Audrey Sternberg

"The hygiene schedule is CRITICAL. 'Hygiene drive practice growth'." -

With any for-profit business, time and money are inextricably linked as the two most important resources. It is important for practice owners, as well as salaried dentists, to determine exactly how much each hour worked is generating for their bottom line. Doing simple mathematics to reveal exactly how much each hour is valued helps to determine if changes are necessary.

Unfortunately, delivering high-quality treatment is not enough to ensure a profitable business. As the head practitioner, dentists need to be aware of the time they spend away from the operatory. A lack of scheduling optimization or staff utilization can waste the most valuable and limited resource — 

. Ensuring that primary and secondary practitioners are allotted the resources they need to be successful will create a better workflow and greater harmony within the office.

Depending on the size of the practice, there should be one, or several, designated scheduling coordinators to ensure continuity in the scheduling of all procedures. Lee Harris, DDS of Harris Dental Solutions Inc. recommended that “one front office person be 

 for the schedule, but all front office staff should be trained according to specific protocols developed for the office to maximize production and efficiency while minimizing patients waiting.” An improperly scheduled appointment can easily become disastrous if there are not enough time units allowed for its completion.

Even worse, giving the doctor or hygienist too many scheduling units can lead to unwanted idle time. “Each dental office will have different guidelines for appointment scheduling depending upon number of doctors, type of practice and many other factors” Harris added.

It is important to be acquainted with the laws in each state outlining services that can legally be rendered by registered dental assistants and dental hygienists. Harris emphasized “auxiliary use should be maximized; anything within the scope of [their] license” should be recognized and implemented into regular practice. For example, having the properly certified dental assistant apply fluoride treatments to pediatric patients can free up the hygienist to move onto the next patient.

Alternately, Harris suggested hygienists “should always perform anesthesia procedures when allowable by law” to prep the patient before the dentist arrives to the operatory for treatment. These minutes saved add up at the end of the day and can alleviate the stresses associated with a backed-up schedule.

In today’s hectic environment, cancellations and late arrivals are inevitable and have become a part of most healthcare practices. Having multiple patient appointments overlapping in the schedule is a controversial topic that some practitioners reject altogether. Harris did not recommend overbooking “unless the office has a no show or cancellation issue”. However, with proper planning and open office communication, this method of time utilization can be successful. If certain patients are chronically late or canceling, plan for them to be unreliable and make sure all staff members are onboard to help in the event appointments begin to overlap.

Another option for filling cancelled appointments is having a designated “short-notice appointment list for those patients nearby” said Harris, adding “I also recommend [being] aware of other patients in the schedule that may be due for hygiene”. A reliable and curated list of patients to fill both the hygienist’s and dentist’s schedule in case of cancellations may minimize lost chairside time.

Eliminate Unnecessarily Lengthy Procedures

Certain treatments that require significant chair time or repetitive treatments may not be the most lucrative choice for all offices. An orthodontic case that generates significant production is tempting to overtake; however, it also entails numerous appointments that require attention from the front desk and clinical staff.

Similarly, an office with a limited number of operatories would be ill-advised to dedicate a chair to an in-office whitening treatment when the patient can have custom trays made in less time. Harris reminded general dentists performing specialty-level care that they “must be able to produce the same outcome” as a specialist in the community — another factor that suggests referrals may be more advantageous in certain situations.

Besides the dentist, the hygienist is the highest paid and most trained employee in the office after the dentist. Making sure the hygienist has enough patients, without overwhelming their schedule, will capitalize on this resource. Additionally, much of the treatment rendered by the dentist will come from hygiene. Harris described the hygiene schedule as a “critical” element to the overall success of the practice; adding to it that the “dental hygienist will develop a better relationship with [the] patient than the [dentist].”

A repetitive, positive experience with the hygienist will make patients feel more comfortable coming to appointments regularly. Patients who fail to come for their check-up appointments will not be alerted to their dental needs, often until it is too late.

For more on the importance of dental hygiene: 

Dental Hygiene - A Driver for Practice Growth

Delivering great dentistry is only part of the profitability equation. It is essential that all members of the dental team assist the dentists in increasing treatment quantity without compromising quality. If the practice is not profitable, there is significant ‘down time’, or the schedule is not running smoothly, a revaluation of quality chairside time will help bolster a routine in a rut.

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If a practice is not profitable, a revaluation of quality chairside time will help bolster a routine in a rut.

Optimize Dentist's Chairside Time

It is important for business owners to consider whether or not their practice emotes a message to their patients, and, if so, what that message is.

 in Phoenix, AZ, the message should translate how much the dentist cares about the patients and the business.

“It comes down to more than just picking pretty colors” Berry stressed, adding “we focus on creating an engaging, well put together space that is meant to perform”.

For practice owners planning a redesign, Berry’s business practices can help guide the flow of the space.

While the design of the office might seem like it is meant to attract new business, Berry’s internal vision focuses heavily on the staff who has to working within the space. “We always try to merge the needs of the patient with the logic of the facility, meaning, if the facility can’t manage the finishes, then the patient will not have a positive experience” she said.

Her attention to detail even extends to the number of steps a clinician must take each time they escort a patient to an exam room. She likens a poorly designed space to arming the team with improper treatment instruments. Helping the team be successful throughout their routine, Berry suggested, can increase staff retention and patient flow.

Berry called her business approach “holistic” — marrying the multiple factors that go into redesigning a space. “If the doctor has a lease for three years, we don’t want to spend a lot of money on flooring” she explained. Designing for all project parameters, such as patient volume, maintenance resources, schedule and budget, is her specialty, as long as the client has a realistic expectation. “Some dentists come to me because they want to give the office a lift with the knowledge that they will probably sell in ten years. But they don’t want to spend any money” she remarked, adding “we have built our business on 

 success”. Upgrading an office with outdated finishes requires and investment of time, money and trust in the professional, but it pays off when patients and potential buyers respond favorably.

Berry’s expertise does not stop at the office remodeling. Logo and graphic design are integral aspects that are tailored to match the practice’s vision and appearance. Something as simple as a logo can take a solo practice from a small business to a brand. “It’s the business of the business that sets them apart”, Berry emphasized. A well-designed logo is a subtle way to show clients there is consideration invested in more than just dentistry.

Previous, outdated graphic undergoes an exciting transformation

GRAPHIC: courtesy of Kelli Berry, Iconic Design Studio

Berry has worked on healthcare settings both large and small as well as with brands whose reach extends over multiple practices, specialties and states. “So much can come together when one person is making it a cohesive package” she said. Although upgrading the appearance of the office does not require a professional consultant, involving an expert can make the overall vision of the design match the dentist’s quality of care.

A dentist will redesign their practice for multiple reasons, but the benefits may extend past the aesthetic appearance. By making the practice more marketable to patients, a design consultant can also influence the success of the staff and attract potential future associates to the business.

Office Redesign Can Impact Business Success

Women consistently report less satisfaction with their healthcare providers - Infographic courtesy of Aetna's inaugural Health Ambitions Study

 show that patients, in particular women, are more concerned than ever about their overall holistic health and are focused on resolving issues, such as stress, to focus extra time on activities that promote mental wellbeing.

Despite ambitious health goals, women consistently report less satisfaction with their healthcare providers. Only 50 percent of women say they are likely to take the recommendations of their doctor and only 70 percent say their doctors are aware of their lifestyle habits. This opposes male respondents who answered at 61 and 81 percent respectively — over a 10 percent increase compared to female respondents in each sector.

Staggering statistics like these leave the dental provider wondering what they can do to increase patient satisfaction and compliance. “It would be beneficial for dental providers to be more in tune with patient’s health goals as most people see their dentists more often than their medical providers” said Michelle Neuman, RDH, Senior Director of Dental Management at Aetna.

Improving mental wellbeing, convenient access to appointments and a cohesive connection between healthcare providers for continued care are some of the most important aspects of the patient experience, according to the study; and all aspects are easy to control for in the dental setting.

The majority of female respondents in the study have either stress reduction or mental health goals on their list of priorities yet not all patients disclose their complete mental health to their dental care provider. Making sure patients fill out a comprehensive medical history form and addressing their conditions without judgement is important for connecting with them. “Certain triggers in the office [could] create potential risks not only for the patient but the staff as well” said Neuman, adding “It will still be up to the patient to disclose their mental health history.”

Mental health conditions, such as Bulimia Nervosa, can lead to oral manifestations of disease; but some issues may be subtler. Dental care providers are encouraged to further educate themselves in the detection of behavioral health issues. By reaching out to a patient in need, a clinician can show that they care about the patient’s comfort and reduce the barriers to a genuine connection.

There are other ways to appeal to the patient’s busy schedule besides offering early morning and late-night appointments. The term “Sandwich Generation” is used to describe women that provide care to both their offspring and dependent parents. They are often seen at doctor’s appointments but are rarely there for themselves. Caregivers who frequently neglect their own needs are often left waiting in the front office while their children or parents receive cleanings and fillings.

Instead of wasting idle time, it’s important to prioritize the needs of both patients so as to optimize both their time and that of the office. In a dental office with one hygiene schedule, it might be worthwhile to incorporate one or two days per month where there are two hygienists working side by side. Caregivers of disabled parents or children can cross two appointments off their list at one time without needing to neglect anyone’s priority.

Patients loathe the possibility of being referred to a specialist, especially in an emergency situation. It incurs high costs and lost time in addition to being unfamiliar territory. Developing good relationships with specialists is as much for the patients benefits as it is for the dentist. A confident referral and the knowledge that there will be collaboration between the specialist and general dentist can help settle their nerves. Plus, a call made directly by the front office staff to the specialist is more likely to result in an immediate appointment — a tangible benefit and relief to the patient.

The modern stressors associate with today’s lifestyle make it difficult for patients to connect with their dentists. Making the needs of the patient a priority will bridge the gap between the patient and their healthcare providers. Dentist’s need to utilize a little intuition coupled with great customer care to keep their patients returning.

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Based on the inaugural Health Ambitions Study by Aetna, females are more likely to be disconnected from their doctor than men. Here are some considerations in bridging the gap between the healthcare provider and these patient populations.

Health Ambitions Study Reveals Women Are Not Connecting with Their Doctors

“This is the first time that cogent healing has been shown in the TMJ area, [and] the first time anyone has shown successful biomechanical healing in any joint” said Dr. Athanasiou PhD, PhM, MS. PHOTO CREDIT: Steve Zylios, University of California - Irvine

Results of a University of California — Irvine 

 show that a tissue implant can safely treat temporomandibular joint disfunction in animal models. Senior author of the study in 

 Kyriacos A. Athanasiou, PhD, PhM, MS has spent close to 20 years researching the widespread condition and potential treatments. “This is the first time that cogent healing has been shown in the TMJ area, [and] the first time anyone has shown successful biomechanical healing in any joint” said Athanasiou.

Many TMJ disfunction suffers are young women who develop defects in the cartilage disk that connects the mandible and the temporal bone. This can lead to difficulties with speaking, eating and more serious conditions like arthritis.

The researches from UCI, University of California — Davis and the University of Texas Houston School of Dentistry used animal models to test the reengineered tissue implant. Scientists utilized existing rib tissue of a donor test subject to isolate cartilage cells, then used it to engineer jaw tissue cartilage. After surgically inserting the new cells into the defective jaw joint of the compromised animal subject, the TMJ issues were completely resolved.

Further insight into the regenerative methods must be obtained before it can be brought to clinical trial. “We follow the FDA paradigm” said Athanasiou, adding “once appropriate [animal] studies are performed, we are keen on proceeding with clinical studies”

Considering the complexity of the temporomandibular joint, Anthanasiou acknowledges the barriers to human treatment. “The main barrier to human treatment is the fact that we have not examined the use of tissue-engineered constructs in a chronically inflamed joint” he clarifies. “We also need to understand that the TMJ is an inadequately studied and ill-understood joint, when compared to other joints in the body; as a result, we need to move into potential clinical use with caution” he adds. And while Anthanasiou acknowledges the limited scope of the research, he does not anticipate the newly engineered tissue being more susceptible to degenerative disease than natural tissue.

According to Natalia Vapniarsky, a veterinary pathologist in the UC Davis School of Veterinary Medicine, the problem with "most medical management approaches for TMJ disc issues [is they are not] curative, but palliative” meaning the patient often needs a prosthetic implant when they end up with destroyed cartilage tissue. Anthanasiou is enthusiastic about the research success and the future potential to aid TMJ disorder suffers. “Assuming that safety and efficacy are shown in clinical studies, then the dental community should be able to point to a successful last resort approach to the very difficult problems associated with TMJ afflictions” he said.

Even with the groundbreaking development, Anthanasiou says surgical intervention for treating TMJ disfunction will still be a last-ditch effort treatment option in dentistry. “Surgery should always be a last resort approach” he said, when asked about the current protocols surrounding treating TMJ disorders. “But based on this work” he continues, “we are excited about the potential of providing a robust way of arresting the development of TMJ disorders and stop their catastrophic effects”.

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Results of a University of California Irvine study show a tissue implant can safely treat temporomandibular joint disfunction in animal models.

New Strategy for Treating TMJ Will Impact Dental Community

	Dr. Jianhua Guo conducting experiments on the affects of triclosan on bacteria (Photo is taken by EAIT Faculty Marketing team, The University of Queensland)

 out of the University of Queensland (UQ) suggest that non-antibiotic, antimicrobial (NAAM) chemicals found in hand soap and toothpaste, such as triclosan, may be contributing to the prevalence of antibiotic resistant bacteria.

Researchers focused on concentrations of antibiotic resistant bacteria in residential wastewater. According to Dr. Jianhua Guo from UQ's Advanced Water Management Centre, "wastewater from residential areas has similar or even higher levels of antibiotic resistant bacteria and antibiotic resistance genes compared to hospitals, where you would expect greater antibiotic concentrations.” Guo went on to explain, "these chemicals are used in much larger quantities at an everyday level, so you end up with high residual levels in the wider environment,” leading him to wonder whether chemicals in household products, like triclosan, can have an effect on antibiotic resistance.

Dental professionals are well aware of the controversy surrounding chemicals like triclosan — a substance used in many commercial toothpastes. Clients with alternative health philosophies have dismissed dental products containing the ingredient long ago for more holistic means of hygiene. Sometimes, they sacrifice their oral health in the process.

While some major brands have sworn off triclosan to attract consumers, others are confident in its effectiveness and think the benefits outweigh the drawbacks. Colgate-Palmolive, manufacturer of Colgate Total®, is the leading 

 brand in the United States and is the only product with both the American Dental Association (ADA) seal of approval and Food and Drug Administration (FDA) acceptance as safe and effective.

When asked about the research on triclosan, a representative from Colgate-Palmolive said: “After an exhaustive review, the FDA concluded that Colgate Total provides a meaningful therapeutic benefit and is safe for consumers. Colgate Total’s NDA approval has not changed in any way, and triclosan’s use at 0.3% in toothpaste has been reviewed as safe and effective by regulatory bodies around the world.”

Specifically addressing the recent study, he added “the experiments were conducted at 98.6° F -- higher than found in waterways -- and with levels of triclosan 100 to 1000 times more than the concentrations in waterways,” citing these weaknesses as evidence for Colgate’s claim that no “real-world antibacterial resistance can be drawn from this preliminary research.”

One troubling detail surrounding the triclosan debate is the FDA’s ban on the substance in antibacterial hand soaps, leaving consumers to wonder why it is still considered safe for use in the oral cavity. And with antibiotic resistance becoming a prominent threat to public global health, this additional information is another strike against the substance.

When asked about the potential future harm to the environment, Guo acknowledged the cumulative effect of triclosan concentrations as the largest threat. “The low efficiency of [waste water treatment facilities] to degrade triclosan results in its presence in receiving water bodies and its accumulation in biosolids and hence release into the environment. Based on pure culture experiment, our findings indicate environmental residues of TCS could facilitate selection for antibiotic-resistant bacteria through mutation.”

Guo went on to say that further investigation into the effects of triclosan, and other NAAM chemicals, is necessary to determine the potential long-term effects. “I would like to suggest people look for triclosan-free personal-care products,” he concluded, adding “antimicrobial resistance is a major threat for human beings, all of us need to fight against it together as a team.”

It is essential for dental providers to stay abreast on the changing regulations surrounding all chemicals used in dental products. Frequently checking FDA regulations is advisable to best inform patients about the most current recommendations.

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Triclosan has surfaced in the news again this time, for its impact on the environment and as a potential contributing factor to the prevalence of antibiotic resistance. Dental care providers should remain abreast to the changing information surrounding chemicals commonly found in dental hygiene products. 

Effects of Triclosan Might Influence Antibiotic Resistance

	Percent Change in Annual Suicide Rate by state - United States, from 1990-2001 to 2014-2016 

	SOURCE: Centers for Disease Control and Prevention - 

Vital Signs: Trends in State Suicide Rates — United States, 1999—2016 and Circumstances Contributing to Suicide &mdash; 27 States, 2015

Mental health conditions and life stressors are contributing to a rise in suicide rates in the United States, according to a recent 

In every state except Nevada, where suicide rates have been consistently high, there has been an increase in the number of suicide deaths from 1999-2016, with a 30% or higher observed rate increase in 25 states.

Dentists, physicians and other healthcare professionals frequently rank among the most at-risk occupations based on historically high statistical rates of suicide. A 

 contributes the higher rates among these groups to easier pharmaceutical access. The same study, however, acknowledges a drop in the prevalence of suicide deaths from 1979 — 2005 for veterinarians, pharmacists, dentists and physicians in the United Kingdom where the study was conducted. Researchers credit relative economic prosperity in early 2000s as a possible driver behind the positive change.

Among white males, who represent the highest risk demographic, dentists today are 70% more likely to commit suicide than the average population, according to data published by 

. The fluctuation in suicide rates and its prevalence within the healthcare sector is alarming. Recognizing stressor events that initiate suicidal tendencies in dentists, healthcare professionals and the general population is important for reducing future outcomes.

Stressor events commonly attributed to suicide include relationship problems with a significant other or family member, legal problems, eviction, financial setbacks and health complications. The recent CDC study links both victims with and without known mental health conditions as experiencing significant life stressors, but those without known mental health conditions had a higher likelihood of experiencing these problems.

A significant portion (about 50%) of individuals with mental health conditions were receiving active treatment when they died, suggesting that more effective, accessible and affordable modes of treatment are necessary for a population base that is already suffering from problems that might accelerate the likelihood of suicidal thoughts.

The consensus surrounding suicide prevention is that it’s a multifactorial issue — mounting stress from several life circumstances leads to most cases. Even with this insight, most prevention resources are focused on mental health conditions, even though the data shows about half of suicides are committed by victims with no known history of mental illness. Identification of suicidal tendencies in the general population is difficult, yet there needs to be a shift in suicide prevention resources to include all at-risk persons.

Some prevention strategies could offer support to those with suicidal thoughts, including a more robust system for economic support, easily accessible means for learning about coping skills and resources for connecting to social networks. Some states, like Colorado, are developing a better understanding of and effective approaches to suicide prevention and are implementing programs for citizens who need help.

The CDC recommends statewide suicide prevention programs be implemented to address a scope of issues that lead to suicide deaths. Awareness of personal stressor events is important to all professions and demographics in the fight against rising suicide rates.

Healthcare professionals continue to be a vulnerable sector of the population. High-pressured careers coupled with the stresses of everyday life can possibly heighten feelings of hopelessness for individuals with or without a history of mental health conditions. Dental providers are trained to focus their attentions on the health of their patients and frequently neglect their own needs, leading themselves to feel burned out, or even anxious and depressed.

International Journal of High Risk Behaviors & Addiction

 are important to keep in mind when it feels like there is nowhere to turn:

		Problem-focused strategies of coping with stress and anxiety are less effective than emotional-focused (resolution) strategies.

		Avoidance or defensive strategies to stress, anxiety and depression may aggravate suicidal feelings. These include negative, wishful or “what if” thinking, drug use, disengagement and denial.

		It is important to reach out for emotional support from a social or familial connection.

		Remember that suicidal thoughts are fleeting and do not require action.

		Ask for help. State organizations for suicide help can be found 

Dental and healthcare professionals are poised to be instrumental in the detection of anxiety and depression in local communities. Personal care must be achieved before the needs of others can be addressed.

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Dentists and other healthcare professionals have been known to be at an increased risk of suicide due to high-pressured careers. A recent report from the CDC shows the nationwide rates of suicide and discusses what can be done to arrest this alarming epidemic.

Addressing Suicidal Tendencies in the Healthcare Population

	Incidents known as “Never Events” (NEs) —  severe healthcare failures by practitioners that should never occur under any circumstances – are well-established and internationally recognized in the medical commumity. Now, a recent 

has compiled similar guidelines surrounding NEs in dental practice.

Previously, there had been no international agreement in the dental community about NEs in patient care. “By listing a consensus position on never events in dentistry, we hope that regulators and professional bodies will be able to assess the frequency of such events and reduce their occurrence,” said Professor Aziz Sheikh, the project lead and director of the University of Edinburgh’s Usher Institute of Population Health Sciences and Informatics.

Examples of NEs in medicine include performing surgery on the wrong part of the body or leaving surgical instruments in the bodily cavity. The dental list includes failures at the diagnostic and surgical levels, too. Many, if not all, of the NEs on the list come as no surprise to practicing dentists who strive to reduce all adverse events in their dental practice. Awareness of the new list, however, is a good reminder of safety practices learned in dental school. Reviewing the dental NEs routinely can help clinicians remain diligent in their safety protocols, and avoid bringing undue costs and frustration into their practice.

Surveys were distributed to participants from many countries with different educational, experience and specialty backgrounds. Initial NEs included on the survey were selected by evaluating NEs for general hospital care, common failures seen in dental safety reports and issues reported in recent dental literature. Primary and secondary rounds of surveys were distributed to participants, with the second survey including more crucial inclusions written in by primary survey participants. NEs in dentistry are broken down into four categories by treatment phase including: routine assessment, preoperative stage, intraoperative stage, and post-operative stage.

Failures at this level happen when basic practices performed routinely by both the hygienist and the dentist are neglected. Failure to record patient medication changes or allergies received the greatest consent among professionals as the worst NE at this level. Other NEs include not performing oral cancer assessments and failure to refer possible oral cancer lesions for evaluation.

NEs at the preoperative level are related to rendering the wrong treatment to a patient or failing to check the patient’s identity before proceeding with treatment. Additionally, failure to sterilize reusable instruments ranks as an important NE.

This treatment level includes the most comprehensive section of the list naming thirteen NEs, with majority consensus for treating the wrong tooth. Using the wrong injectable anesthetic, or using an unlabeled cartridge, both rank on the list because of their potential to cause adverse events. Jaw fractures associated with improper, or misplaced, implant procedures rank as important NEs as well as safety concerns including eye injuries due to lack of protective eye wear, 

of any materials and injection of sodium hypochlorite into surrounding structure of the root canal.

Post-operative failures mainly include improperly prescribing medications to vulnerable populations such as pregnant women, children and people with allergies. Retained foreign objects, like broken needles or root canal files, also make the list.

A comprehensive list of NEs for the dental community is a much-needed addition to continuing education on patient safety protocols. Sheikh hoped NEs are incorporated into the dental awareness as a “vital way to flag failures in procedure that put patient safety at risk.” Ensuring the entire dental team monitors appointments for these failures can take the headache out of unwanted, preventable treatment complications down the road.

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International consensus on the most preventable safety incidents in medicine is compiled into a list of so-called never events. Dental experts have recently gathered a similar list of the worst failures to occur in the practice of dentistry to help guide safety protocols.

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Ensuring patients are being treated with the utmost ethical standards of dental care will help providers avoid legal troubles and maintain a meaningful connection with their patients and communities.

 was filed against a dental practice owner in Hudson, WI on behalf of two defendants who claim their children suffered at the hands of their pediatric dentist. Plaintiff allegations range from unnecessary tooth extractions to taking an extensive number of dental x-rays — treatments for which the dentist profited by collecting on insurance claims.

Similar cases are becoming more and more common in the dental community. While the verdict in this case is yet to be determined, the reputation of the practice is irrefutably compromised by the public allegations. It is clear that better adherence to the “

American Dental Association Principles of Ethics and Code of Conduct: Section 5 — Principle: Veracity

” might have helped avoid a lawsuit. Ensuring patients are being treated with the utmost ethical standards of dental care will help providers avoid legal troubles and maintain a meaningful connection with their patients and communities.

Section 5.A.1 of the ADA code subtitled “Dental Amalgams and Other Restorative Materials”, states that no dentist may replace older restorative materials on the pretense of toxicity, or danger to the patient’s health, except for reasons associated with allergic reactions. Previously, it was common practice for dentists to encourage patients to replace their “silver” fillings because of the health concerns surrounding mercury seepage and heavy metal exposure. However, replacement of any existing dental restorations under the cover of safety is not acceptable when there are no real threats to the patient’s health.

In an age where consultant groups are commonly an integral part of the dental team, “selling” dentistry has become a valuable skill for the entire staff. Often, patients are presented with treatment plans involving costly restorative treatment to replace outdated, broken-down or undermined existing restorations. Although dental professionals can recommend a preferred treatment course, the differences between elective and necessary treatments must be well-defined. Frightening a patient with threats of broken teeth or tempting them to opt for the higher cost treatment can often go unnoticed because patients are generally misinformed about the reality of the condition. Exploiting individual ignorance can lead to severe consequences such as a tarnished reputation, and even legal repercussions.

Practitioners can ensure their ethicality by giving patients an array of treatment options. Limiting patients to two or three avenues shows that the dentist is concerned about their patient’s health and respects the patient’s autonomy. Keeping the “do nothing” option on the table, while advising against it in cases where it could lead to further complications, can limit practitioner liability since the pressure to accept expensive or extensive treatment is relieved.

Billing for an insurance code that fetches a larger payment than the service rendered, or upcoding, is a difficult offense to prove, but it is a 

 in the dental and medical communities alike. Common examples of upcoding in dentistry include billing for periodontal maintenance appointments on patients who receive an adult prophylaxis or substituting a surgical extraction code for a simple tooth extraction. In both instances, the patient is unaware of the technical difference between the procedures and the dental practice stands to make more money. It is up to the provider to comply with the ADA’s insurance code descriptions to remain ethical.

Legal concerns of the modern day make it more important than ever for dentists and dental auxiliaries to give patients all the facts, so they can make an informed decision. And while patients’ knowledge of dental procedures limits their ability to detect dishonesty and fraud, it is up to each individual dental provider to protect their reputations through veracity.

Legal suits are an ever-present concern for healthcare professionals. Adhering to the American Dental Association's Veracity Code is the first line of defense against unwanted legal repercussions and the public scrutiny that can result.

Protect Your Bottom Line with Ethical Practices

Dr. Martha Cortés, DDS credited sleep apnea oral appliances with leading to "health benefits such as restorative sleep, sustained daytime energy, mental clarity, and balanced emotions".

The global demand for sleep apnea oral appliances is forecasted to double in the next five years from 233.2 million USD to roughly 482 million by 2023, according to a 

The striking rise in the market can be attributed to several factors, including a rise in awareness of sleep apnea, more sophisticated oral appliances, undiagnosed sleep apnea and an increase in the popularity of sleep apnea oral appliance over traditional methods of treatment. Possible restrictions to forecasted growth are complicated referral pathways and limited access to sleep centers due to long waiting periods. Dentists trained to fabricate sleep apnea appliances can help their patients bypass these complications if dental intervention is sufficient in treating their sleep apnea.

, DDS of Cortés Advanced Dentistry in New York, is a dental-sleep medicine expert 

dedicated to solving patients’ sleeping problems through various oral appliances. 

When asked about the increase market demand, Cortés explained the change came after the 

 (AASM) approved the use of dental appliances as the “first line of treatment for mild to moderate sleep apnea”. Professionally fabricated appliances “are also a therapeutic alternative to continuous positive airway pressure (CPAP) mask therapy due to non-compliance”, she added, since cumbersome devices are frequently abandoned due to low patient tolerance.

The benefits of sleep appliances don’t stop there. Other “co-occurring conditions linked to abnormal breathing”, like bruxism, are “not caused by stress, but rather, a breathing obstruction” Cortés remarked “Many patients are shocked to learn that a dental device may treat the condition.”

To top it off, patients are typically satisfied after delivery of their custom appliances. Added to the benefits of replacing a bulky CPAP machine, Cortés said patients “experience health benefits such as restorative sleep, sustained daytime energy, mental clarity, and balanced emotions” — a relief for patients formerly plagued by sleep problems.

The financial benefits to patients and providers are clear. Patients suffering from sleep apnea are at an increased risk of “metabolic syndrome, cardiovascular disease, hypertension, glucose intolerance, high cholesterol, central obesity, and neurocognitive decline”, Cortés warned adding “sleep apnea appliances literally save lives.” The dental provider’s ability to improve patients’ overall health can reinforce their role as an integral link in the 

healthcare team and will increase patient satisfaction and loyalty to the practice.

The types of sleep apnea appliances available on the market vary between physician-prescribed and over the counter appliances for purchase online, but the largest growth is expected to come from custom-made mandibular advancement devices (MAD). Other custom devices, like tongue-retained devices (TRD) are not as popular since their efficacy is considerably less than that of MAD’s.

Offering patients sleep apnea appliances from their regular dental office can give providers an advantage over their competition. With the market on oral appliances predicted to grow, the ability to recommend and prescribe the devices to existing and future patients can help boost a practice’s production while simultaneously giving patients a reason to keep returning.

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An increase in sleep apnea awareness, among other factors, is leading patients to their dentists for custom-made appliances that are favorable compared with traditional CPAP devices.

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"Patients who develop severe ulcerative oral mucositis are 3-4 times more likely to experience an interruption in their chemoradiation" said Alan F. Joslyn, PhD, President & CEO of Oragenics, Inc.

A rinse formulated from a Gram-positive bacterium for the treatment of oral mucositis is showing positive results in its interim safety analysis on patients from its Phase 2 clinical trial. Oragenics, Inc. holds the worldwide license on 

, a food grade microbe Lactococcus lactis producing human Trefoil Factor 1(hTFF1), an essential protein to the mucosa lining of the oral cavity. The information in the study indicates that the incidence of oral mucositis is likely less than in the general population and the clinical trial is permitted to proceed with no changes to the study.

Oral Mucositis, a painful condition beginning after the initiation of chemotherapy and radiation treatments, is a prevalent side effect of cancer treatment therapies. Inflammation of the oral tissues causes ulcerations to occur as soon as a week after the first administration and can lead to nutritional problems and an increased risk of infection. Patients who suffer from oral mucositis avoid activities resulting in tissue manipulation, like homecare routines and necessary dental office visits.

Other side effects from chemotherapy and radiation, such as reduced salivary flow, nausea and vomiting, further compromise the patient’s oral health after receiving cancer treatments. Avoidance of dental treatment during periods of compromised immunity often leaves patients with severe complications such as dental decay and periodontal disease. New measures to reduce complications from oral mucositis might help dentists remain more involved in the treatment process.

When asked about the potential for preventative use, Alan F. Joslyn, PhD, President & CEO of 

, Inc., said “The primary endpoint is reduction in number of days of ulcerative oral mucositis” adding “we are also collecting information on the number of patients that never develop ulcerative oral mucositis, which would be ‘responders’ and this would constitute a prevention claim.” The trial’s conclusion will provide more evidence on the claim.

Patients who have an increased risk of developing oral mucositis, like individuals with poor hygiene, compromised immunity and smokers, might benefit from a product commercialized for the prevention of oral mucositis. The dental professional’s awareness of risk factors places them at the forefront of prevention in the fight against the condition. Open communication between the patient, dentist and oncologist will be imperative for proper administration of the AG013 rinse.

Joslyn says reducing the likelihood of treatment interruption from ulcerative oral mucositis has the greatest potential cost benefit for patients. “Patients who develop severe ulcerative oral mucositis are 3-4 times more likely to experience an interruption in their chemoradiation regimen and experience a 2-8 times greater cost” he said, adding that affected patients experience “on average 9 extra days in the hospital related to management of oral mucositis.”

The research has not extended to the potential benefits it could offer to dentistry, according to Joslyn, but its advantages to the dental community are apparent. Losing track of patients during cancer treatment is a common issue aggravated by the presence of oral mucositis. The ability to combat painful oral ulcerations with a well-tolerated prescription rinse could reduce treatment avoidance.

-use at home rinse”, said Joslyn, adding “in office treatments may occur but are not necessary”. When asked who the primary prescribers of the AG013 mouth rinse would be, Joslyn says it is undetermined. When the product is developed for release into the market, dentists will have a new tool in their armamentarium for combating adverse side effects associated with necessary chemotherapy and radiation treatments.

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Chemotherapy and radiation treatments for head and neck cancers cause serious oral side effects, oral mucositis as the primary culprit. A new rinse in Phase 2 clinical trials shows positive results in reducing oral ulcerations with a possibility for prophylactic use.