jorge Centurion, Miami Dr. Stephen Cochran, Jacksonville • Dr. Lee Cohen, Palm Beach Gardens Dr. Don Erbes, Gainesville • Dr. Don Ilkka, Leesburg • Dr. Jolene Paramore, Panama City Dr. Rudy Liddell, Brandon • Dr. Tom Ward, Miami Dr. Ethan Pansick, Delray Beach, speaker of the house Dr. Paul Miller, New Port Richey, treasurer • Dr. Bryan Marshall, Weekiwachee, treasurer-elect Dr. John Paul, Lakeland, editor

publishing information Today’s FDA (ISSN 1048-5317/USPS 004-666) is published bi-monthly, plus one special issue, by the Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. 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 2013 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, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.

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, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. 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 Applications available from your component dental association or the FDA website: www.floridadental.org/leadership-roster-forms

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For display advertising information, contact: Jill Runyan at jrunyan@floridadental.org or 800.877.9922, Ext. 7113 Advertising must be paid in advance. For classified advertising information, contact: Jessica Lauria at jlauria@floridadental.org or 800.977.9922, Ext. 7115.

www.floridadental.org


Contact the FDA Office

800.877.9922 or 850.681.3629 1111 E. Tennessee St. • Tallahassee, FL 32308

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

Executive Office Drew Eason, Executive Director deason@floridadental.org 850.350.7109 Rusty Payton, Chief Operating Officer rpayton@floridadental.org 850.350.7117 Graham Nicol, Chief Legal Officer gnicol@floridadental.org 850.350.7118 Judy Stone, Agency Relations Manager jstone@floridadental.org 850.350.7123

Accounting Jack Moore, Chief Financial Officer jmoore@floridadental.org 850.350.7137 Leona Boutwell, Bookkeeper – FDHF & A/R lboutwell@floridadental.org 850.350.7138 Deanne Foy, Bookkeeper – PAC & Special Projects dfoy@floridadental.org 850.350.7165 Tammy McGhin, Payroll & Property Coordinator tmcghin@floridadental.org 850.350.7139 Mable Patterson, Bookkeeper – A/P mpatterson@floridadental.org 850.350.7104

Florida National Dental Convention (FNDC) Crissy Tallman, FNDC Convention Manager ctallman@floridadental.org 850.350.7105 Kaitlin Alford, FNDC Meeting Assistant kalford@floridadental.org 850.350.7108 Elizabeth Bassett, FNDC Exhibits Planner ebassett@floridadental.org 850.350.7106 Mary Weldon, FNDC Program Coordinator mweldon@floridadental.org 850.350.7103

Governmental Affairs Joe Anne Hart, Director of Governmental Affairs jahart@floridadental.org 850.350.7205 Alexandra Abboud, Governmental Affairs Coordinator aabboud@floridadental.org 850.350.7204 Casey Stoutamire, Lobbyist cstoutamire@floridadental.org 850.350.7202

Membership David Higgins, Director of Member Relations dhiggins@floridadental.org 850.350.7121

Sandy Merrill, Membership Coordinator smerrill@floridadental.org 850.350.7110

Josh Freeland, Membership & Marketing Assistant jfreeland@floridadental.org 850.350.7111

Christine Mortham, Member Relations Assistant cmortham@floridadental.org 850.350.7100

FDA Services 800.877.7597 or 850.681.2996 1113 E. Tennessee St., Ste. 200 Tallahassee, FL 32308 Group & Individual Health • Medicare Supplement • Life Insurance Disability Income • Long-term Care • Annuities • Professional Liability Office Package • Workers’ Compensation • Auto Scott Ruthstrom, Chief Operating Officer scott.ruthstrom@fdaservices.com 850.350.7146 Carrie Millar, Membership Services Manager carrie.millar@fdaservices.com 850.350.7155 Carol Gaskins, Assistant Membership Services Manager carol.gaskins@fdaservices.com 850.350.7159

Ron Watson, Lobbyist rwatson@floridadental.org 850.350.7203

Debbie Lane, Assistant Membership Services Manager debbie.lane@fdaservices.com 850.350.7157

Information Systems

Allen Johnson, Support Services Supervisor allen.johnson@fdaservices.com 850.350.7140

Communications and Marketing

Larry Darnell, Director of Information Systems ldarnell@floridadental.org 850.350.7102

Jill Runyan, Publications Manager jrunyan@floridadental.org 850.350.7113

Lisa Cox, Database Administrator lcox@floridadental.org 850.350.7163

Lynne Knight, Marketing Coordinator lknight@floridadental.org 850.350.7112

Ron Idol, Network Systems Administrator ridol@floridadental.org 850.350.7153

Kristen Barrett, Membership Services Representative kristen.barrett@fdaservices.com 850.350.7171

Florida Dental Health Foundation

Maria Brooks, Membership Services Representative maria.brooks@fdaservices.com 850.350.7144

www.floridadental.org

risk experts

Jamie Chason, Commissions Coordinator jamie.peddie@fdaservices.com 850.350.7142

Marcia Dutton, Administrative Assistant marcia.dutton@fdaservices.com 850.350.7145

Stefani Dedmon, Coordinator of Foundation Affairs sdedmon@floridadental.org 850.350.7161

Porschie Biggins, Membership Services Representative pbiggins@fdaservices.com 850-350-7149

Angela Robinson, Customer Service Representative angela.robinson@fdaservices.com 850.350.7156

Jessica Lauria, Publications Coordinator jlauria@floridadental.org 850.350.7115

(FDHF)

Pamela Monahan, Commissions Coordinator pamela.monahan@fdaservices.com 850.350.7141

Nicole White, Membership Services Representative nicole.white@fdaservices.com 850.350.7151

Dan Zottoli Atlantic Coast District Insurance Representative 561.791.7744 Cell: 561.601.5363 dan.zottoli@fdaservices.com

Dennis Head Central Florida District Insurance Representative 877.843.0921 (toll free) Cell: 407.927.5472 dennis.head@fdaservices.com

Joseph Perretti South Florida District Insurance Representative 305.665.0455 Cell: 305.721.9196 joe.perretti@fdaservices.com

Rick D’Angelo West Coast District Insurance Representative 813.475.6948 Cell: 813.267.2572 rick.dangelo@fdaservices.com

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President’s message Terry Buckenheimer, DMD

How Do You Become Aware of “Best Practices?” Over the years, I’ve found that I am not the best at anything! That’s difficult to admit, but it is easy to stay humble when you’ve reached that conclusion. It’s also easier to stay in “learning mode” in an effort to try to improve. Improvement applies to clinical, communication and management skills. Life seems to involve a constant learning process, with the exception of our teen years — when we knew everything! Surely you’ve sat through many a lecture having an “expert” tell you what works best for them and therefore, for you. I’ve found I can relate to an issue much better when I live it or hear about it from others who have experienced it. That is why I have enjoyed being a member of our organization so much. One can interact with fellow dentists at your local affiliate or component meeting where friends and acquaintances share their stories of the day and you decide, based on their experiences, what would be best for you. (Of course, discussion of evidence-based dentistry is included.) This leads to opportunities for mentoring. Experienced dentists can share with younger members the techniques used to solve a common problem or their best method to avoid that problem all together. We are not in competition with one another, but rather, in competition with ourselves as we attempt to improve our skills to better serve our patients. It’s exactly the same when you experience a learning opportunity at the state or national level. That common bond of “thinking like a dentist” allows you to relate to one another. “Best practices” are determined by deciding what the best method is to meet a certain goal or overcome a problem. They are developed by gathering evidence to support the method and then sharing those ideas with one another to discuss, critique and develop an even better “best practice.”

“Best practices” are determined by deciding what the best method is to meet a certain goal or overcome a problem.

In this issue of Today’s FDA, we are sharing some “best practices” that have been discovered. Share these with some of your colleagues at local meetings. Better yet, share them with other dentists who have not yet found the benefits of membership in the Florida Dental Association. Imagine how great the profession of dentistry would be if we all used best practices to serve our patients and communities!

Dr. Buckenheimer is the FDA president. He can be reached at tlbdmd1@gmail.com. www.floridadental.org

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renew your membershIP for 2014! Look for your “investment” statement in November.

Together, the American Dental Association, the Florida Dental Association and your district dental association form a partnership with you that helps you succeed every day.

Your Practice It’s the “Power of 3” and It’s for members only!

American Dental Association

Florida Dental Association

District Dental Associations

What’s happening with the Affordable Care Act? As we move into a new era for health care, don’t you want a powerful ally at the table as new rules are written for the way we care for patients? Your membership strengthens the ADA’s position as the voice of all dentists.

Fantastic Savings! Most dentists could pay their dues with savings from using the services of the FDA’s Corporate Affiliation Program (CAP). And, now you can save 18-22 percent on dental supplies! Visit www.fdaservices.com for more information on CAP programs and insurance options for your practice, staff and family.

Close to Home! Looking for colleagues and maybe some of the best friends you’ll ever make? District dental associations offer you the chance to share meals, opinions, advice, support, politics, continuing education and family events at local venues with your professional colleagues.

Information Galore! Get free subscriptions to the Journal of the American Dental Association, the most-trusted scientific publication in dentistry and ADA News. Plus, the ADA provides web content on practice management, continuing education, evidence based dentistry and national laws and rules that affect your practice.

Free CE! You could fulfill almost all your requirements for licensure renewal with free CE from the FDA. Earn up to 30 scientific/clinical/practice management CE credits a year at the FDA’s online CE site. Also, get free pre-registration to FNDC, the best CE buy in the Southeast. FNDC also offers many opportunities for free CE onsite.

The FDA Peer Review program is run by your district and local dental associations. Members provide this service free to other members. You can often avoid costly legal fees and all the stress and headaches involved in a malpractice suit just by taking part in this process.

dentists across florida benefit from membership in three associations.

Dr. Beatriz Terry Miami Springs SFDDA

Dr. Cecil White Jr. Atlantic Beach NEDDA

Dr. Tanya Orr Santa Rosa Beach NWDDA

Dr. Yvette Godet Gainesville CFDDA

Dr. Federico Schmid Hidalgo Fort Lauderdale ACDDA

Dr. Nishith Patel Bradenton WCDDA

These are just a few of the benefits of membership! Find out more at ada.org, floridadental.org and your district’s website. Questions about your benefits? Call the FDA Member Services Number at 800.877.9922.


Legal Notes

Compliance Deadline for New HIPAA Rules Graham Nicol, Esq., Health Care Risk Manager, Board Certified Specialist (Health Law)

Dentists who are “covered entities” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will shortly need to revise their Notice of Privacy Practices and their Business Associate Agreements. You are a “covered entity” if you electronically use or disclose protected health information. The U.S. Department of Health and Human Services, Office of Civil Rights released an “omnibus final rule” that changes HIPAA’s privacy, security and enforcement rules. The deadline for covered entities and business associates to comply with the new rules was Sept. 23, 2013. Sample policies can be found online at http://www.hhs.gov/ocr/privacy/hipaa/ modelnotices.html. The new rules, more than 500 pages in length, implement requirements mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was enacted as part of the American Recovery and Reinvestment Act of 2009. The final rule also increases protections for genetic information as required by the Genetic Information Nondiscrimination Act of 2008 (GINA).

The new regulations: q make business associates of covered entities directly liable for compliance with certain of the HIPAA Privacy and Security Rules’ requirements. q strengthen the limitations on the use and disclosure of protected health information for marketing and fundraising purposes. q modify the breach notification requirements for covered entities. When unsecured individually identifiable health information is used or disclosed to unauthorized parties, HIPAA requires that it be reported to HHS. Previously, the breach notification obligation was triggered based on the level of “harm” set forth in a 2009 interim final rule. Now, the breach notification requirement focuses less on subjective assessments of harm, and instead uses objective criteria. q prohibit the sale of protected health information without individual authorization. q expand individuals’ rights to receive electronic copies of their health information. q restrict disclosures to a health plan concerning treatment for which the individual has paid out-of-pocket in full. q require modifications to, and redistribution of, a covered entity’s notice of privacy practices.

The ADA Complete HIPAA Compliance Kit – J598 This kit has tools to help you design and implement a comprehensive HIPAA compliance program using a step-by-step approach. Revised to reflect the changes prescribed by the 2013 Omnibus Final Rule, “The ADA Practical Guide to HIPAA Compliance” has the following tools to aid in comprehension and documentation: sample policies and procedures; revised sample Business Associate Agreement; revised sample Notice of Privacy Practices; glossary of key terms; and a CDROM to help you tailor the content to your practice. “The ADA Practical Guide to HIPAA Training” is a two-level CD-ROM training program. Level 1 teaches the basics of HIPAA compliance to dental office staff. Level 2 is a more in-depth module designed for managers who are developing their office’s HIPAA program in conjunction with “The ADA Practical Guide to HIPAA Compliance.” Please go to http://bit.ly/15AokIm to order your kit today.

Please see Legal, 7

www.floridadental.org

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Legal Notes

legal from 7

q modify requirements to facilitate

WCDDA 40 & UnDer netWorking event

Thursday, OcT. 17, 2013 • 6-9 p.m. • AQUA, Tampa www.wcdental.org • 813.654.2500 • wc.dental@gte.net

WCDDA Women’s netWorking event

SATUrdAy, Nov. 9, 2013 • 11:30 a.m. • Neiman Marcus, Tampa www.wcdental.org • 813.654.2500 • wc.dental@gte.net

WCDDA AnnUAl meeting

Jan. 17, 2014 • St. Petersburg Hilton Bayfront Speakers: Nasser Barghi, D.D.S., M.S.; David Beach, D.M.D., M.S.; Cynthia Fong, R.D.H., M.S.; Wayne Kerr, D.D.S., M.A.G.D.; Mary O’Neill, M.A., M.F.T. www.wcdental.org • 813.654.2500 • wc.dental@gte.net

miAmi Winter meeting

FeB. 21-22, 2014 • Jungle Island, Miami Speaker: Dr. Jose-Luis Ruiz www.sfdda.org • 305.667.3647 • sfdda@sfdda.org

nWDDA AnnUAl meeting

FeB. 21-22, 2014• The Grand at Sandestin resort Speakers: Dr. Alex Fleury – New Dimensions in Endodontics; Dr. Joe Steven Jr. – Efficient Dentistry www.nwdda.org • 850.391.9310 • nwdda@nwdda.org

CFDDA AnnUAl meeting

FrIdAy, MArcH 14, 2014 • Weston Lake Mary orlando North Continuing Education Session with Dr. John Burgess www.cfdda.org • 407.898.3481 • lindaannelowell@gmail.com

CFDDA islAnD getAWAy

APrIL 24-27, 2014 • Puerto rico: Great Times, Great Profession “Let’s Make Memories”

ACDDA Winter meeting

FrIdAy, FeB. 28, 2014 • embassy Suites, West Palm Beach Speakers: Rita Zamora & Dr. Michael Ragan – Marketing Your Dental Practice with Facebook & Social Media www.acdda.org • 561.968.7714 • acdda@aol.com

www.floridadental.org

research and disclosure of child immunization proof to schools and for family members to access decedent information. q adopt the HITECH Act enhancements to the Enforcement Rule that increase civil monetary penalties for noncompliance with the HIPAA Rules due to willful neglect. q modify the HIPAA Privacy Rule as required by GINA to prohibit most health plans from using or disclosing genetic information for underwriting purposes. The HHS Office of Civil Rights estimated that the cost to comply with the new rules will be between $114 million and $225.4 million in the first year of implementation, and approximately $14.5 million annually thereafter. Members have access to “The ADA Practical Guide to HIPAA Compliance,” which has been updated to include the new omnibus rules. This information was previously distributed thru News Bites. If you did not receive News Bites, please update your email information by calling the Membership Department at 850.350.7111. 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. Graham Nicol is the FDA’s Chief Legal Officer. September/October 2013

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Where in the World is Today’s FDA? ook ently t c e r e ayn na bert P FDA o Dr. Ro of Today’s agua. py his co trip to Nicar n joying missio , for en ls! e n y a r. P ave you, D your tr Thank FDA during ’s Today

Are you planning to take a copy of Today’s FDA on your next trip? Have someone snap a photo and send it to Today’s FDA Editor, Dr. John Paul, at tfdaeditor@floridadental.org and you could be featured in the next issue of the journal!

30 MINUTE WEBINAR PRESENTED BY FDA SERVICES office ergonomics WEDNESDAY, OCT. 9, 2013 1 PM EST/NOON CST

Go to: fdas.adobeconnect.com/powerlunch/

Please join us for a 20-minute discussion to review office ergonomics as they relate to dental offices. Sitting postures, placement of computer monitors, keyboards, record and file storage, lighting and eye strain are some of the issues that will be reviewed as well as personal workplace assessments to minimize risk of ergonomic-related injuries. Presented by Edward Dodenhoff, Technical Consultant for Liberty Mutual Insurance.

800.877.7597 • insurance@fdaservices.com • www.fdaservices.com

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Information Bytes

New Features Make Member Information More Accessible By Larry Darnell

If you have never checked out the members-only part of our website before, you will be required to provide a username and password to gain access to members-only benefits like the ones mentioned here. To do that, your username is your email address that is on file with the FDA Membership Department. The password is the same for everyone: Password1 — we will be changing the security protocols before November 2013 to allow you to create your own unique password, but for now it is unable to be changed.

Director of Information Systems

If you have not checked out the Florida Dental Association’s (FDA) website floridadental.org. lately, I encourage you to take a look at it again. We have added a few new member features in the last couple of months. Under the “Benefits and Resources” tab at the bottom, there are three exclusive members-only features. The first is an online version of our Member Sourcebook (MS). Many years ago, the MS was produced in printed form and our members found it so beneficial, that we brought it back as an easily accessible download. The MS can be searched either alphabetically by name, or by city and specialty. The online MS is updated quarterly. Our Member Lookup is another new feature to use for an instant search of other FDA members. Try it out by looking up your own record! You also can search by city or first name. Your results also show a map location.

www.floridadental.org

Thirdly, if you find that some of your information is incorrect or out of date, the menu choice labeled Member Portal will give you the ability to update your information online, without having to contact us by phone, fax or email. We will be enhancing some exciting features in the Member Portal very soon, so check back! If you have any difficulty changing the information, a membership representative is just a phone call away to make those information updates for you. Call the FDA Member Services number (800.877.9922) M-F, 8 a.m. - 5 p.m.

The FDA website is your members-only resource available 24/7/365. If you have any questions concerning the website, please contact me directly at ldarnell@ floridadental.org or at 850.350.7102. Mr. Darnell is the FDA’s director of information systems. He can be reached at ldarnell@floridadental.org.

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keynote SpeakerS

Free for FDA Members!  IrwIn Becker, DDS Inspiring Your Team to Reach Its Full Potential

Creating a

 kIrk BehrenDt Win Every Season: the Secrets of Team Success  kellI Vrla Stress Busting with Humor

Masterpiece MAstering the Fine Art OF Dentistry

SAVE THE DATE!

JUNE 12-14, 2014 | ORLANDO, FL 12 FDAPASeptember/October 2013 G AYToday's L OR D L M S R E S ORT &

C ON V E N T ION C E N T E R

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news

@fda

important news for FDA members

FDA’s Board and House Vote to Reduce Your 2014 Dues! By increasing office efficiencies and continuing with our budget-minded philosophy, the Florida Dental Association (FDA) Board of Trustees and House of Delegates were able to reduce your 2014 association dues by five dollars! While dues have been reduced at the state level, the FDA continues to improve on your member benefits, services and customer service. Need assistance? We’re here to help — as an extension of your own office staff. Call us at 800.877.9922 and let us know what we can do for you!

New Dentist Now: Life as a New Dentist — Let’s Talk About it Everything from the amusing “Gerbils on a Train” dental ad to student loan advice to practice management to ADA networking opportunities is assembled on the ADA’s new dentist blog, New Dentist Now. Easy to navigate, the site’s focus is on issues relevant to new dentists and students and the lively exchange of comments. Go to http://newdentistblog. ada.org/ and look for something new every day! New Dentist Now is brought to you by the New Dentist Committee of the American Dental Association and features resources for new dentists and dental students as well as news and insight on the dental profession and beyond.

www.floridadental.org

Deadline for Employers to Send Notice of Coverage is Oct. 1. The Affordable Care Act (ACA) requires employers across all segments to provide their employees with a written notice of the existence of public health insurance exchanges and eligibility for premium tax credits or cost sharing (if applicable for employer’s plan), regardless of whether the exchange is operated by the state or the federal government. The Department of Labor has indicated there is no penalty for not providing the notice. Here are some frequently asked questions and answers about the Notice of Coverage: Can an employer be fined for failing to provide employees with notice about the Affordable Care Act's new Health Insurance Marketplace? No. If your company is covered by the Fair Labor Standards Act, it should provide a written notice to its employees about the Health Insurance Marketplace by October 1, 2013, but there is no fine or penalty under the law for failing to provide the notice. Basically the answer is now that no notice needs to be given by anyone. The Dept of Labor official said this was a “clarification” of the agency’s position – there is no penalty. That’s agency speak for “we changed our minds but can’t say so.” Who do employers need to notify? Employers must send a notice to all full- and part-time employees, whether or not they are on the employer’s group

health plan. Employers do not have to notify employees’ dependents or others who are eligible for coverage but are not employees. When do employees need to be notified? Current employees must be notified by Oct. 1, 2013. New employees hired on or after Oct. 1 must receive this notification within 14 days of their start dates. Is there an approved template employers should use? The U.S. Department of Labor (DOL) created model notices that your clients can use to notify their employees and can be found at http:// www.dol.gov/ebsa/healthreform/.

Did You Know You Can View the FDA’s Master Calendar? The Florida Dental Association’s (FDA) master calendar can be viewed by any member. Visit floridadental.org and go to the “About the FDA” tab across the top menu. In the drop-down menu, select “FDA Calendar” to see what’s scheduled.

American Dental Association Offers Updated Coding Books The American Dental Association (ADA) is offering two updated dental coding books to help dentists stay up to date on the proper codes to use when billing their patients for dental procedures. The new “CDT 2014” contains the Code on Dental Procedures and Nomenclature, which is the standard

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news from 13

Maine Hospital Opens Dental Clinic to Alleviate ER Burdens

for recording dental services in patient records, on paper claim forms and on HIPAA standard electronic claim transactions. The new book is the only official source for the latest dental procedure codes. The CDT book (J014) is available for $39.95 for ADA members and $59.95 retail price.

Like many hospitals across the country, Waldo County General Hospital, in Belfast, Maine, has found itself increasingly swamped with patients seeking treatment for dental pain in its emergency department.

The ADA also is offering the “Dental Coding Made Simple: Resource Guide and Training Manual, 2013-2014” to help dentists and their staff understand the basics — and the complexities — of today’s dental coding system. “Dental Coding Made Simple” (J443) is available for $49.95 to ADA members and $74.95 retail price. To purchase these books, please visit adacatalog.org or call the ADA Member Service Center at 800.947.4746.

ADA Appoints Dr. David Preble to Lead the New ADA Practice Institute The American Dental Association (ADA) recently promoted David Preble, DDS, JD, to vice president of the newly created ADA Practice Institute. He had previously served as the director of the ADA Council on Dental Benefit Programs since 2007. The Practice Institute will provide input on programs, products and services to help ADA members better operate their dental practices. It will also promote the interests of the dental profession on health care finance, health outcomes and quality, and informatics and standards.

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“About 20 percent of our recent ER patient encounters have involved dental pain,” said Dale Kuhnert, a member of the hospital’s board of directors. Waldo County’s ER could provide pain relief and treat infection, but was not staffed or equipped to treat the underlying problems. Waldo County’s problem reflects a disturbing national trend. Recent research carried out by the ADA Health Policy Resources Center (HPRC) concludes that the number of dental ER visits in the U.S. jumped from 1.1 million in 2000 to 2.1 million in 2010. Learn more about innovative ways dentists are moving patients out of the ER and into the dental chair by going to http://www.ada.org/8601.aspx.

Letter from the President of Nova Southeastern University Dear Students, Faculty and Staff members of the College of Dental Medicine, I am pleased to announce the appointment of Linda Niessen, DMD, MPH, MPP, to the position of Dean of the College of Dental Medicine. Dr. Niessen is an internationally renowned academician, researcher, author and public health advocate. Dr. Niessen will commence her appointment on Oct. 1, 2013.

September/October 2013

Dr. Niessen currently serves as clinical professor in the Department of Restorative Dentistry at the Texas A&M University’s Baylor College of Dentistry. Dr. Niessen recently served as vice president and chief clinical officer for DENTSPLY International Inc., where she oversaw the global clinical education and professional relations activities for this worldwide dental equipment and consumables company. George L. Hanbury II, PhD President/CEO Nova Southeastern University

Awards Special Recognition Award

Dr. Robert Payne was presented the "Special Recognition Award" during FNDC2013. He has served on Florida Dental Association (FDA) agencies for many years, such as the Council on Communications, the Committee to Develop Access to Care and the ACHA Medicaid Advisory Council, among others. He has been active with the Florida Dental Health Foundation (FDHF) since 2004 and is currently vice president. He served as a Northwest District Delegate since 2002 and as chairman of the Council on Dental Health since 2005. Dr. Payne also serves on the Florida Delegation to the ADA. Dr. Payne volunteers many hours of his personal time treating underserved children. He holds an annual Give Kids a Smile (GKAS) event in conjunction with the Jackson County Health Department. He was involved with the mobile dental unit at Dentists’ Day on the Hill www.floridadental.org


this past April. For the past 33 years, he has regularly donated his services to the Florida Baptist Convention’s Mobile Dental Care Unit. Dr. Payne has just completed his 36th foreign mission trip, and also has taken University of Florida dental students with him six times to Central America for mission work. Service Award

Dr. Alfred H. Underwood was presented a Service Award during FNDC2013. He has been an FDA member for 55 years. He received his dental degree at Emory University School of Dentistry.

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Humanitarian Award

Dr. Barry Setzer was presented the Humanitarian Award by Dr. James Walton during FNDC2013. He has actively participated in the Children’s Medical Services Cleft Palate Clinic and Nemours Children’s Clinic for more than 26 years. Since the start of his affiliation, he has donated one day each month to serving children with cleft palates in Jacksonville, Fla. and surrounding areas.

More Parents Report Healthy Tooth Brushing Habits after First Year of Ad Council Children’s Oral Health Campaign On the one-year anniversary of their Kids’ Healthy Mouths campaign, the Ad Council and the Partnership for Healthy Mouths, Healthy Lives are pleased to announce results from a new study that demonstrates substantial progress in the effort to improve children’s oral health habits. The survey, administered to English and Spanish-speaking parents, indicates that more parents report regularly monitoring and maintaining their child’s oral health; subsequently, more children are regularly brushing. For the full press release, go to http://bit. ly/14eFCev.

September/October 2013

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Health Care Reform

Health Care Reform:

Frequently Asked Questions Can anyone purchase on the health insurance marketplace? Yes, no matter your income level or whether employer group health insurance is offered, anyone can purchase a plan. However, to qualify for a subsidy, you can only purchase on the health insurance marketplace.

By Carrie Millar, Membership Services Manager, FDA Services Inc.

This is a general overview of the health care reform law as it relates to small business dental practices. It does NOT attempt to cover the law’s provisions and should not be used as legal advice for implementation activities. Since the Affordable Care Act (ACA) was signed into law in March 2010, changes to everyone’s health insurance have already occurred. You may or may not have noticed these changes. In January 2014, however, a majority of the ACA provisions will be implemented. We address here some of the questions we get asked on a daily basis. What is the Individual Mandate? The ACA imposes tax penalties on individuals who do not maintain minimum essential coverage starting Jan. 1, 2014. The penalty is on a sliding scale and the flat dollar amount per individual is $95 in 2014; $325 in 2015 and $695 in 2016. There are exemptions to the flat amount based on lower household income.

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If I have a pre-existing condition, will I be able to get an individual plan? Yes! Starting in 2014, individual health insurance plans, whether purchased on the individual exchange or in the private market, cannot be declined or rated up based on pre-existing conditions. In fact, the only rating variances can be demographic area, tobacco use, age and family composition. What is the Marketplace (individual exchange)? The ACA has a provision that requires the creation of a health insurance exchange in every state beginning Jan. 1, 2014. Currently, Florida has opted for the federally run exchange as opposed to a state exchange.

September/October 2013

Will FDA Services be able to help me or my employees on the individual marketplace? Yes, FDA Services will be fully certified to sell health insurance plans on the exchange. Enrollment will start on Oct. 1, 2013 and continue through March 31, 2014. Will I qualify for a subsidy? If your household income is between 100-400 percent of the federal poverty level (FPL), and you are not offered an affordable health care plan from your employer, you could qualify for a premium subsidy. Additionally, if your income is between 100-250 percent of the FPL, you also could qualify for a cost-sharing subsidy. What will the plans on the individual marketplace (exchange) look like? The exchange plans are named by metals and are based on the actuarial value of

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Health Care Reform

the plan, which is the projected amount the insurance company would pay out-of-pocket. The plans are as follows: Bronze, 60 percent; Silver, 70 percent; Gold, 80 percent; and Platinum, 90 percent. It is important to note that a Silver plan with Company A will not have the same co-pays and deductibles as a Silver plan with Company B, only the projected actuarial value would be the same. What is a grandfathered plan? Individual or small group plans can be grandfathered if they were in place prior to March 2010, have had no changes to the plan and are still offered by the carrier. Additionally, many carriers are requiring that you sign annually that you want to maintain your grandfather status. You can call your carrier directly to find out if you have grandfather status. What changes will there be to my individual/family coverage in 2014? If your plan is not grandfathered, at your 2014 renewal your plan will have to cover the 10 essential health benefits, which includes maternity coverage. Additionally, the maximum out-of-pocket expense in 2014 for an individual will be $6,350 and $12,700 for a family. What changes will there be to my group health insurance plan in 2014? If your plan is not grandfathered, at your 2014 renewal your plan will have to cover the 10 essential health benefits. Additionally, the maximum deductibles allowed will be $2,000 for employee only and $4,000 for family coverage.

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How will the ACA affect my group health insurance premiums? The increase or decrease for groups will vary greatly. Younger, healthier groups will see their rates increase because they no longer benefit from the medicalrating factor. Conversely, older, medically-rated groups will possibly see their premiums decrease. Additionally, groups that currently are offering a high deductible plan will see their premium increase because they will have to offer a lower deductible plan. How will the ACA affect my individual/health insurance premiums? If your plan is not grandfathered, the premium most likely will increase in 2014 due to the additional benefits that must be included in the policy (like maternity) and because of the new rating structure (same rate regardless of gender and medical factor discount). However, the amount of the increase is yet to be determined. It is being estimated at anywhere from 5-75 percent, depending on the source. As a small-business employer, will I be fined for not offering coverage? No, if you are an employer with less than 50 full-time employees, which most dental offices are, you are not subject to any fines or penalties for not offering coverage. If you have more than 50 fulltime employees, the fines and penalties will not apply until 2015.

About FDA Services Inc. FDA Services is the wholly owned, for-profit insurance agency of the Florida Dental Association. FDAS was founded in 1989 to help our members manage the ever-escalating malpractice premiums of the 1980s with the FDA Endorsed Professional Liability program, our first line of business. Over the years, FDAS has become a full-service insurance agency and takes pride in managing the insurance portfolios of each and every client. Last year alone, FDAS contributed more than $825,000 to the FDA to help reduce membership dues.

What should I be doing right now? If your health insurance plan — either group or individual — is too expensive or does not have enough coverage, then it would make sense to see what your options would be starting in October. However, to compare your options on the exchange to your 2014 renewal, you will have to wait until your renewal. Only then you will be able to fully evaluate all your options. FDA Services’ experienced staff is ready to get to work for you. If you need a review of your current insurance policies, call FDA Services at 800.877.7597 or email insurance@fdaservices.com. Ms. Millar can be reached at carrie.millar@fdaservices.com.

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Board of Dentistry

Board of Dentistry Meets in Orlando

By Ron Watson

FDA Lobbyist

The Florida Board of Dentistry (BOD) met in Orlando on Thursday, Aug. 22, and Friday, Aug. 23. All 11 BOD members were present, which included Dr. Dan Gesek, chair; Dr. Robert Perdomo, vice chair; Dr. William Kochenour; Dr. Carol Stevens; Dr. Joe Thomas; Dr. Wade Winker; Dr. Leonard Britten; hygienists, Ms. Catherine Cabazon and Ms. Angie Sissine; and consumer members, Mr. Tim Pyle and Mr. Anthony Martini. This was the first BOD meeting for the four newly appointed BOD members (Dr. Britten, Ms. Sissine, Mr. Pyle and Mr. Martini). Florida Dental Association (FDA) President Dr. Terry Buckenheimer sent letters to congratulate all new members prior to the meeting. The FDA was represented by FDA BOD-Liaison Dr. Don Ilkka, Dr. Larry Nissen and FDA Lobbyist Ron Watson. Other FDA members in attendance included Drs. Andy Brown, Barry Setzer, Clive Rayner, Matt Dennis and others. During the meeting, the BOD dealt with 13 disciplinary cases and three voluntary relinquishments. Disciplinary cases included a settlement offer which drew media attention after an emergency restriction order (ERO) was executed due to allegations of sexual misconduct; several cases involving failure to meet minimum standards; record keeping violations; and violations of previous BOD orders. The voluntary relinquishments were for trafficking in controlled substances; sub-standard care; and failure www.floridadental.org

to prove full-time Florida practice in the first year of using American Board of Dental Examiners (ADEX) exam results from another state. After the sexual misconduct case, BOD members recommended, as a smart risk management office policy, that dentists or staff never be alone with any patient in the recovery room. Do not put yourself and/or your dental license (practice) in jeopardy of being disciplined. If you have never attended a BOD meeting, take the opportunity to attend and see the work of the BOD. It is much better to be a spectator than a participant in BOD disciplinary cases and you can earn continuing education (CE) credits for your attendance. Other notable issues included: n The BOD voted to refer newly drafted proposed rules dealing with hygienists administering local anesthesia to a patient after nitrous oxide has been administered back to the BOD Council on Dental Hygiene. n However, a BOD vote in February allowing this to occur is still in place despite an FDA letter stating it is prohibited by law. The FDA has argued that nitrous oxide is a form of sedation and thereby prohibited in the law that granted hygienists this new ability in Florida. n A rule workshop was conducted at the request of the Florida Association of Nurse Anesthetists (FANA), who are challenging the draft BOD-proposed rule requiring direct supervision of CRNAs by a dentist and limiting the level of anesthesia the CRNA is allowed to administer to that which the dentist’s anesthesia

permit allows. The FDA testified in favor of the proposed rule. n The BOD chose not to draft rules to clarify the 60 hours of training required for the course work for certifying local anesthesia. They left this up to the schools/programs, which must be CODA approved, to decide the specifics. n A brief review of the draft sedationbasics guidelines occurred. This summary is an attempt by the BOD attorney to explain, in plain language, all the recent anesthesia rule changes. When finalized, the FDA has received permission to publish this guide in an FDA publication to be sent to our members. n Former BOD member Dr. Betty Klement asked the BOD to adopt guidelines/requirements to deal with minimal sedation. The BOD referred them to the BOD Anesthesia Committee for further analysis. n There was no discussion about the Task Force to Study Proper Dental Record Keeping, which was created at the May 2013 BOD meeting. It has yet to meet. n The BOD took no action nor had any discussion on the FDA’s Restorative Functions Dental Auxiliaries proposals. The BOD has a new website and can be found at www.floridasdentistry.gov. The next full BOD meeting is scheduled for Friday, Nov. 15 in Gainesville. Ron Watson is one of the FDA’s lobbyists and regularly attends Board of Dentistry meetings. He can be reached at rwatson@ floridadental.org.

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FLA MOM

Florida’s First Mission of Mercy Program Comes to Tampa March 28-29, 2014 By Dr. Nolan Allen and Dr. Leo Cullinan

FLAMOM Co-chairs

If you or your organization have been associated with a Mission of Mercy (MOM) event, or participated in one, you no doubt have captured the passion — there is nothing like it! Two days of absolutely free dental care to all who come leaves most volunteers and patients with a renewed perspective on the goodness of mankind. “The largest free dental clinic in the world!” “A life-changing experience!” “For me, an experience of a lifetime!” “The greatest active charity in the nation!” These are just a few of the statements made by those who have been involved in a MOM event to praise its generosity and profound effect on so many people. Thousands come and wait, no matter the situation: standing in snow calf-deep for hours; waiting in quarter-mile-long lines in 100 degree weather; sleeping outside entrances on below zero nights — all just to receive dental care. These are the underserved — those who cannot afford quality dental care. Their need has been defined at each and every MOM event held in Virginia, Texas, North Carolina, Nebraska, Missouri, Kansas or any of the many other states that have joined in along the way. The need is there — and through the generosity of dental professionals, dental technicians, lay volunteers, community leaders and businesses across the country, and the charitable work of dental agencies and organizations throughout America — those needs are being addressed. Over the course of two full days, more than 300 dentists, dental specialists, registered dental hygienists and physicians — along with more than 1,000 support volunteers — will descend on the 40,000 sq. ft. Special Events Pavilion of the Florida State Fairgrounds in Tampa to treat approximately 1,600-2,000 patients! 22

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FLA MOM

With the blessing and support of the Florida Dental Association (FDA) and Florida Dental Health Foundation (FDHF), a FLA MOM Committee has been formed, including Drs. Nolan Allen, Terry Buckenheimer, Leo Cullinan and Robert Payne. Drs. Allen and Cullinan have been assigned as co-chairs, and the subcommittee chairs are as follows:

Clinical Co-chairs: • Dr. Chris Bulnes • Dr. Oscar Menendez Facility Chair: • Dr. Craig Oldham

Hospitality Chair: • Dr. Robert Churney Media/Public Relations Fundraising Co-chairs: • Dr. Johnny Johnson • Ms. Karen Pesce Fundraising Chair: • Dr. Rudy Liddell Volunteer Coordinator Co-chairs: • Dr. Reza Iranmanesh, • Dr. Robin Nguyen • Mrs. Lissette Zuknick

We need volunteers! We are encouraging “teams” of dentists, staff and nonprofessionals to volunteer from each of our component and affiliate associations and societies within the FDA. You can register today by going to www.flamom. floridadental.org and clicking on the “Volunteer Registration” button on the right hand side. We encourage everyone to be a part of this wonderful community service event and priceless volunteer experience. Mark your calendars: March 28-29, 2014! Drs. Nolan Allen and Leo Cullinan are FLAMOM co-chairs and can be reached at mom@floridadental.org.

r eg i STe r noW To voLu nTe e r!

FLA-MOM’s First event Providing Free dental ServiceS For the UnderServed

Who:

Members of the Florida Dental Association and Florida Dental Health Foundation When: March 28-29, 2014 Where: Florida State Fairgrounds in Tampa, FL

regiSTer To voLunTeer AT WWW.FLAMoM.FLoriDADenTAL.org www.floridadental.org

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The Pregnant Patient

l a t

t n n e e D atm e h e t t r T of nan

: g t e n r P atie P

w e e i h v t e r n R o f re es icia u t in in a r el Cl e t Li Guid ing d ctic n a ra P

26 26 Today's Today's FDA FDA September/October September/October 2013 2013

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The Pregnant Patient By Bradley A. Shessel, DMD; Jason E. Portnof, DMD, MD; Steven I. Kaltman, DMD, MD; and Romy Nitsch, MD

Abstract The purpose of this review article is to assist the practicing clinician by categorizing and packaging useful clinical information into a format that will assist with the treatment of pregnant patients. Our goal is to offer the scientific foundations that lead to current practice guidelines, specifically those that are of particular relevance to today’s dental professional.

Overview Pregnancy causes an array of complex physiologic changes in the female patient that must be appreciated by the dental health professional. These varied changes occur across multiple organ systems and significantly affect the patient’s cardiovascular/hemodynamic, hematologic, respiratory, gastrointestinal, genitourinary/renal and immune systems.1 Pregnancy is divided into three trimesters based on a 42-week gestation, or three months (14 weeks) for each trimester. Since the standard of care for dental maintenance and recall is regular, sixmonth comprehensive oral evaluations, every pregnant patient is expected to seek dental treatment at some point during pregnancy. Dental care has been proven to not only be safe and effective during pregnancy, but also necessary to promote sound oral health. It is imperative that dental treatment be coordinated among obstetric and oral health care providers. While some may recommend that all treatment be completed only after consultation with the patient’s physician, this is not necessary for most dental procedures.2 The following items, howwww.floridadental.org

ever, should be addressed by obtaining a medical consultation: m treatment of any pre-existing past medical conditions (aside from pregnancy) m clarification of all medications being provided to the patient during pregnancy m elucidation of medical complications that may be the result of pregnancy m any special treatment recommendations that may improve individualized care for the pregnant patient Pregnancy by itself is not a reason to defer routine dental care or necessary dental treatment. However, prudence may dictate that elective treatment is deferred until after delivery. It is important to remember that there are actually two patients to be considered, and all clinical decisions should be made to minimize risks to both the mother and fetus.

Common Physiologic Changes

Physiologic changes occur during pregnancy and are known to affect a wide array of organ systems. Most commonly, cardiovascular, hematologic and respiratory changes can be expected. However, pregnancy exacts a systemic toll and, in actuality, all organ systems are affected to some degree. In this review, we will attempt to highlight the concerns that may be considered most clinically relevant to the dental health provider. Cardiac output increases during the late second trimester and can be associated with a systolic heart murmur which may be heard in up to 90 percent of pregnant patients.3 Of particular importance is a phenomenon which may be seen in the second and third trimesters known as supine hypotension syndrome (SHS).4 SHS is caused by a decrease in blood

pressure and heart rate when the patient is in the supine position. This is thought to be caused by compression of the inferior vena cava (IVC) by the gravid uterus, which results in up to 14 percent decrease in cardiac output.5 Clinical manifestations of SHS may include a transient initial increase in heart rate and blood pressure that is followed by hypotension, bradycardia and syncopy.5 It is important to note that even though the aforementioned symptoms may be absent, a significant decrease in uteroplacental perfusion pressure may still be present.5 If SHS is expected, it can be managed by placing the patient in a 5-15 percent tilt on her left side to relieve pressure on the IVC.6 Hematologic changes are varied and significant. Intravascular blood volume increases by 40 percent by the end of pregnancy due to increased fluid retention; however, blood cell mass remains relatively unchanged. The result of this hemodilution is a physiologic anemia with the average hematocrit ranging from 30-35 percent.2 Additionally, iron deficiency and hypercoagubility, due to the increased production of clotting factors, may be present.3 Pregnant women are, in fact, at a five times greater risk of thromboembolism as compared to non-pregnant women.5 Pregnant patients experience an increase in leukocyte count of 5,000 to 10,000 cells. This is secondary to an increased circulation of catecholamines and cortisol, which causes a demargination of leukocytes from the endothelial lining of the vasculature.7 The respiratory system experiences several changes that must be considered when treating the pregnant patient. Hyperventilation begins during the first trimester and persists throughout preg-

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The Pregnant Patient pregnant from 27

nancy; as such, pregnant patients should be considered to have a baseline respiratory alkylosis. Capillary enlargement leads to increased upper airway edema and, therefore, an increased risk of supraglottic obstruction. The gravid uterus causes a superior displacement of the diaphragm of up to 4 cm, which leads to a decrease of 15-20 percent in functional residual capacity (FRC).2,8 Additionally, the pregnant patient experiences an increased oxygen consumption of 15-20 percent.2,5 Resultantly, pregnant patients experience a significantly reduced oxygen reserve. As previously mentioned, there are several other organ systems that are significantly affected in the pregnant patient. A full listing of this complex physiology has not been provided in this paper as it goes beyond the scope of this review. Clinicians who may be interested in additional reading are directed to the references section for further information.

Treatment Considerations by Trimester The initial determination prior to treatment of the pregnant patient focuses on the patient’s total weeks of gestation or term. This calculation is based on the patient’s estimated date of delivery. The estimated date of delivery is calculated by counting 40 weeks from the first day of the last menstrual period.

Emergency dental procedures can be performed during any trimester when a delay in necessary treatment could result in significant risk to the mother and an indirect risk to the fetus.5,9 Special precautions may need to be taken during these instances.

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First Trimester First day of the last menstrual period until 13 weeks and six days gestation Diagnosis, oral prophylaxis and treatment, including necessary dental X-rays, can be safely performed during the first trimester in order to diagnose disease processes that require immediate treatment.5 Important issues to consider are: m Fetal organogenesis occurs during the first 12 weeks of gestation. The conceptus is called an embryo until the ninth week, when it becomes a fetus. m It is during the embryonic period when the risk of teratogenicity is highest. m Dental care during early pregnancy has not been reported to increase the rate of malformations or pregnancy loss. m Morning sickness usually resolves after the first trimester, so women may be more comfortable receiving non-emergent dental care at that time.

Second Trimester 14-20 weeks gestation It is generally accepted that the safest time to perform elective dental procedures is in the early second trimester.1,2,3,5,9,10

Third Trimester 28 weeks gestation until birth In the third trimester, when the preg-

nant patient is supine, the gravid uterus may obstruct the IVC and pelvic veins, impeding venous return to the heart and causing SHS. As previously mentioned, the common clinical manifestations of SHS include lightheadedness, hypotension, tachycardia and syncope. Proper patient positioning is therefore very important. Left uterine displacement is achieved by placing a small pillow under the patient’s right hip and lifting the right hip and buttock 15 degrees. Alternatively, the patient can lean on her left side, thereby reducing the pressure on the vena cava.

Medications

The Food and Drug Administration has classified the safety profile of medications for use during pregnancy. The following charts are helpful guides illustrating this classification scheme (Tables 1, 2). Clinicians should be mindful that when treating pregnant patients, all medications prescribed should be for the lowest effective dose and for the shortest duration possible.

Local Anesthetics

The use of local anesthetics is necessary and acceptable during pregnancy.12 The clinician should be aware that local anesthetic agents may exhibit a more rapid onset and longer duration of action during pregnancy. Local anesthetics freely cross the placenta, and the potential for fetal toxicity is also a concern. (Table 2)

Table 1 United States FDA Pharmaceutical Pregnancy Classifications www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/labeling/ucm093307.htm

Pregnancy Category A Pregnancy Category B Pregnancy Category C Pregnancy Category D Pregnancy Category X

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Safety established using human studies Presumed safety based on animal studies Uncertain safety. No adverse effect demonstrated in human and animal studies. Unsafe. Evidence of risk that may in certain clinical circumstances be justifiable. Highly unsafe. Risk of use outweighs any possible benefit.

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Anal

Loca thetic


The Pregnant Patient The use of vasoconstrictors with local anesthetics during pregnancy is controversial. Judicious use of a vasoconstrictor, however, is permissible. Obtaining profound local anesthesia and thus, preventing extensive endogenous catecholamine release is the objective. A major concern with the use of local anesthetics containing epinephrine involves the inadvertent intravascular injection. Accidental intravascular injection of epinephrine can cause uterine artery vasoconstriction and decreased uterine blood flow.13 Proper aspiration techniques and limitation of alpha-adrenergic agents (such as epinephrine) are advised to avoid this complication. 13 Clinicians may consider using carpules with 1:200,000 concentrations of epinephrine as an alternative.

Table 2

Analgesics Acetaminophen is the analgesic of choice in the pregnant patient. NSAIDs such as Ibuprofen and naproxen must be administered with particular care. These drugs are both classified as Category B for the first and second trimesters, but are considered Category D in the third trimester. This is because they have been shown to increase the risk of closure of the fetal ductus arteriosus; they have been shown to cause fetal renal damage and inhibit clotting.13 Codeine should be considered as a first choice narcotic when indicated, as it has been proven safe by evidenced-based studies.14 While all narcotics should be used judiciously, it is reasonable to use adequate analgesia to control maternal pain symptoms.

Benzodiazapines such as midazolam and diazepam have been implicated as a possible cause of craniofacial defects, such as cleft lip and palate; however, no definitive causal link has been established.15

Antibiotics Odontogenic and other maxillofacial infections must be treated with particular alacrity in the pregnant patient. This often necessitates the administration of antibiotics. Fortunately, most of the commonly used antibiotics in dentistry are classified as Category B drugs. These include: penicillin, amoxicillin, cephalexin, clindamycin and azithromycin.11 Importantly, antibiotics such as sulfamethoxazole/trimethoprim and Please see pregnant, 31

Acceptable and Unacceptable Drugs for Pregnant Women Acceptable Drugs for Use During Pregnancy

Food and Drug Administration Category

Unacceptable Drugs for Use During Pregnancy

Food and Drug Administration Category

Penicillin Amoxicillin Cephalosporins Clindamycin Erythromycin (except for estolate form)

B B B B B

Tetracyclines Erythromycin (estolate form) Quinolones Clarithromycin

D B

Acetaminophen Acetaminophen with codeine Codeine Oxycodone Hydrocodone Meperidine Morphine

B C C B C B B

Aspirin

C

After first trimester and for 24-72 hours only: Ibuprofen Naprosyn

B B

Local anesthetics

Lidocaine Mepivicaine Bupivicaine

C C C

Adrenergic Agent

Epinephrine

C

Inhalational Agent

Nitrous Oxide

Controversial teratogenicity in first two trimesters.

Sedatives/ hypnotics

Diazepam Midazolam Methohexital Lorazepam

D D B D

Antimicrobials

Chlorhexidine

B

Antibiotics

lgesics Analgesics

al anescs

C C

Adapted from Kumar J. Samelson R. Oral Health During Pregnancy Recommendations for Oral Health Professionals. NYSDJ: 29-33, November 2009; Lawrenz DR, Whitley BD, et al. Considerations in the Management of Maxillofacial Infections in the Pregnant Patient. J Oral Maxillofac Surge 54: 474-485, 1996.11

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ciprofloxacin are classified as Category C, and their use should be avoided if possible.11 Tetracycline and its derivatives are Category D, and their use is contraindicated throughout pregnancy.11 This is because they have the capacity to bind to hydroxyapatite within the developing tooth bud, thus impairing enamel formation and causing tooth discoloration.16 Furthermore, these drugs have been shown to effect bone formation.16 Finally, it bears noting that due to increased maternal blood volume, often times conventional doses of antibiotics may prove ineffective in pregnant patients.17 Infections must be monitored closely and those that show poor response should be referred to an oral and maxillofacial surgeon for in-patient hospital management when applicable.

Nitrous Oxide The use of nitrous oxide (N2O) during the treatment of pregnant patients remains the subject of great controversy. Most providers agree that N2O should be used only when local anesthetics are inadequate and after consultation with the patient’s prenatal care provider. One important consideration for pregnant patients is to avoid hypoxia, and as such, N2O should be used judiciously. If used, it is not recommended to exceed a 50 percent mixture of N2O to oxygen.18 Anecdotal surveys of several dental practitioners have suggested that long-term exposure to N2O may be associated with spontaneous abortion and birth defects, but there is a lack of concrete evidence to validate these assertions.18 It is known, however, that N2O affects vitamin B12 metabolism, which in turn inactivates methionine synthase, an enzyme which is necessary for the production of DNA.18 www.floridadental.org

Therefore, it is recommended that N2O be avoided during the first trimester when organogenesis occurs.18 Since the 1960s, there has been a lot of concern regarding the risk not only to patients, but also to health care workers who are subjected to chronic exposure of N2O. However, it cannot be overemphasized that a definitive relationship between N2O exposure and reproductive sequelae has never been established. In spite of this, great care is taken to reduce chronic N2O exposure in the medical setting. In 1977, the National Institute for Occupational Safety and Health (NIOSH) researched the efficacy of scavenger systems and chose 50 ppm to be the maximum exposure limit for personnel in a dental setting.19 This is measured most easily by time-weighted average (TWA) dosimetry, which is a badge that may be worn much like radiation dosimeter and analyzed by an infrared spectrophotometer. However, in 1995, a comprehensive literature review conducted at University of Colorado regarding biohazards associated with N2O use concluded that there was no scientific basis for these previously established levels. As a result, the American Dental Association’s (ADA) Council on Scientific Affairs and Council on Dental Practice issued the formal position statement that a maximum N2O exposure limit in parts per million has not been determined.18

Table 3 Suggested Office Protocol for N2O Use 1. Possess appropriate delivery system with scavenging capabilities, accurate flowmeter, adequate vacuum and variety of sizes of masks. 2. Assess the adequacy of ventilation system.

• Vent exhaust to outside.

• Provide fresh-air exchange whenever possible. 3. Assess the adequacy of suction system. • Ensure vacuum at 45L/min. Select appropriate size of mask • Establish appropriate tidal volume.

• Discourage patient talking.

4. Assess ambient air for trace gas levels at baseline and periodically thereafter. Periodic personal sampling of personnel should be conducted as well. 5. Assess cylinder attachments, lines, hosing, and reservoir bag for leaks. Use IR spectrophotometer and soap-and-water tests. 6. Calibrate flowmeter(s) every two years.

At present, no direct evidence exists of any causal relationship between chronic low-level exposure to N2O and potential biologic effects. Regardless, use of evacuation scavenger systems remains the stan1.dard of care, and every attempt should be made to reduce the level of trace N2O Please see pregnant, 32

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The Pregnant Patient

pregnant from 31

to exposed health care personnel. The recommended evacuation flow rate has been established by NIOSH as optimal at 45 L/min (Table 3).

General Anesthetic Considerations Pregnant patients must be considered to have a “full stomach” and have an increased risk for aspiration. Physical changes during pregnancy include an increased size of the uterus, which causes a mechanical superior displacement of the stomach and increases intragastric pressure. These patients also are prone to increased gastric reflux, delayed gastric motility and reduced competency of the gastroesophageal sphincter. The decreased lower esophageal sphincter tone may be due to direct hormonal effects of progesterone. Administration of H2 blockers and metoclopramide should be considered in these patients. If a general anesthetic is to be used, it is preferable for the patient to have an empty stomach for at least six hours.

Radiology Dental radiographs are both safe and necessary for the treatment of pregnant patients. None of the conventionally employed radiographic modalities will generate a significant dose of ionizing radiation that may threaten the wellbeing of the developing embryo and fetus. Regardless, collimated beams, high-speed film (or digital systems), a lead apron and a thyroid collar are protective measures that should always be used. Certainly, avoiding radiation

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exposure throughout the first trimester is paramount, and accordingly, this should be limited to only emergent situations. However, it has been well-documented that there has been no increase in reported congenital anomalies or intrauterine growth retardation for radiation exposure less than 5-10cGy.20,21 Practitioners should feel confident in knowing that a full-mouth series of dental radiographs results in only 8 × 10–4 cGy, while bitewing or orthopantomagram (panoramic) radiographs generate about one-third this amount.20 At present, the use of cone beam computerized tomography (CBCT) scanners has become an ever-increasing part of dentistry. CBCT scans provide a useful modality for evaluating dental implant treatment planning, dentofacial anomalies, craniofacial pathology and temporomandibular joint disorders.22 Therefore, CBCT scans may likely be considered during the course of treating pregnant patients. It must be noted that there are two major differences that distinguish CBCT scanners from helical or “medical grade” CT scanners.28 The first is that CBCT machines use a lowenergy fixed anode tube to generate the flow of electrons, and secondly, CBCT machines only rotate around the patient one time as they capture data.22 The net result is that the patient is exposed to approximately 20 percent of the ionizing radiation dose as that of a helical CT scan.22 This is approximately equivalent to the radiation exposure from a fullmouth series of conventional radiographs.22 Obviously, the use of CBCT scans should be exercised judiciously and certainly lead aprons and thyroid

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collars should again be used at all times. If CBCT is deemed to be the necessary imaging modality, then the best decision is to limit the field of capture as much as possible to only the necessary anatomical structure in question. The fundamental principle that should be maintained at all times is that the patient should be exposed to the lowest dose imaging modality possible, while still achieving the necessary diagnostic data.

Treatment of the Postpartum Breastfeeding Patient The American Academy of Pediatrics (AAP) has formally stated its position that breastfeeding is the optimum nutritional source for the newborn infant in the first six months of life.23,24 Not surprisingly, a high percentage of postpartum women breastfeed throughout the first year. In fact, in 2010 the Centers for Disease Control and Prevention (CDC) released data on breastfeeding in the US. They report that from 2000-2008, the percentage of breastfeeding in the early postpartum period was 81.9 percent; 60.06 percent at six months; and even at 12 months after delivery, it still remained at 34.1 percent.25 Therefore, it is reasonable for the dental health practitioner to be concerned with any medications they provide to a breastfeeding patient and what sequelae may exist. Several studies have examined the transmission of medications into milk in the bovine model.26 It is important to be aware that there is a paucity of data regarding human breast milk, primarily www.floridadental.org


The Pregnant Patient

because radioactive isotopes are necessary for data collection.25 One problem with attempting to extrapolate information from the bovine model is that there is a difference in the pH between human milk and breast milk.25 So, while a direct correlate is not possible, the information available can be applied in a useful manner. The general rule is that for most drugs, the infant is exposed to a considerably higher dose in utero than during lactation.25 Therefore, there is a much safer therapeutic index for medications that are used during lactation. However, lactating patients should consider the “pump and discard” model. This is based on the fact that it takes the human body four half-lives of a drug to eliminate 90 percent of a drug. Prior to the application of a drug (especially a short-acting medication), the patient can be counseled to pump and store an appropriate amount of breast milk to last the duration of four half-lives of the drug. Then after administration of the drug, she can pump and discard all breast milk for the corresponding time frame.25

Conclusion The dental health practitioner should feel comfortable in knowing that the treatment of pregnant patients is not only permitted, but actually is necessary in order to promote sound oral health. The recommendations compiled within this review highlight the major treatment considerations that one may reasonably encounter over the course of routine practice. The purpose of this article is not to create treatment algorithms, but rather to suggest that the treatment www.floridadental.org

administered must be individualized to each patient. However, if the principles and guidelines set forth here are applied in good judgment, then the treatment of this patient cohort can be administered in a both safe and effective manner.

References 1. Gier RE, Janes DR. Dental management of the pregnant patient. Symposium on the patient with increased medical risks. Dent Clinics North Am 27:419-28, 1983. 2. Livingston HM, Dellinger T, Holder R. Considerations in the management of the pregnant patient. Special Care in Dentistry, 18, 5:183-188, 1998. 3. Tarsitano BF, Rollings RE. The pregnant dental patient: evaluation and management. J Gen Dent 41:226-31, 1993. 4.Holmes F: Incidence of the supine hypotensive syndrome in late pregnancy. J Obstet Gynaecol Br 67:254, 1960 5. Lawrenz DR, Whitley BD, et al. Considerations in the Management of Maxillofacial Infections in the Pregnant Patient. J Oral Maxillofacial Surgery 54: 474-485, 1996. 6. Katz VL: Physiologic changes during normal pregnancy. Curr Opin Obstet Gynecol 3:750, 1991 7. Lund CJ, Donovan JC: Blood volume during pregnancy. Am J Obstet Gynecol 98:393, 967 8. Kumar J. Samelson R. (eds). Oral Health Care during Pregnancy and Early Childhood: Practice Guidelines. New York State Department of Health. August 2006. Available at http://www.health.state.ny.us/publications/0824.pdf. 9. Jo J, Jo C, Bagheri SC. “Perioperative Considerations of the Pregnant Patient” Clinical Review of Oral and Maxillofacial Surgery. Mosby Elsevier, St. Louis, 2008. p. 48-50. 10. Turner M, Aziz SR. Management of the Pregnant Oral and Maxillofacial Surgery Patient. J Oral Maxillofacial Surgery 60: 1479-1488, 2002. 11. Lawrenz DR, Whitley BD, Helfrick JF. Considerations in the management of maxillofacial infections in the pregnant patient. J Oral Maxillofac Surg 54:474-85, 1996. 12. The Journal of the American Dental Association June 2008 vol. 139 no. 6 685-695n 13. Malamed SF. Handbook of Local Anesthesia. 5th ed. St. Louis, MO: Mosby; 2004. 14. Aselton P, Jick H, Milunsky A, Hunter JR, Stergachis A. First-trimester drug use and congenital disorders. Obstet Gynecol 1985; 65(4):451-5.[Medline] 15. Dolovich LR, Addis A, Vaillancourt JM, Power JD, Koren G, Einarson TR. Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies. British Medical Journal 317(7162): 839-43. Sep 26, 1998. 16. Newman MG, van Winkelhoff AJ. Antibiotic and Antimicrobial Use in Dental Practice. 2nd ed. Chicago, IL: Quintessence; 2001. 17. Larsen B, Glover DD. Serum erythromycin levels in pregnancy. Clin Ther. 1998; 20(5):971-977. 18. Clark MS, Branick AL. Handbook of nitrous oxide and oxygen sedation. 2nd ed. St. Louis: CV Mosby; 2003. p. 173-90.

19. Tarascon Pocket Pharmacopoeia 12th Edition. 2011 Deluxe Lab-Coat Pocket Edition. Editor in Chief: Richard J. Hamilton. Jones & Bartlett Learning, Sudbury MA. 20. National Council on Radiation Protection and Measurements. Recommendations on limits for exposure to ionizing radiation. Bethesda, Md. NCRP, 1987. NCRP report no. 91. 21. Katz VL. Prenatal care. In: Scott JR, Gibbs RS, Karlan BY, Haney AF, editors. Danforth’s obstetrics and gynecology. 9th ed. Philadelphia: Lippincott, Williams and Wilkins; 2003. p. 1-20. 22. Quereshy FA, Savell T, Palomo JM. Applications of Cone Beam Computed Tomography in the Practice of Oral and Maxillofacial Surgery. J Oral Maxillofac Surg 66:791-796, 2008. 23. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Neonatal Risk. 5th ed. Philadelphia, PA: Williams and Wilkins; 1999. 24. American Academy of Pediatrics. AAP issues policy statement on the transfer of drugs and other chemicals into human milk. Am Fam Physician 1994; 49(6):15271529. 25. Donaldson M, Goodchild JH. Pregnancy, breastfeeding and drugs used in dentistry. JADA 2012;143(8):858871 26. Hendrickson RG, McKeown NJ. Is maternal opioid use hazardous to breastfed infants? (published online ahead of print Dec. 13, 2001). Clin Toxicol (Phila) 2012; 50(1):1-14. doi:10.3109/ 15563650.2011.635147. 27. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 9th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2011: xvii, 406-408, 497. 28. Kumar J. Samelson R. Oral Health During Pregnancy Recommendations for Oral Health Professionals. NYSDJ: 29-33, November 2009. 29. Giglio JA. Lanni SM. Laskin DM. Giglio NW. Oral Health Care for the Pregnant Patient. J Candian Dental Assoc: (1) 75: 43-48, Feb 2009.

Dr. Shessel is a resident at the Department of Oral and Maxillofacial Surgery at Nova Southeastern University in Fort Lauderdale. Dr. Portnof is an Associate Professor and Director of Pediatric Maxillofacial Surgery and Craniomaxillofacial Surgery at Nova Southeastern University. Dr. Kaltman is Professor and Chairman of the Department of Oral and Maxillofacial Surgery at Nova Southeastern University. Dr. Nitsch is an Assistant Professor of Obstetrics and Gynecology at Queen’s University, Kingston in Ontario.

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Licensure Renewal

Licensure Renewal: Frequently Asked Questions By Dr. Dan Gesek

Chairman, Florida Board of Dentistry

Q.

There has been a great deal of confusion regarding the Department of Health’s (DOH) postcard to dentists. This card referenced a new requirement that all continuing education (CE) courses must be entered into the state’s electronic database at the time of licensure renewal, or the renewal will be denied. Is that correct, and what is the status of implementing this proposal?

A.

As required by Florida law, all dentists must complete a minimum of 30 hours of CE every biennium. For the Feb. 28, 2014 renewal cycle, compliance with the requirement that all of your CE credits must be recorded in the state’s electronic database prior to licensure renewal is OPTIONAL. During the 2014 renewal process, you will be allowed to renew your dental license whether or not all 30 hours are electronically recorded in the database.

Q. A.

Will inputting all your CE credits electronically ever become a required mandate? For the Feb. 28, 2016 renewal cycle, the DOH will require that all dentists’ and dental hygienists’ CE credits be recorded in the state’s electronic database prior to licensure renewal. It has yet to be determined if an incomplete record will result in a non-renewal or if the state will grant a liberal grace period to comply. The Board of Dentistry (BOD) and the Florida Dental Association (FDA) have both requested input on clarifying these policy discussions. But, remember, for the 2014 renewal cycle, it is optional.

Q. A.

Will the 2014 renewal process include another dental workforce survey?

2014. However, this also is optional. Dentists (and hygienists) will have to click through each workforce survey screen when renewing online, but you can answer all of the questions, some of the questions or none of the questions.

Q. A. Q. A.

Will there be any additional fee assessments during the 2014 renewal process? As BOD chairman, I am pleased to report that there are no additional fee assessments or licensure renewal fee increases for the 2014 renewal cycle! How does a dentist renew their license online and what is the link for licensure renewal? Online licensure renewals have been increasing every year since the DOH first started this process. It is the easiest and most cost-effective way for the BOD to process the large number of applications for renewal. I encourage all Florida dentists to visit the new BOD website, which was recently upgraded, and renew electronically at http://www.floridasdentistry.gov/ renewals/.

Q. A.

What are the 2014 licensure renewal dates and deadlines? Another postcard from the DOH reminding all dentists and dental hygienists that their license must be renewed by Feb. 28, 2014 will be mailed sometime in November 2013. Even though the licensure renewal deadline is at the end of February, you can go online and renew early! Make sure your address is current with the BOD so you receive all the relevant information and forms, and stay legal, too. Also, this is a reminder that the FDA does not share your address with the BOD when you update your address with the association. You must contact the BOD yourself.

Yes, the dental workforce survey will once again be a part of the renewal process for both dentists and dental hygienists in

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Scott Ruthstrom

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Scott Ruthstrom

What has FDAS been doing to prepare for the new health exchanges that open on Oct. 1?

By Lynne Knight, MS

FDA Marketing Coordinator

Scott Ruthstrom has been the Chief Operating Officer at FDA Services (FDAS) for almost three years. He joined FDAS in 1994 and quickly began moving up the ranks, first serving as a customer service representative and then as a licensed agent. He then became FDAS’ membership services manager — overseeing the sales and policyholder services of the agency.

Where did you grow up? go to college? your family? I grew up in Tampa, before leaving in 1987 to attend Florida State University in Tallahassee. My wife Shelly and I have a blended family — together we have five children. She has two boys and I have two boys and a girl. Their ages range from 20 to 15 years. We stay pretty busy!

How do you relax? Three mornings a week I meet a group at the gym for weight training. I play basketball and do an occasional 5K run. Last April, I finished a “Tough Mudder,” an 11-mile obstacle course race, with my two college roommates and my oldest son. Shelly and I love to travel every chance we get. Our recent adventures have taken us to Napa and Santa Barbara, Calif., and later this fall we travel to Naples and Rome, Italy. www.floridadental.org

We have a two-pronged attack to prepare our agents to protect and advise members when the individual mandate of the ACA takes effect — understand the law and understand the new plan designs. We are taking the U.S. Department of Health and Human Services (HHS) course to become certified agents who can sell insurance offered on the federal health exchange. We have 10 FDAS staff members who have completed this comprehensive training — a 20-30 hour course.

You’ve been COO of FDAS for almost three years. What’s been the most gratifying? I am so impressed with staff we have assembled — I am certain it’s the finest in my 19 years at FDAS. They are knowledgeable, talented and go the extra mile for members every day. I also can boast that five staff members have risk management and insurance degrees from FSU.

What line do you find most interesting? I think I would say, professional liability. FDAS was founded to have a voice in the dental professional liability market in Florida. We’ve built a successful program for our members. It’s an important program, so I give it a lot of attention to make sure we serve members with the best possible coverage.

Not only is the law changing, but carriers are changing their plan designs. We are attending training seminars and webinars offered by Florida Blue (FB) and other health insurance carriers. As an FB Contracted General Agent, we have exclusive access to a range of FB plans. We think FB is committed to staying in the Florida market, and they offer plans in every Florida county. Ms. Knight is the FDA marketing coordinator. She can be reached at 850.350.7112 or lknight@floridadental. org. You can reach Scott Ruthstrom at 800.877.7597 or scott.ruthstrom@ fdaservices.com.

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8

5

Dental Safety

By Captain Stephen W. Harden, BS, ATP, B-737, B-727, MD-11 and John B. Roberson, DMD

More than 3,000 hospitals around the world have registered with the World Health Organization (WHO) to implement the use of a pre-procedure safety checklist. This is not surprising given the widely publicized data proving the use of safety checklists reduces complications, errors, infections and mortality. With documented results like these, more than 300 professional societies, health organizations, ministries and non-governmental organizations have endorsed the concept of using checklists to provide safe care.

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Dental practices are also taking advantage of safety checklists to make dental care safer for their patients, and more efficient, profitable and trouble-free for their office. How? Proactive dental offices are using a detailed checklist protocol similar to the safe surgery checklist developed by the WHO — which is itself based on the checklists that professional pilots have used for years to prevent human error and prevent accidents. The aviation checklist system has significantly reduced airline mishaps. Dentists are finding that checklists work as well in their practices as they do in commercial aviation. It’s not hard to see why. Both professions rely on teamwork and attention to detail to achieve the best result. And, both have serious consequences for human error. The dental checklist system is used to failsafe personnel, equipment and data. It helps office staff to think ahead during each case and catch errors early in the processes used in dental practices. Catching human error becomes very

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important, as one unchecked early error can snowball into a catastrophe for dental patients, especially if the practice is using conscious sedation. One error caught early not only prevents catastrophe and stops lawsuits, it also improves the efficiency of office operations. Thus, safety checklists are not only the right thing to do for patient safety, they are the right thing to do for a practice’s bottom line. A professor of dentistry and two practicing dentists — who are also commercial airline pilots — spearheaded the development of the dental checklist system. They created a checklist that optimally standardizes dental procedures for preemptive error discovery. Their checklist is categorized into five typical timeframes: u Appointment summarization u Prior to procedure u During procedure u Prior to patient release u Following patient release

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Dental Safety

Using this checklist system as a starting point, each dental practice adapts and revises the checklist to fit their own office procedures and culture. The customized, office-specific checklist establishes standard, optimum protocols. While creating and implementing a safety checklist seems intuitively easy, experience has shown that implementation mistakes are common and can ruin the effectiveness of checklists. Having helped more than 110 organizations around the world create and successfully implement checklists, author Harden offers eight tips to boost the success rate of the checklist implementation process in dental practices.

Tip 1: Ensure your checklist is user-built and maintained. The most important phrase on the current WHO Surgical Safety Checklist is located on the bottom of the page: “This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.” Administrators ignore this piece of advice at their peril. Effective checklists borrow heavily from the “Kaizen” methodology of the Toyota Manufacturing Process. In Kaizen, the people who actually do the work are best suited and most responsible for creating the standard for how the work is accomplished. Checklists created by other people at other facilities will rarely work well. There is no emotional investment and no pride of authorship in an “off-the-shelf ” checklist. To overcome this, put a small team together with representatives from each work group that will participate in using

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the dental safety checklist. Allow them the freedom to customize the tool in a way that makes sense for them and that aids their workflow. As an administrator, give them the resources and support they need to be successful, then get out of their way and allow them to do their customization. Want to avoid the “not made here” syndrome and all the problems that it brings? Ensure your checklist is built and implemented by your clinical staff — not your administrators, and certainly not the staff from a different facility.

Tip 2: Keep it short. Not everything has to be on a dental safety checklist. Checklists are used to verify only the critical items of a procedure. Critical items are those that if not done correctly will cause harm to patients or caregivers before that error can be stopped. For example, there are approximately 65 items for an airline captain to check to prepare a modern airliner for engine start and flight. However, most “before start” checklists have only 11 or 12 items to be reviewed. These are the items, that if missed, will not be self-correcting before some harm to the aircraft, passengers or crew is caused. With checklists, shorter is better.

Tip 3: Don’t confuse your checklist with an audit tool.

Effective checklists will trigger a scripted conversation and verbal cross-check of critical steps in the procedure.

Great checklists are not designed to use as an audit tool. Dental Safety Checklists are not about creating a paper trail; they’re a critical job aid to help the team (not the individual) cross-check and verify, with two or more independent sets of eyeballs, that critical items haven’t been missed. This cross-check by mulPlease see checklist, 42

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Dental Safety

checklist from 41

tiple team members creates the needed engagement and mindfulness by the dental team during the checklist process, and is much more valuable to overall safety than having tick marks in the appropriate boxes. In fact, you should seriously consider getting rid of the tick boxes on your checklist. A check-in-the-box makes it easy to pretend something has been done when it really hasn’t.

Tip 4: Include speaking parts for the team on the checklist. Effective checklists will trigger a scripted conversation and verbal cross-check of critical steps in the procedure. The more speaking parts different members of the team have, the more mindfulness and involvement you’ll have in the checklist process. The reason is simple — if a team member knows they have a speaking part, they must pay attention to the checklist flow and be ready with their verbal response. No one wants to be the sour note in the symphony of a wellexecuted checklist. No team member wants the public embarrassment of being the one who declares an item has been checked when it hasn’t. The timely public declaration, in front of a team of peers, that the item you are responsible for has been checked, and is as it should be, creates a sense of responsibility and mindfulness in each member of the team that has a speaking role in the checklist.

Tip 5: Use standardized and scripted language. Speaking parts only work if the exact language and words that should be used for each item on the checklist are crystal 42

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clear and standardized — down to the exact word or phraseology that must be used. In other words, checklist dialogue should be scripted. Scripting will answer a number of questions. u Who is responsible to “call out” an item on the checklist? u Does this statement or “call out” require a verbal response? u Who should respond to “call outs,” and what, exactly, should their verbal response be? u What should be cross-checked and confirmed before a verbal response is made? Without an exact script to follow here, staff will create a wide variety of methods to accomplish steps in the checklist, introducing time-consuming confusion, uncertainty and frustration.

Tip 6: Design your checklist as a “Read and Verify” tool. There are essentially two types of checklists in use by high reliability organizations (HROs): Read and Do and Read and Verify. In a Read and Do checklist, the operator reads the item on the checklist and then does that step immediately after reading it. Then the next item is read and subsequently immediately accomplished. Checklists done this way are extremely time-consuming and act as giant speed bump for workflow and efficiency. This cumbersome approach to checklists will cause most surgical teams to resist using a pre-procedure checklist.

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Overcome this resistance by teaching your teams to use a Read and Verify checklist system. With this method the team accomplishes critical and routine actions from working memory. They periodically pause and use the checklist to verify that the most critical actions have been accomplished. Used this way, it takes only seconds for the team to crosscheck and verify that nothing critical has been missed. The speed and efficiency of this method will greatly reduce the resistance you experience with implementing a checklist.

Tip 7: Use a slider board instead of a paper checklist. Once a customized office checklist is finalized, have the checklist printed on an acrylic board with corresponding “sliders” for each item on the checklist. These sliders must be physically moved from “red” to “green” to complete the checklist. The movement of the slider must be verified by two team members from the office staff. Slider checklist boards typically contain a blank section where staff can use a dry erase marker to make additional notes about the case or procedure. Dental offices find these checklist slider boards more effective than paper checklists because they: u create team engagement — as attention is focused on a single place for verification of process. u provide a strong visual cue to begin the cross-check process.

Please see checklist, 45

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Dental Safety

Dental Checklist for Outpatient Dental Visits* CHALLENGE RESPONSE

Completed Not Applicable Appointment Review Verbalize medical history; medications current, updated, reviewed Verbalize premedication status Review allergies (medications, materials) Update dental history (such as periodontal examination, oral cancer screening, TMJ) Review notes from other health care providers, including specialists Review treatment plan documentation Verbalize procedure; confirm if informed consent required Verbalize that radiographs and/or study models are available Verbalize that all equipment and materials are available Verbalize the level of assistance required Review special instructions, needs for today’s procedure

Before Procedure Verbalize anesthetic method, location, expected amount Verbalize critical steps in sequence Verbalize potential deviations from treatment plan

Procedure Perform preliminary procedure (such as caries removal, gross debridement) Determine final procedure and inform patient Verbalize critical new steps in sequence

Before Dismissal Review with patient the treatment performed Review with patient postoperative instructions and care Prescribe medications (verbalize that no contraindications exist) Complete referral forms Inform patient of next step

After Dismissal Review unexpected events Inform team members of necessary follow-up items Review any equipment problems Complete laboratory prescriptions Record legible notes in patient’s dental record * Sources: World Health Organization and American Dental Association Council on Dental Practice and Division of Legal Affairs.

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Dental Safety

checklist from 43

u create mindfulness and attention to detail as each team member can see an instant visual indicator of checklist completion. u engage the visual senses through the use of color (green for go, red for stop). u proactively eliminate error and improve efficiency. u mention in dental office marketing as a patient benefit.

Tip 8: Make it dentist-led. In HROs such as commercial aviation, checklists are “owned” by the team leader — the captain of the crew. The captain uses the checklist to manage workflow and team performance. Checklists are one of the primary tools for supervising the team. Airline captains understand the value of checklists in creating teamwork, fostering communication and setting expectations that team members will be vigilant and provide safety monitoring. In the case of the dental team, checklists are owned by the dentists performing the procedure. Dentists, just like airline captains, have a vested interest in ensuring checklists are used effectively and completely. As team leaders, it’s their responsibility to initiate the checklist at the time of their choosing, and to insist on professional accomplishment of the checklist in its entirety.

Bonus Tip 8.5: Use checklists to avoid distractions. A recent study conducted during invasive medical procedures revealed that these fairly simple distractions caused an eight-

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fold increase in major medical mistakes during those surgical procedures: u unexpected movement by an observer u a cell phone ringing and answered by an observer u an unrelated conversation between an observer and a third party u noise made by dropping a metal tray u a question about a problem that came up regarding a recovering patient u a question about a resident’s career choice Additionally, more than 50 percent of the physicians in the study forgot a key surgical task when these distractions were present. In comparison, only 22 percent forgot a memory task when there were no distractions. Properly constructed and used checklists create a “no interruption zone” where dentists and their staff can concentrate soley on the upcoming patient visit and ensure everything is double-checked for accuracy and efficiency. These “no interruption zones” minimize distraction-induced errors and improve the safety, quality and reputation of a dental practice. No matter where you are on your checklist journey, these eight and a half tips will improve the speed of your implementation process and help you reap the patient safety rewards of a well-designed checklist system. Properly created and implemented, your Dental Safety Checklist should offer these benefits: u increased patient safety u reduced overhead costs u reduced medical errors u reduced medication errors u improved dental team’s skills

u improved performance of yourself and your teams u reduced risk of negative patient outcomes u improved level of quality, safety and reliability toward patient care u increased competence and confidence for improved patient outcomes u decreased mortality rates u improved patient care experience u increased heightened morale of your dental team u prevented distraction-induced errors. Reprinted with permission from Dentaltown Magazine and Dentaltown.com Stephen Harden is Chairman and CEO of LifeWings Partners LLC and co-founder of Crew Training International Inc. (CTI). He has helped more than 110 health care organizations in 29 states implement the best safety practices from aviation and other high reliability industries. Mr. Harden has been involved in human factors and safety training for a wide variety of military and commercial customers for 21 years, producing more than 40 separate training programs. A professional pilot with 35 years of experience, he is a captain for a major international airline and a former U.S. Navy TOPGUN instructor pilot. He can be reached at sharden@saferpatients.com. Dr. John B. Roberson is a full-time practicing oral and maxillofacial surgeon. He is a former co-founder and former CEO of the Institute of Medical Emergency Preparedness (IMEP). He can be reached at drjohnroberson@megagate.com.

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Diagnostic Discussion

Diagnostic Discussion By Dr. Indraneel Bhattacharyya

A 40-year-old African-American female was referred for evaluation of multiple oral sores to Dr. Indraneel Bhattacharyya at the Oral Medicine Clinic at the University of Florida College of Dentistry. The patient first noted lesions on her skin around six months ago; three months later, she started feeling soreness in her mouth. She also reports scalp irritation and itchiness of the skin. She additionally reported her mother has a history of purple pruritic lesions of the skin and tends to “break out.” She had been to her primary care physician and been treated for ring worm infection of the skin. Her oral lesions were treated for candidiasis. She also reports having seen a dermatologist where skin biopsy was performed and “dry skin” was diagnosed. Lichen planus was suspected, but could not be proven by the biopsy. She was prescribed topical triamcinolone (low-potency steroid) for use on the oral lesions, but the lesions only marginally improved with this medication. The lesions move around her mouth and she believes it has affected her voice. A systemic steroid dose pack (Medrol®) was prescribed, which helped improve her hoarseness in voice, but failed to clear up her oral lesions.

The lesions involve much of her oral mucosa, including the buccal mucosa bilaterally, the lower labial mucosa, the hard palate and the anterior maxillary facial gingiva (see Fig. 1, 2). The left buccal mucosa and lip lesions were very painful. The patient’s medical history is non-contributory and she is a nonsmoker. During examination, positive Nikolsky sign was noted. Both routine and direct immunofluorescence examinations were performed on biopsy specimens at the UF College of Dentistry Biopsy Service. Histologic examination revealed intra-epithelial separation with minimal inflammation and immunoglobulin G (IgG) in the intraepithelial zones (Fig. 3).

Question: What is the most likely diagnosis? A. Aphthous ulcers B. Lichen planus C. Primary herpetic ulcers D. Aspirin/chemical burn E. Pemphigus vulgaris (PV)

Continuing Education Opportunity You can now earn continuing education credit for reading Diagnostic Discussion articles! Visit the FDA website at www.floridadental.org and click “Online Education” under the “Benefits and Resources” tab for this free, members-only benefit. You will be given the opportunity to review this column and its accompanying photos, and will be asked to answer five additional questions. If you have questions about this opportunity, email Publications Manager Jill Runyan at jrunyan@floridadental.org or call 800.877.9922. Be sure you are logged in to the members-only side of www.floridadental.org to access the online CE.

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Fig. 2

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Diagnostic Discussion A. Aphthous Ulcers Incorrect. Aphthous ulcers are undoubtedly very painful and almost never affect the bound-down or masticatory mucosa, such as palate or gingiva. In addition, they never exhibit a positive Nikolsky sign and do not produce epithelial separation. The aphthous lesions, unlike those seen here, are almost always surrounded by a red halo. The involvement of the keratinized mucosa, such as gingiva and hard palate seen here, is also highly unusual in aphthous ulcers. Extensive aphthous ulcerations may be seen in patients with severe immune suppression, such as AIDS. Aphthous ulcers are usually seen in young individuals and importantly, do not last for more than two to four weeks. Repeated episodes or crops of new ulcers, referred to as recurrent aphthous ulcerations (RAUs), may be seen on a variable recurrence pattern, but almost never continuously as seen here. Also, microscopic examination will not exhibit epithelial separation and will be negative for direct immunofluorescence. Intense inflammation is noted with most ulcerative lesions unlike the lesions noted here. B. Lichen Planus Incorrect. This was a strong contender on the differential diagnosis list since the patient had been biopsied by the dermatologist with this entity in mind. In addition, the patient had both skin and 48

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oral lesions that are often seen in lichen planus. However, when the oral lesions are carefully examined, there is a total absence of striations — even in the areas where the ulcerations are less severe. The other confounding issue in this specimen was the presence of epithelial separation, which is sometimes seen with lichenoid lesions. However, the most important diagnostic tool is the direct immunofluorescence testing that often clinches the diagnosis. Though erosive lichen planus may be desquamative and vesiculobullous in presentation, such lesions are common on the gingiva and almost always accompanied by areas of typical white striations on the mucosa. Typically, lichen planus does involve the buccal mucosa. Though lichen planus may be seen at any age, it is usually seen in older women over 50. In addition, direct immunofluorescence exhibits presence of fibrinogen at the basement membrane zone, not IgG within the epithelium or around the epithelial cells as in this case. C. Primary Herpetic Ulcers Incorrect. Good thought! Primary herpes simplex infection usually presents with widespread involvement as in this case and in rare cases, particularly in immunocompromised patients, also may involve the skin. In addition, the presence of marginal gingival and palatal involvement is also very characteristic of primary herpes. However, some of the clinical features of this case detract from this diagnosis. Firstly, primary herpes typically presents in individuals less than 20 years of age and is more common in children. Secondly, though primary herpes usually begins with small vesicles that ulcerate and eventually coalesce into

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large lesions (ulcers), these lesions almost always heal within a few weeks, unlike the duration of several months for the lesions noted here. Moreover, the lesions in primary herpes are often accompanied by constitutional signs and symptoms such as fever, malaise and lymphadenopathy, which were conspicuously absent here. Though primary herpes of the oral mucosa may clinically resemble the current condition, the involvement of skin in the initial phase as seen in the patient here, is also highly unusual. The lesions similar to this case are very painful, but there is no Nikolsky sign. The other similarity with primary herpes is in the microscopic presentation of epithelial separation (acantholysis). The characteristic virally involved epithelium may demonstrate ulceration with single or groups of acantholytic Tzanck cells. Immunofluorescence testing is usually not useful in herpetic lesions. D. Aspirin/chemical Burn Incorrect. The possibility of a chemical or aspirin burn should be considered whenever ulcerative lesions in the oral cavity are evaluated. The whitish, thickened lesions on the buccal mucosa and ulcerations observed in this patient are suggestive of this diagnosis. Chemical burns are quite common in the oral mucosa, with topically applied aspirin being a common offender. However, the patient initially complained of skin lesions months before her oral lesions began to appear. This fact alone detracts from this diagnosis. In addition, the chronicity of the oral lesions also weakens this diagnosis since once the chemical burn related lesion(s) start in the oral mucosa; most patients will cease placing

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Diagnostic Discussion

the offending agent in the oral cavity due to significant discomfort. Many of the chemicals used for dental care, such as mouthwashes, can cause burns in the oral mucosa. Chemicals used by dentists can also cause burns if not used carefully, such as sodium hypochlorite; acid etch preparations; bleaching agents, especially hydrogen peroxide; phenols; etc. Typically, chemical burns are seen on buccal mucosa or vestibular mucosa; therefore, involvement of the gingiva and hard/soft palate is highly unusual. As mentioned above, the presence of a white plaque or painful superficial sloughing membrane is characteristic of a chemical burn and may resemble a vesiculobullous disease. However, the presence of Nikolsky sign is not present. In addition, a history of topical aspirin/caustic chemical use is confirmatory and usually requires careful history taking. Profound chemical burns with extensive tissue damage may be seen with accidental or intentional ingestion of industrial drain clearing agents such as Drano. E. Pemphigus Vulgaris (PV) Correct! Pemphigus vulgaris (PV) is an uncommon condition with uncertain incidence and prevalence. It is reportedly more common in certain populations of the world, such as people of Mediterranean origin. The incidence of PV has been estimated to be one to two cases in a population of 100,000. Interestingly, up to 50 percent of the cases first present with oral lesions before any skin manifestations, unlike the patient presented here. The word pemphigus is derived from Greek pemphix meaning “bubble.”

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Pemphigus comprises a group of autoimmune mucocutaneous blistering diseases, of which PV is the most common variant. The average age at diagnosis is 50 years. PV is characterized by the presence of tissue bound and circulating IgG antibody directed against the cell surface of keratinocytes. The antibodies in PV bind to the desmosomes of the keratinocytes — specifically desmoglein 1 and desmoglein 3 — resulting in separation of the epithelial cells, causing acantholysis and blister formation. The basement membrane proteins are spared; hence, the blisters in PV are intraepithelial and tend to be weak, rupturing easily. Patients with PV have circulating autoantibodies (in 80-90 percent of the cases) as well and disease activity can be monitored by estimating the serum titers of antibody. The antibody binding triggers a complement cascade, which in turn releases chemical mediators of inflammation. Patients usually complain of oral soreness and multiple superficial, ragged ulcers affecting any part of the oral mucosa. Typically the palate, labial and buccal mucosa, and gingival epithelium are involved as seen in the patient presented here. Oral lesions precede cutaneous ones by up to a year and occasionally may be limited to the oral cavity. The skin lesions appear as flaccid vesicles and bullae that rupture quickly, leaving an erythematous, denuded surface. Characteristically, a positive Nikolsky sign is typically seen where vesicles and bullae can be induced on normal-appearing skin or oral mucosa with firm lateral pressure.

Importantly, a biopsy from perilesional tissue demonstrates a classic intraepithelial separation, which occurs just above the basal cell layer of the epithelium, that remains adherent to the connective tissue, creating a “tombstone” effect. The spinous epithelial cells are often found freely floating near the surface (acantholysis) and can be diagnostic even on a cytologic smear where these Tzanck cells are identifiable. The diagnosis of PV should be confirmed via direct immunofluorescence examination of fresh perilesional tissue placed in Michel’s solution. A “chicken wire” appearance of positive IgG antibodies highlighting the epithelial cell membranes involved epithelial cells. It is very important to obtain perilesional tissue for both light microscopy and direct immunofluorescence for accurate diagnosis, since a biopsy from the ulcerated area may not contain any epithelium. The mainstay of PV treatment is immune suppression and may involve any of a variety of steroidal and non-steroidal immunomodulatory drugs, such as prednisone, mycophenolate mofetil, azathioprine, methotrexate, dapsone, etc. Newer agents such as rituximab and/ or intravenous immunoglobulin (IVIg) are also increasingly used as first-line therapy. Early diagnosis is critical because disease control is easier and improved in most cases. Obtaining serum titers of circulating autoantibodies, particularly anti-desmoglein 1, using indirect immunofluorescence is very important in the monitoring success of therapy. Often repeating the direct immunofluoresPlease see discussion, 50

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cence testing to demonstrate absence of intraepithelial IgG is a good indicator of remission. Maintenance of oral hygiene in PV patients is challenging when active disease is present. PV requires long-term care and careful adjustment of dosage of immunosuppressive medication(s). The mortality rate in PV patients is reported to be in the range of 5-15 percent and is considered to be largely associated with therapy. It is of importance to note that PV, or PV-like diseases, have been reported with certain medications and as a paraneoplastic condition. Medications such as penicillamine, non-steroidal antiinflammatory drugs (NSAID), etc. and underlying conditions such as leukemia, lymphoma, and other malignancies have been associated with PV. Note: This patient continues to be treated and under careful follow up. She is currently free of any oral or skin lesions and remains on mycophenolate and prednisone.

Useful references: 1. Ruocco E, Wolf R, Ruocco V, Brunetti G, Romano F, Lo Schiavo A. Pemphigus: associations and management guidelines: facts and controversies. Clin Dermatol. 2013 Jul-Aug; 31(4):382-90. doi: 10.1016/j.clindermatol.2013.01.005.

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2. Venugopal SS, Murrell DF. Diagnosis and clinical features of pemphigus vulgaris. Immunol Allergy Clin North Am. May 2012; 32(2):233-43, v-vi. 3. Helander SD, Rogers RS 3rd. The sensitivity and specificity of direct immunofluorescence testing in disorders of mucous membranes. J Am Acad Dermatol. Jan 1994; 30(1):65-75.

Dr. Bhattacharyya

4. Fitzpatrick RE, Newcomer VD. The correlation of disease activity and antibody titers in pemphigus. Arch Dermatol. Mar 1980; 116(3):285-90. 5. Ahmed AR, Moy R. Death in pemphigus. J Am Acad Dermatol. Aug 1982; 7(2):221-8. 6. El Tal AK, Posner MR, Spigelman Z, Ahmed AR. Rituximab: a monoclonal antibody to CD20 used in the treatment of pemphigus vulgaris. J Am Acad Dermatol. Sep 2006; 55(3):449-59. 7. Yeh SW, Sami N, Ahmed RA. Treatment of pemphigus vulgaris: current and emerging options. Am J Clin Dermatol. 2005; 6(5):327-42. 8. Harman KE, Albert S, Black MM. Guidelines for the management of pemphigus vulgaris. Br J Dermatol. Nov 2003; 149(5):926-37. 9. Hashimoto T. Recent advances in the study of the pathophysiology of pemphigus. Arch Dermatol Res. Apr 2003; 295 Suppl 1:S2-11. [Medline].

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Dr. Cohen

Diagnostic Discussion is contributed by UFCD professors, Drs. Nadim Islam, Indraneel Bhattacharyya and Don Cohen, and provides 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 the service receives every year from all over the United States.

Clinicians are invited to submit Dr. Islam cases from their own practices. Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter. Drs. Bhattacharyya, Cohen and Islam can be reached at ibhattacharyya@dental.ufl. edu, dcohen@dental.ufl.edu, and MIslam@dental.ufl.edu, respectively.

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1113 E. Tennessee St., Ste. 200TALLAHASSEE, FL 32308 Tallahassee, FL 32308 800.877.7597 insurance@fdaservices.com

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Anxious Dental Patient

Management of the

Anxious Dental Patient


Anxious Dental Patient By Morton I. Lieberman, DDS; Ines Velez, DDS, MS; Lina Mejia, DDS; Lynn Solomon, DDS, MS; and Michael A. Siegel, DDS, MS, FDS RCSEd

Abstract The anxious patient in the dental office reacts with panic and inability to cooperate with necessary treatment. It is the dentist’s responsibility to recognize and assuage the patient’s anxiety on both psychological and medical levels. The diagnosis, etiology and treatment of anxiety will be investigated and presented as any other disease entity. It is an illness that contributes to dental neglect and subsequent pain, disease and dysfunction. The purpose of this paper is to discuss the recognition and etiology of patient anxiety and to offer treatment solutions and behavior modification techniques. The discussion will include psychological insight as well as the use of anxiolytics and nitrous oxide-oxygen (N2O-O2) sedation to ameliorate the symptoms. Finally, a presentation will be made of the modern application of philosophic dicta of Plato and Aristotle in which the doctor is considered a philosopher who values the concept of self-healing based on the doctor-patient relationship. These techniques and concepts of totality in diagnosis and treatment are applicable today just as they were 17 centuries ago.

Introduction The concept of anxiety derives from the Latin “angere,” which means squeezing or strangling. It is a psychological aberration resulting in irrational fear. Understanding anxiety begins with recognition of signs and symptoms associated with its onset. The anxious patient perspires, grips the armrests or

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clasps the hands tightly. The patient may speak in an abnormally loud voice with a quick cadence. Breathing is rapid, the lips are pursed, and the heart rate and blood pressure may be elevated. These are not manifestations of rational fears but are usually based on a pre-existing mental state and the belief that a visit to the dentist is equivalent to a painful and frightening venture. These fears may be related to a previous negative dental experience or to the urban legend created in the media via television or film presentation.

Overview The duty of the dentist is to calm the patient’s fears and establish an aura of relaxation and confidence. The demeanor, appearance and gestures of the dentist are modes of communication with the patient that may serve to allay apprehension. A sensitive use of semantics, with a careful choice of words, delivered with a calm cadence and inflection further influence the professional relationship between doctor and patient. Nuance and body language come to bear in every utterance and promote an enhanced interpersonal trust. In the delivery of dental care, this relationship must be nurtured to make dental procedures more pleasant and thus encourage the patient’s cooperation, confidence and comfort. A dental visit typically involves a medical history followed by a clinical examination of the head and neck, oral cavity, oropharynx and dentition. Illnesses, medications, surgeries, family history, genetic phenomena and syndromes are investigated and documented. Medications used by the patient for management of anxiety or depression may be elucidated while taking the medical history. A routine set of questions is used to gather information regarding behavioral

aspects, dental IQ and comfort level, including a history of negative experiences and expectations of treatment. The existence of anxiety and depression may be ascertained through information regarding difficulty in falling asleep and the need for alcohol or soporific medications. The patient may awaken before daylight and may lie awake for hours. In addition, the anxious patient may admit to fear of facing each new day regardless of what it may hold. These inquiries may be conversational, rather than read from a strictly organized format. Early indicators of patient anxiety may thus be observed during the process of obtaining the patient’s history. Physical assessment follows the history and continues with investigation of “nervous” body language and speech patterns. Observable signs of anxiety may include perspiration, gripping the armrests or literally wringing the hands. Eye contact may be avoided and the patient may speak with an abnormally loud voice with a quick cadence. Breathing may be rapid and shallow through tensely pursed lips, and the heart rate and pulse may be elevated. Dental phobias are not rare and exist on both conscious and subconscious levels. They may be exacerbated in the dental office by the patient’s traditional positioning in the dental chair. The sounds of suction and the dental handpiece are neither cheerful nor reassuring. Impression materials may impinge on sensitive areas of the soft palate and the application of a rubber dam threatens impaired access to a patent airway. The mere proximity of the dentist can trigger claustrophobic discomfort through intrusion into peripersonal space. Phobias can and will develop and persist without recognition,

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understanding and active intervention. Amelioration of anxiety may require tranquilizing medications, primarily benzodiazepines (BZDs) and administration of N2O-O2 analgesia.

Epidemiology/Demographics Dental anxiety and phobias are quite common and are certainly not restricted to a specific country or region. They have been researched internationally and similar data have been reported. A study done in Amsterdam comparing dental fear to fears of snakes, heights and physical injuries, concluded that dental phobias were the most common. Females in particular exhibited fear of dentistry more than any other fear. The study further concluded that such fear is quite stable and long lasting.1 A Brazilian investigation of patients’ phobias reached conclusions of a similar nature, again with increased anxiety related to gender.2 Increased dental anxiety in older women was the focus of a Swedish study as well.3 Dental anxiety has been reported as an international and intercontinental entity, apparently not based on culture nor restricted to mapped boundaries.

Etiology and Pathogenesis The phobic patient need not have experienced personal traumatic dental procedures. A family member or friend may have related some exaggerated tale of an unpleasant dental procedure. The use of inappropriate semantics with terms such as “long needles” or “yanking teeth” can traumatize the prospective patient and evoke expectations of pain and suffering. Even appropriate use of terminology such “root canal therapy” can create fear in some patients. Anxious patients may insist on extraction of teeth that might otherwise be preserved with endodontic

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treatment. Television and movie concepts of dentists often cast the profession as comedic figures in contradistinction to physicians, police and attorneys. These conceptual portrayals do little to assuage fears of dental treatment.

Medical/Psychological Management and Treatment Modalities used for this purpose include empathy, optimal communicational skills, possible psychological intervention (with behavior modification), hypnosis, inhalant analgesia and anxiolytic drugs. On a philosophical level, the concepts of hermeneutics and phronesis will be discussed regarding their use in furthering and enhancing the interpersonal doctorpatient relationship. Logic dictates that communication skills with proper use of semantics are essential in welding this relationship. Models have been scrutinized and evaluated internationally, reaching a conclusion indicating a need for analysis of interactive communication.4 A Department of Periodontology at a Turkish dental university related the positive attitude of the caregiver together with communication skills and determined that they have a beneficial effect on successful dental care.5 An Israeli school of medical psychology explored the spread of dental problems in spite of improved modalities of care. They concluded that a “bio-social-psycho approach” must be established based on a positive relationship between the doctor and the patient. They suggested conventions and seminars where communication techniques are enhanced. Stress is placed on information, positive rapport, and use of reminders through calendars and phone calls. They also encourage support by the patient’s family and friends to further ensure compliance.6

The psychological approach is useful in other aspects of care. Regarding oral hygiene adherence, where anxiety exists, traditional methods of interventions do not enhance successful behavioral change. Psychological interventions with trained medical specialists actually resulted in improved home care. Additional studies have encouraged further investigational trials in this modality.7 Behavior modification, along with cognitive methods, may require further training of the general dentist. For many patients, dental fears can be alleviated by a sympathetic approach, but severe cases may require “cross-disciplinary efforts involving both dentists and psychologists.”8 Pediatric dentists are especially well-trained in relief and control of anxiety and address their young patients’ fears with behavior management sessions as regularly scheduled appointments. Hypnosis has been used successfully in dentistry. Since it is the application of enhanced positive suggestion, it can be employed at an interpersonal level involving the relationship between the dentist and patient. This is established basically through communication. Deep hypnosis requires training and the skills of an experienced hypnodontist. It has been recommended that all dentists should be skilled in hypnosis.9 A phobia may be a comorbidity of cognitive or physical impairments. Special needs patients may benefit from “relaxation, breathing, imagery, hypnosis and effective use of operatory language.”10 It would seem appropriate to apply these techniques to every anxious patient to establish relationships, relieve anxieties and improve the outcome of dental care. Please see anxious, 58

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Additional training via competent accredited instructors is necessary for efficient, safe delivery of inhalant analgesia. The patient must be fasting, so morning appointments are preferable. All necessary emergency medications must be available, and a thorough understanding of the physiological changes and stages of analgesia is mandatory. The patient must be monitored and the depth of anesthesia must be carefully controlled. The nitrous oxide and oxygen proportions must be accurately calibrated. An extra oxygen tank, preferably in tandem with the tank in use, must be on hand. It is mandatory that these tanks be checked before use to ensure adequate supplies of oxygen. Fail-safe equipment is a further essential safeguard. State Board of Dentistry certification may be required for the practicing dentist to use inhalant analgesia in the dental office. There will be some patients who are extremely afraid of all things associated with dentistry and will require additional care with a pres cription of anxiolytic drugs. Instructions should be carefully explained, including the absolute need for a responsible third-party to drive them to and from the office. It is suggested that prescriptions should be limited to one or two tablets and perhaps one refill. Psychologically unstable patients may develop chemical dependency and the dentist is not trained to deal with extreme aberrant personalities. The prescribed medications may give the patient a feeling of well-being never before experienced. It is natural that they will want this feeling to persist, but it is the function of a medical professional trained in the field of psychology to deal with this problem.

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If prescribed medications are given, BZDs have been proven to be safe and effective. These are considered to be psychotropic drugs and have been found to be successful in handling and assuaging dental phobias. They create a dreamlike state which contributes to amnesia to the extent that the patient cannot recall with clarity the dental procedures which have been performed. The pharmacology of these drugs deals with central nervous system neurotransmitters. They have the ability to potentiate gamma-aminobutyric acid (GABA). The latter inhibits neurotransmitter activity in the central nervous system, inducing a calming effect so that the patient can cooperate with planned procedures. BZDs used as anxiolytics include: lorazepam, bromazepam, diazepam, flunitrazepam, midazolam, oxazepam, and triazolam.11 BZDs are generally short-acting, but should not be prescribed beyond the scope of dental procedures due to their propensity for psychological dependence. As with all drugs, consideration must be given to interactions with other drugs. With BZDs, macrolide antibiotics such as erythromycin must be avoided because of resulting increased serum levels and half-life of the sedatives. This occurs because of competition for CYP3A4 enzymes that limits the sedative action though oxidation. The only exceptions include lorazepam and any other anxiolytics that are not metabolized through oxidation.12 The combination of BZDs and N2O-O2 analgesia has the advantage of the phobic patient’s cooperative acceptance of dental procedures and departing in a calm state of mind. In particular, the dental use of midazolam (Versed®) with conscious N2O-O2 sedation has been evaluated extensively and has been found to be

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safe and effective. Suggested technique uses 10 percent nitrous oxide analgesia with gradual increase to 40 percent; then starting 2 mg of intravenous midazolam and titrating 1 mg every two minutes until desired sedation is achieved.13 Without such effective combinations, a deeper stage of anesthesia with loss of consciousness might be necessary, especially in children.14 The dosages of oral or injectable administered anxiolytics for children are modified and titrated according to weight of the child. In some protracted procedures, as well as for medically compromised patients with conditions such as morbid obesity, emphysema or blood dyscrasias, hospital facilities must be used for the patient’s safety. The combination of administering intravenous midazolam (Versed®) and N2O-O2 analgesia, administered by oral and maxillofacial surgeons, is particularly effective because of the ease and efficiency of the technique and the patient’s total inability to recall the events of surgical procedures is an exceptionally valuable method in ameliorating fear. With heightened awareness and proper technique, the doctor-patient relationship is enhanced beyond actual knowledge and experience. Perhaps the patient’s judgment is based on the premise that if he or she has chosen the doctor, then the doctor is a good person; otherwise, the patient has made a serious mistake in choosing him. Evaluation of patients’ satisfaction may be based on the dentist’s ability to communicate.15 This communication is far more than linguistic. It exists on a level beyond words, as described in the philosophical concepts of hermeneutics and phronesis. The application of hermeneutics is based on the Platonian view of the doctor as a philosopher. It involves the healing

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Anxious Dental Patient process as a totality and further suggests that the patient’s self-healing should be a primary focus.16 Hermeneutics historically recommends using four forms of acquisition of information. These are: 1) experiential (patient’s perceptions); 2) narrative (history); 3) physical examination; and 4) instrumental (determined by diagnostic technologies). In modern dentistry, we can acquire these sequential steps of information by listening, observing, examining for pathology and employing modern diagnostic modalities (e.g., radiographs, electronic pulp testing and sphygmomanometer). Essentially, hermeneutics begins with empathy prior to physical examination. We must attempt to understand the totality of the patient — his perceptions and needs — before proceeding with other diagnostic modalities.17 Phronesis is an Aristotelian concept that is equivalent to the doctor’s practical knowledge based on personal experience. It goes beyond text books and includes communication skills that can actually influence the patient’s ability to engage in a lifestyle change.18 The application of phronesis by the dental practitioner can lead to improved home care and compliance with recommended dental procedures. This approach may be useful in influencing healthy lifestyle changes, such as smoking cessation. It is of interest to note that the concept of phronesis applies primarily to the interpersonal relationship between doctor and patient. If the doctor gives good advice, he must therefore be a good person. Properly used, phronesis reflects the practical wisdom and moral character of both doctor and patient. It results in an interpersonal understanding that en-

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hances this relationship. As such, it can be applied to encourage healthy behavior in each patient and to help ameliorate anxiety through confidence in the doctor’s abilities and good intentions.

Conclusion With a combined approach involving empathy, efficient communication skills and the available anxiolytic and analgesic modalities for relieving anxiety, the dentist will be better prepared to evaluate and deal with each patient’s phobic problems. When presented with anxiety, the practicing dentist must remain calm and self-assured at all times. This air of confidence is the essence of the relationship between doctor and patient. Confidence is required in dealing with the concerns of all patients, with or without dental anxieties. Evaluation of the patient as a whole and interpretation of each patient’s needs must precede the oral exam. The most intelligent treatment plan may not succeed in an atmosphere of anxiety and the gentlest hands may not assuage a patient’s fears.

References 1. Oosterink FM, deJongh A, Hoogstraten J. Prevalence of dental fear and phobia to other fear and phobia subtypes. Eur J Oral Sci 2009; 117(2):135-43. 2. Carvalho RW, Falcao PG, Campos GJ, Bastos Ade S, Pereira JC, Pereira MA, Cardoso Mdo S, Vasconcelos BC. Anxiety regarding dental treatment: prevalence and predictors among Brazilians. Cien Saude Colet 2012; 17(7):1915-22. 3. Hagglin C, Berggren U, Hakeberg M, Ahlqwist M. Dental anxiety among middle-aged and elderly women in Sweden. A study of oral state, utilization of dental services and concomitant factors. Gerontdonology 1996; 13(1):25-34. 4. Boiko OV, Robinson PG, Ward PR, Gibson BJ. Form and semantics of communication in dental encounters; oral health, probability and time. Social Health llln 2011; 33(1):16-32. 5. Yamalik N. Dentist-patient relationship and quality care 3. Communication. Int Dent J 2005; 55(4):254-6. 6. Poplinger A. Adherence to oral hygiene and dental self-care. Refuat Hapeh Vehashinayim 2010; 27(2):38-49:62-3. 7. Renz A, Ide M, Newton T, Robinson PG, Smith D. Psychological interventions to improve adherence to oral hygiene instructions in adults with periodontal diseases. Cochrane Database Syst Rev 2007; 18(2):CD005097.

8. Berggren U. Long-term management of the fearful adult patient using behavior modification and other modalities. J Dent Educ 2001; 65(12):1357-68. 9. Shaerlaekens M. Hypnosis and dentistry: water and fire? Rev Belge Med Dent 2003; 58(2):118-25. 10. Peltier B. Psychological treatment of fearful and phobic special needs patients. Spec Care Dent 2009; 29(1):51-7. 11. Mandrioli R, Mercolini L, Raggi MA. Metabolism of benzodiazepine and non-benzodiazepine anxiolytic-hypnotic drugs: an analytical point of view. Curr Drug Metab 2010; 11(9):815-29. 12. Becker DE. Psychotropic Drugs: implications For Dental Practice. Anesth Prog 2008; 55(3):89-99. 13. Venchard GR, Thomson PJ, Boys R. Improved sedation for oral surgery by combining nitrous oxide and intravenous midazolam: a randomized, controlled trial. Int J Oral maxillofac Surg 2006; 35(6):522-7. 14. Uldum B, Hallonsten AL, Poulsen S. Midazolam conscious sedation in a large Danish municipal dental service for children and adolescents. Int J Paedaitr Dent 2008; 18(4):256-61. 15. Schouten BC, Eijkman MA, Hoogstraten J. Dentists’ and patients’ communicative behaviour and their satisfaction with the dental encounter. Community Dent Health; 20(1):11-5. 16. Lingiardi V, Grieco A. Hermeneutics and the philosophy of medicine: Hans-Georg Gadamer’s platonic metaphor. Theor Med Bioeth 1999; 20(5):413-22. 17. Leder D. Clinical interpretation: the hermeneutics of medicine. Theor Med 1990; 11(1):9-24. 18. Konghorn WA. Medical education as moral formation: an Aristotelian account of medical professionalism. Perspect Biol Med 2010; 53(1):87-105.

Dr. Lieberman is a Clinical Assistant Professor in the Department of Oral Medicine and Diagnostic Sciences at Nova Southeastern University and can be reached at ml1094@nova.edu. Dr. Velez is a Professor in the Department of Oral Medicine and Diagnostic Sciences at Nova Southeastern University and can be reached at ivelez@ nova.edu. Dr. Mejia is an Assistant Professor in the Department of Oral Medicine and Diagnostic Sciences at Nova Southeastern University and can be reached at lm1273@nova.edu. Dr. Solomon is an Associate Professor in the Department of Oral Medicine and Diagnostic Sciences at Nova Southeastern University and can be reached at lsolomon1@nova.edu. Dr. Siegel is a Professor and Chair of the Department of Oral Medicine and Diagnostic Sciences, and a Professor of Internal Medicine (Dermatology) in the College of Osteopathic Medicine at Nova Southeastern University and can be reached at masiegel@nova.edu.

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September 1

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Dental Caries: Advances in Detection & Disease Management

Clearing the Fog on Different Types of Bone Grafting & Ridge Augmentation

Oral Surgery for the General Practitioner

Blood, Spit & Fears: A Painless OSHA Update

Ms. Doreen Smeltzer Expires 11/30/13

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Five Factors to Dramatically Improve the Patient Experience

Patient Experience

62 Today's FDA

3 start strong 3 connect emotionally 3 interview eloquently 3 educate with impact 3 close powerfully

By Edward Leigh, MA

Create a great experience and you’ll have a lifelong patient! Patients have many choices when it comes to their dental care. But when you get a new patient, once you have them in your office you want them to become a permanent patient. With that in mind, it makes sense to identify the key factors that will dramatically increase the likelihood they’ll return. When you do this, these enthusiastic patients will become your best marketers. They’ll be sure to tell their family members and friends about their great experiences in your office! Here are my five factors that will dramatically improve the patient experience in your office:

Factor One: Start With a Strong Opening The first few moments set the tone for the patient experience — what happens in the first minute makes or breaks the experience. Here’s the sequence of events for seeing a new patient: Say the patient’s name (“Hello, Mrs. Smith”). If you’re unsure of pronunciation, ask first before attempting to state the name.

September/October 2013

You may also want to check with other people in the office about pronunciation before stating the patient’s name. This point is critical; I have interviewed patients who left a practice because their names were constantly mispronounced. State your name and role. For example, say: “I’m Mary. I’m a dental hygienist.” The dentist can say, “I’m Dr. John Stevens.” Recent research has shown that patients prefer hearing both the first and last names of their doctors. Meet the guests. If possible, ask the patient to introduce you to others so that you can learn about their relationships (e.g., “This is my daughter, Carol.”). Repeat the name — say, “Hello Carol, it’s a pleasure to meet you.” Remind them to feel free to add information and ask questions. It’s vital to establish a great relationship with the patient’s guests. The guest(s) must also have a great experience. Signpost. This word means to tell people what’s coming next — provide them with direction. Explaining to patients what will be happening relieves their anxiety. For example, you can say, “Today, we’ll first talk about what brought you in, and then I’ll order X-rays and discuss treatment options.” Be sure to discuss issues related to pain management.

Factor Two: Connect Emotionally We connect with each other through emotion, not information. Just because we provide information to patients does not mean we are automatically connecting with them on an emotional level. And yet, this is a “must.” We have to connect with patients on an emotional level to “sell them” on the importance of compliance. This makes perfect sense. After all, if we feel connected with people, we tend to follow their advice. Start with empathy. In non-emergency situations, address the psychosocial before the

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Patient Experience dental/medical issues. Empathize before you educate. Put yourself in their shoes. People are fearful and they feel a loss of control. Those two factors alone can turn a sweet, kind person into a hostile nightmare. Patients want someone to listen to them — the correct use of empathy tells them you are present and that you care. Then, reflect back what you feel they are experiencing. This could be as simple as stating, “This must be very stressful for you.” Use “I” language, not “you” language. Directly state, “I want to help you.” For example, if a patient is angry about taking a certain medication, state, “I know you have concerns about this medication, but it’s going to help you feel better. I want you to feel better.” This statement is much more effective than saying, “You have to take this medication.” Empathize with angry patients. When dealing with angry patients, it is best to use empathy — such as, “I know this is very frustrating for you.” Do not say something like “Calm down.” That statement makes people even angrier. I was once in a department store and a customer was very angry. The sales clerk said to her, “I need you to settle down.” The customer became even more enraged!

Factor Three: Interview With Eloquence The interview portion of the patient experience is when the professional(s) gather information. These techniques will help you gather information while simultaneously creating an excellent patient experience. Start with a general question, such as, “Tell me what brought you here.” Before asking any details about the first issue, ask the patient, “What else?” There

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may be no other issues, but asking this question in the beginning will reveal all the pertinent issues and will avoid those dreaded, late-occurring “Oh, by the way” issues. Here’s an example: Dental Professional: “Tell me what brings you here?” Patient: “I’ve been having a toothache.” Dental Professional: “What else?” Patient: “Well, sometimes, my gums bleed.” Mute yourself. Once you begin the information-gathering phase, please don’t interrupt. Give patients one or two minutes to fully tell you their story. Then ask for details. Be careful with the “why” question. Using the word “why” can often be seen as judgmental. Avoid it. Removing “why” questions creates a more comfortable experience for patients, rather than putting them on the defensive. I suggest converting “why” questions to “what” questions. For example: “Why” question: “Why didn’t you call us sooner?” “What” question: “What was happening that led to the delay in contacting us?” Too many issues and not enough time. If the patient has multiple issues and there isn’t sufficient time to discuss everything, the situation has to be handled delicately to retain an excellent patient experience. Don’t tell the patient you don’t have time to discuss all his or her issues. Instead, use an “I wish” statement, such as: “I wish we had time to discuss everything that’s going on. How about if we discuss these two issues and schedule

an appointment to discuss the other items? How does that sound?”

Factor Four: Educate With Impact This section will focus on educating the patient. Traditionally, the beginning of the medical interview involves the patient giving you information — telling you his or her story. As the interview progresses, the tables are turned. You become the one who’s giving the information. This is when you provide education to the patient regarding diagnosis, testing and treatments. There are several strategies you can employ to educate your patients. It’s important to remember that while you are very familiar with the information, your patient may be hearing it for the first time. Everyone is in “sales.” Everyone sells something. We might not be selling TVs or cars, but we all sell something. With the same skills that a salesman uses, you can sell good dental health. “Sales” is not a dirty word. Rather than view sales in negative terms, think of sales as a set of useful tools to educate your patient. Part of your job is “selling” the patient on your proposed plan. Telling stories of other patients who have been successful with certain treatments can be a major selling point for a patient who feels ambivalent. Information tells them — stories sell them. Avoid dental/medical jargon. Use everyday language instead of dental/medical terms. This may sound obvious, but in my work with practices, I often hear jargon used without proper explanations. I read about one patient who complained that her doctor called her an “idiot.” He actually used the term, “idiopathic.”

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Patient Experience

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Avoid describing test results as “negative” or “positive,” or “unremarkable” or “insignificant.” Patients are often confused about these terms. Some patients that are unfamiliar with the terms may even find the jargon offensive. They may feel you are personally calling them unremarkable and insignificant! Sketch a diagram. Hand-drawn sketches are very effective, and patients feel special that you did this just for them. Of course, preprinted charts and graphs also are effective. Effectively use brochures. Provide written information that the patient can take home. Just before giving the brochure to the patient, briefly review key sections with them. Keep a pen or highlighter nearby; you may want to mark certain parts of the brochure. Taking a moment to review key points in the brochure has dramatic impact, as opposed to simply handing the patient a brochure. Teach back. There are serious problems associated with the question, “Do you understand?” Just because the patient says, “Yes,” doesn’t mean they truly understand. So, how can you be sure they understand? Use the “teach back” method! Teach back is a powerful communication tool to assess a patient’s understanding. After you share new dental information with the patient and family members, the patient (or family member) is asked to “teach back” what he or she just heard, either verbally or in the form of a demonstration. This allows the

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professional to correct misunderstandings and provide additional information, if necessary. Don’t simply tell patients to “Repeat back what I just said!” That comment will put them on the spot and cause anxiety. They’ll feel like a school kid who was just told he is having a pop quiz. A better approach would be to say, “I’ve given you a lot of information — just to make sure you understand everything, I’d like you tell me what you heard.” Chunk and check. Instead of giving people a huge amount of information at one time, break the information into manageable units (“chunks”). After giving a chunk of information “check” in with them to be sure of their understanding. This strategy helps patients who feel overwhelmed with too much information.

Factor Five: Powerful Close Many of the issues we face near the end of the interview could be avoided by following all the steps we previously discussed, such as asking, “What else?” early on to avoid late-occurring “Oh, by the way” issues from surfacing. Repeat! Restate key pieces of information. Repetition leads to retention. Savvy salesmen know they have to repeat key pieces of information to make the sale. Likewise, in order for you to “make the sale” with your patients — in other words, to gain their agreement or compliance — repetition is vital. Patients are under stress and they don’t remember information very well.

General closing elements include: Ask the open question, “What questions do you have?” (Do not ask the closed question, “Do you have any questions?”) Summarize the discussion and confirm understanding with the patient and family members. Signpost (explain future plans). Use the patient’s name (and the family member names, if you can recall). Close with a partnership statement, such as, “I know this is happening to you, but we’ll face it together” or “we’ll be with you every step of the way.” In summary, the five key topics mentioned in this article will transform your dental practice! Your patients will love you, and also will become your most enthusiastic supporters. A satisfied patient is your best promotional tool! Reprinted from the Journal of the Michigan Dental Association, May 2013 issue. Used with permission. Edward Leigh is the founder and director of The Center for Healthcare Communication, focusing on dramatically improving the patient experience. His new book is titled, Engaging Your Patients. He has appeared on numerous television programs, including “The Today Show,” and on the Oprah Winfrey Network.

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Florida Department of Health

Florida Department of Health Cuts Complaint Response Time

By The Doctors Company

The Florida Department of Health (DOH) recently reduced the amount of time permitted for processing complaints. This new development reinforces the importance of immediately notifying The Doctors Company Claims Department of any investigation or inquiry by the DOH. Time limitations for responses to DOH investigations have always been in existence. Previously, the limitations were 45 days for responses by allopathic and osteopathic physicians and physician assistants, and 20 days for responses by dentists, podiatric physicians and all other health care practitioners. Some circumstances may significantly reduce these response times. Previous enforcement of the reporting time standards varied, making it more likely to obtain additional time upon request in order to respond to a complaint. However, this flexibility has changed due to recent inquiries into the DOH’s ability to adhere to processing goals established by the Legislature. Recent reviews have shown poor compliance with this standard. Consequently, members must promptly contact The Doctors Company if they receive notification of an investigation by the DOH — taking this step is now more urgent and vital for a proper defense. In an effort to provide assigned defense counsel sufficient time to prepare an appropriate response, all Florida members of The Doctors Company should immediately notify the Claims Department of the existence of a DOH investigation as soon as any notification letter is received. A complete copy of all correspondence received from the DOH is required to properly assign the case and implement immediate action to prepare a response. In addition, complete copies of appropriate and available patient records, as well as copies of X-rays and materials, including a narrative of the circumstances related to care of the patient, must be provided. This narrative is a privileged document and will be used solely by assigned defense counsel as background information to aid in the preparation of the response on the health care practitioner’s behalf. A current copy of a curriculum vitae or resume also is required.

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If you are contacted by the Florida Department of Health about a complaint or investigation, notify our Florida Claims Department immediately at 800.741.3742.

Reprinted with permission. © 2013 The Doctors Company (www.thedoctors.com). 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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Dentists’ Day on the hill 2014

Making a Difference TogeTher!

It’s a family affair! Bring your spouse!

Briefing

LegisLATive visiTs

Tuesday, April 1, 2014

Wednesday, April 2, 2014 sponsored by

For more information: 321.452.5500 • Email: JWSRGN@aol.com • www.floridadental.org/ddoh

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mediation makes sense with the FDA Peer review Mediation Program MEDIATION VS. LITIGATION The Peer Review Mediation Program settles disagreements between patients and dentists more economically and efficiently than the legal system and is available only to FDA members. This program is free of charge. Only cases involving problems with actual treatment and procedures are eligible for mediation. Mediation takes place at the local level, so problems can be resolved more effectively.

FOr MOrE INFOrMATION

about the FDA Peer review Mediation Program 800.877.9922 • fda@floridadental.org www.floridadental.org/peer-review

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Cases not eligible for the program include: malpractice litigation; formal regulatory investigations; disputes over dental fees; treatment that occurred more than 12 months before the patient’s last appointment with the dentist; and cases involving dentists who are not FDA members.

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Skilled and Kind Dentists. Are you tired of working in

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opportunity to join our established state of the art private practice. No HMOs are accepted. Talented and friendly Minimum of one year experience. Please email resume and photo to donnaharvey@gmail.com. Dentist Opportunities. Dental Partners is one of the fastest growing family dental practice groups in the Southeast. We give you the ability to focus on patient care while earning a base of $125K-$200K and the opportunity to earn more based on production. Benefits package of medical/vision/life/ FSA, 401K, professional liability and yearly CE allowance. Relocation and student loan repayment assistance program

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Your Classified Ad Reaches 7,000 Readers! classifieds from 75

Endodontist — Christie Dental Established Group Practice.

Florida, Key West — Live and practice dentistry in paradise!

Christie Dental is a multi-specialty dental group with

Well-established, four-operatory dental practice with

Orthodontist. We are seeking an energetic, team oriented

approximately 55 dentists and specialty doctors in 24 practice

1,850-square-foot, stand-alone building for sale. Great office

Orthodontist who enjoys their profession and who will

locations in the Brevard, Ocala and Orlando, Florida

layout, high quality staff, room for growth. Great opportunity!

work side by side with us to expand this specialty in our

markets. Christie Dental offers individuals and families a full

Call 305.394.2874 for details.

practice in this long term opportunity. Our culture includes

range of dental care, including general dentistry, hygiene

modern technology and a deep focus on our patients.

and specialty care, such as pedodontics, oral surgery,

Degree from an accredited U.S. Dental School, Orthodontic

endodontics, orthodontics and periodontics. kateanderson@

Residency completion, 3 years of experience. APPLY:

amdpi.com.

REDUCED PRICE FOR IMMEDIATE SALE. 3 OPS, IN THE

Implants and Periodontal Services. Periodontist looking for

for more details: www.NaplesFloridaDentalPracticeForSale.

1 day per week (Thursday) to place implants and perform

com. Email: NaplesFloridaDental@Yahoo.com.

PEDODONTIST. We are seeking an energetic, team oriented

periodontal services in fee for service office. Ft. Lauderdale

Pedodontist who enjoys their profession and who will work

area or Palm Beach to Jupiter area. Please email implant.

side by side with us to expand this specialty in our practice

perioddsmsd@gmail.com.

in this long term opportunity. Our culture includes modern technology and a deep focus on our patients. Degree from an accredited U.S. Dental School, Pediatric Dentist

For Sale/Lease

Residency completion, 3 years of experience. APPLY:https:// audiologyjobs-audigygroup.icims.com/jobs/2308/

$165,000.00 (NEGOTIABLE) LIMITED TIME. ABSOLUTELY MOST EXCLUSIVE HIGH-END AREA IN NAPLES. View website

https://audiologyjobs-audigygroup.icims.com/jobs/2307/ orthodontist/job.

Naples FL Dental Practice for Sale on Best Offer.

Pompano. Small office in nice professional building on US 1 central Pompano. Great potential as a “startup” practice! Michael.Finnan@henryschein.com. Pembroke Pines — #FL501. 12 year old practice in high traffic area of Pembroke Pines. Office is beautiful with good exposure and ample parking. This practice is equipped

Large Office for Specialty Practice. Large 6 op practice for

with latest technology including Dentrix, digital intraoral,

sale to specialist. No patient records included. 5 rooms

panographic and lasers. 8 days of hygiene and averaging 35

Dentist. Neighborhood practice in the Treasure Coast with

fully equipped with Adec and x-ray units. Lease transferable.

new patients per month. Michael.Finnan@henryschein.com.

a full-time Associate Dentist position available. Clinical

Office located in middle of Boca Raton Florida. Please call

freedom and autonomy enjoyed in a traditional private

646.642.2747 or email lamloann@gmail.com.

pedodontist/job.

practice without the additional financial or administrative burdens associated with practice management. Unlimited production based earnings, a solid benefits package, a stable patient base, training opportunities, and long-term practice or regional career growth. Please fax resume to 770.242.3251.

Gross receipts $1.2M+. Owner retiring. Michael.Finnan@

with beautiful furnishings, high-end finishes and modern

henryschein.com.

equipment...all included in the price. Great area and the busiest road in SWFL. Fitted for 6 operatories, 1 of which is fully equipped with chair and supporting equipment. Lab, Data Vacuum all in place. Move in to an existing practice with

Orthodontist for Private practice in Miami with many active

3-4 days’ worth of appointments. Seller Financing/Lease also

patients. sheila@prodentgroup.com.

negotiable. info@adampalmer.net.

Endodontist. Neighborhood practice in Tampa Bay with a

Architecturally Designed Dental Office Available. Proven

part-time Endodontist position available. Clinical freedom

successful dental office space for sale or lease in booming

and autonomy enjoyed in a traditional private practice

Fleming Island, Florida. Free standing, street side, brick

without the additional financial or administrative burdens

building in the “Professional Center” located between Pace

associated with practice management. Unlimited production

Island and Eagle Harbor communities. All hook ups, some

based earnings, a solid benefits package, a stable patient

equipment, and all cabinetry in place to enable a quick start

base, training opportunities, and long-term practice or

up. smiledoc@hotmail.com. South Miami Dental Office. South Miami Dental office for

ASSOCIATE DENTIST NEEDED. Full time General Dentist

sale as a physical entity. Doctors are relocating and will take

needed for a 100% fee for service private practice on the

patient base only. Turn-key, older practice in nice shape. 2

beautiful space coast in Rockledge, FL (just south of Cocoa

new ops. Has 6 plumbed, and equipped rooms with X-rays.

Beach and Merritt Island & minutes from Melbourne, Viera

Has pano with digital conversion Denoptics. 2 other rooms

& Satellite Beach). Our modern, state-of-the-art practice

are plumbed and can be equipped. Call 305.282.5296 for

is located in a free standing building, is digital, paperless

info. Asking price is negotiable.

& equipped with televisions in all ops. The ideal candidate must be capable of both simple and surgical extractions, molar endo and be proficient in all other areas of general dentistry. Compensation is $500.00 a day guarantee or 35% of production. You will be joining a well-trained, experienced, highly motivated team. Please email your CV and contact info to 2001molardoc@gmail.com. All inquiries will be strictly confidential. We look forward to hearing from you.

Pedo practice. 9 operatories in 3,800 SF office. 2012

Turnkey Office — Furnished and Equipped. Turnkey office

We are seeking a team oriented Pedodontist and an

regional career growth. Please fax resume to 770.242.3251.

Lake County — #FL503. Central Florida Medicaid based

DENTAL OFFICE FOR SALE OR LEASE. 6200 RENTABLE SQUARE FOOT 2 STORY BUILDING. 7311 SW 62 AVENUE, SOUTH MIAMI, FL. 3,700 sq. ft. 2nd floor. Former group practice located here for 35 years. Consisting of 12 operatories. All modern upgrades, including wiring for digital radiography and computers, etc. Large waiting room, business area, staff room, labs, private offices, etc. Located

West Coast Dental Practice. Collections in 2012 of 647,00.00. 5 operatories with computer monitors. Dexis; Dentrix. Incredible staff! 1600 sq. ft. building with 2013, newly installed roof and 2 AC units also FOR SALE. View practice details and photos on www.dentaldirect.com. Contact: Nancy Perron @ 941.224.9124 or nmpdental@ gmail.com. Buyers and Sellers: We have over 100 Florida dental practice opportunities, and the perfect buyer for your practice. Call Doctor’s Choice Companies today! Kenny Jones at 561.746.2102, or info@doctorschoice1.net. Website: doctorschoice1.net. Seminole County, FL (Sanford). Good opportunity to take over thriving practice of 38 years with good patient flow. Doctor retiring. Building and practice separate, but both available. Gross income 5-600k. Listed for 330k. Three ops. Contact Dr. Roger Stewart, DMD 407.323.5340. Brickell, Miami Dental Office for SALE. A professional dentist’s DREAM PRACTICE! With perpetual growth of the downtown Miami area, this 1,600 sq. ft., storefront layout has 20 ft. ceilings and packs exponential profitability potential. This turn-key, ultra-modern practice is a masterpiece of design with the patient’s experience as its number 1 focus. Whether this is your first practice, or second, you honestly cannot miss with this opportunity. (4 ops, capable of 5.) tbecher2@gmail.com.

next door to large metropolitan hospital with very high traffic count and exposure. 1st floor 1,800 sq. ft. dental office. This is a unique opportunity for an entrepreneurial dentist to practice and own its own building in a AAA location. For further information call: Joe Wieselberg, Concorde Properties, 305.282.5371.

76

Today's FDA

September/October 2013

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Griggs Practice Transitions, LLC - Licensed Real Estate Broker September/October 2013

Today's FDA

77


Dental Staff

Your Team’s Personal Appearance: Why You Need a Formal, Documented Office Policy Regarding the Way Your Team Looks

Create a dress code and appearance policy specific for your practice that promotes your style of practicing dentistry and represents your business as you see fit.

78

” Today's FDA

By Fred Heppner

“Several interviewing applicants had impressive resumes, but they had tattooed arms, facial piercings and wild hairdos, so I didn’t hire them. Should I have a written policy on professional appearances, and if so, what should it contain?” This is a two-part question because it deals with potential hires and current staff. Unfortunately, you may have let some excellent candidates with impressive resumes slip away because there is no office policy regarding personal appearance expectations in place. Had there been a personnel manual that states what is expected of employees, the dentist could have hired the interviewee — provided he/she is made aware of the dress code during the hiring process and agrees to follow the standards to which all employees are expected to adhere. Many dental offices acknowledge the value of having a personnel manual with specific policies that clearly define expectations. Unfortunately, few small businesses actually have such a document in place. Similarly, dentists in private practice often do not have a personnel manual because they are unfamiliar with the process of publishing such a book, unique to their practice and beliefs. A personnel manual is as much a declaration of philosophy and behavioral expectations as it is a written document that provides employees with the rules and guidelines of the workplace. Employees will know what is expected of them and what they can expect from the employer. The manual also serves as legal protection if employees claim they were wrongfully dismissed. Keeping the manual current is important, as laws change over time.

September/October 2013

www.floridadental.org


Dental Staff

Purchasing an office manual that is already written (requiring limited modification) is one way to integrate this important management tool into the practice’s operations. Conversely, creating one without a pre-formed template is another way, albeit more difficult. Whether a practice purchases and modifies a pre-written manual or creates one from scratch, it is vital to make sure the manual contains basic elements, and that it speaks for the uniqueness of the office’s philosophy and practice of dentistry. It is important to make clear that the personnel manual is the property of the practice. A copy is kept in a designated place in the office for easy reference, and it must not be removed from the premises.

What Should be in Your Manual? Begin by describing the practice’s philosophy of both dentistry and employment protocols. Upholding a fair and safe work environment along with providing equal opportunity for employment are cornerstones of proper employee management. Also, describe the principles that are the foundation of the practice’s philosophy. This may take the form of a mission or vision statement, or even a simple paragraph relating the practice’s philosophy. Dental offices should have guidelines that help employees understand what the appropriate dress and grooming practices are for the workplace. There are several reasons for implementing these standards, such as: to present a uniform and professional appearance for patients; to limit distractions caused by offensive,

www.floridadental.org

inappropriate or provocative dressing; and, to ensure safety while working. Remember, employees are representatives of the practice. An employee’s personal appearance, which includes dress, grooming, personal hygiene, makeup, tattoos and piercings affect both the patients’ impression of the office and internal morale among staff. Ultimately, having an enforced, nondiscriminatory dress policy helps to promote a professional and positive working environment for all. The next step is to define office and employment policies. This is where the employer can be specific regarding personal appearances. This section must express the expectations of the employer, such as: assigning and supervising personnel; supporting positive contributions with praise; reprimanding when necessary; and, changing office policies as a result of internal circumstances, competitive forces, economic conditions, or to comply with state and federal regulations. The mainstays for this section can include having a strong work ethic, being friendly and courteous to others, adhering to office policies, and working toward solutions of any grievances justly and fairly. When detailing office and employment policies, the segment covering what is expected in regard to personal appearance standards should remain specific. Expectations regarding personal appearance are codified for the employee to easily understand. For example, “Employees are expected to maintain a professional appearance, which includes proper grooming and dress. Visible tattoos and facial piercings, excluding earlobes, are

prohibited. Hair needs to be pulled back. Dangling or large pieces of jewelry cannot be worn, as they may compromise job performance. Fingernails are to be kept short, and acrylic nails are not allowed. Makeup should be kept to a minimum. If an employee has a question in regard to the dress/appearance policy, the office manager or dentist needs to be contacted so that approval as to the dress code is given prior to the working day.” Once the manual is complete, it is wise to contact a local professional with legal experience in personnel law to help with specific questions and issues relating to this project. After formal editing and final publishing, circulate the manual among the employees and require them to sign a form that acknowledges they have read and agree to the policies set forth. These signed forms should be kept in the individual personnel files and updated periodically whenever a change in the manual is set forth. In conclusion, create a dress code and appearance policy specific for your practice that promotes your style of practicing dentistry and represents your business as you see fit. If that includes not allowing body piercing and unsightly tattoos, then so be it. Reprinted with permission by the Arizona Dental Association. Fred Heppner is a business management advisor, speaker and author. His firm, Proactive Practice Management, specializes in professional, objective practice guidance for dental professionals nationwide. He can be reached at fred-heppner@cox.net.

September/October 2013

Today's FDA

79


OFF the cusp John Paul, dmd, Editor

How Smart is Smart Enough? I was looking at “Star Trek” the other day (“TNG” for those geeks that require precision) and there was a 15-year-old boy using his iPad to redesign faster than light engines for his starship. I was a little impressed that “Star Trek” had the iPad before Apple, but then Capt. Kirk had a flip open communicator in the 60’s, nice to know the flip phone will make a comeback. It got me thinking: If future teenagers will understand how to manipulate quantum physics and interstellar travel, how smart will we need to be just to get by in the future, much less be successful? Where will we learn this stuff? I’m not sure I’m smart enough to get by now. I don’t know what generation of bonding agent I’m using, and the only engines I’m likely to be repairing any time soon are the air turbines in my handpieces (only three moving parts). I like collections of best practices, like we have featured in this issue of Today’s FDA: a lot of good information in one easy to use package. I’m even looking forward to evidence-based dentistry (EBD). That statement probably has a few of you checking to see if I’ve given up my membership in the conservative curmudgeon’s club. You’re thinking, “That’s OK for him, but nobody tells me what to do or when I’m going

80

Today's FDA

The trick is to be working with the most current research and that the research is relevant to your circumstances.

to change.” Just like my entire class in dental school, I wanted to be a dentist so I could be my own boss and help people the way I thought best without someone looking over my shoulder. The truth is, there’s always someone watching you. Those giants whose shoulders we stand on are always in our conscience. My first year in private practice, I prepared a DO cavity and pushed my chair back from the patient. After a few minutes, my assistant asked me what I was doing. I was waiting on the instructor to check on the prep so I could then fill. I can still hear what Drs. Welch, Sneed and Rivers would say of the work I just finished. Just like we all practice under supervision, even if it’s only our own con-

September/October 2013

science, we all practice EBD. Everything we do has reams of research to back it up. The trick is to work with the most current research, and that the research be relevant to your circumstances. Even if it’s peer reviewed, all research isn’t of equal quality. You have to use your own good judgment before you use any new information to change what you do. What I’m happy about is that alot of people are coming together to talk about current research and whether or not it can be applied to improve current practice. This is the evidence-based dentistry program that is happening at the American Dental Association. Like any man-made construct, EBD can be used for good or evil. People will misinterpret and manipulate results to suit their own selfish needs. That’s no reason to throw out EBD, just a challenge to be ever-vigilant. The more people paying attention to the research, the harder it will be to fool the masses. None of us is as smart as all of us, and like Walter Hailey always said in his workshops, “It is foolish to create mediocrity when you can easily copy excellence.”

Dr. Paul is the editor of Today's FDA. He can be reached at jpdentz@aol.com. www.floridadental.org


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