DSOs have the data. With artificial intelligence, they can put it to good use.

Artificial intelligence is the science and engineering of making intelligent machines, especially intelligent computer programs, says the U.S. Food and Drug Administration.

How do those machines get so smart? By collecting, annotating and analyzing data. Lots of it. The kind and amount of data that some DSOs are capable of generating.

“Data tells a story,” says Seth Gibree, DMD, FAGD, senior director of clinical advocacy for Heartland Dental. “It is used to analyze trends and identify potential issues and patterns of behavior – positive and negative. Obviously, the amount of data that exists is growing by the minute.”

DSOs can potentially play a big role in helping develop artificial intelligence platforms because of the amount of data that is accumulated every day, says Dr. Gibree. Heartland Dental provides non-clinical administrative support to a network that spans 37 states, with more than 1,000 supported offices and more than 1,600 supported doctors. “The more data a dental support organization has access to, the more valuable and useful we can be to strategically improve our support for the doctors and teams.”

Is it enough data to justify building their own platform?

“I think it’s possible – but very challenging – to build one’s own AI platform,” he says. “It all goes back to, What is your area of expertise? Ours at Heartland Dental is to support doctors and their teams as they deliver the highest quality dental care and experiences to the communities they serve. We would not build our own. Ideally, having strategic partners in a mutually beneficial relationship would be best.”

Possibilities, challenges

Regardless of how DSOs resolve the make-or-buy decision, what isn’t up for discussion is the potential role AI can play in dentistry.

“There could be many benefits for applying AI-based diagnostic assistance to clinicians,” says Dr. Gibree. In minutes, AI can review the amount of information a typical dentist sees over the course of their whole career. “Exponentially move out that ability to learn, and the possibility arises of highly reliable, predictable diagnosis assistance. Ultimately, it is still up to the clinician … to determine whether to proceed with treatment based on numerous factors, one of which would be predictive AI interpretation.”

The potential clinical applications of AI are appealing, including the ability to automatically chart levels of disease and bone loss based on radiographs and intraoral scans, he says. AI can also lead to more predictable, medically based treatment planning, determined by clinical presentation along with medical history and specific medical conditions, when added to the clinical judgment of dentists. For labs, it can mean better design of crowns, margin marking and
material selection.

Applications for the non-clinical support that Heartland Dental provides are plentiful as well, says Dr. Gibree. They include:

• Support with patient communications.
• Marketing support.
• Discussions on establishing ideal office hours to meet the needs of the community.
• Scheduling assistance.
• Insurance verification and approval assistance.
• Support with payment/billing of office patients and insurance companies.
• Supply management and ordering assistance.
• Collaboration on measuring patient experience.
• Payroll support.
• Time management assistance

Of course, change won’t occur overnight, he says.

“Change is always difficult, but it is the one constant in life. Predictability and accuracy of the AI is necessary, first. It cannot be set up for failure from the beginning. Workflow implementation, trialing and evaluation are critical to future acceptance. If it doesn’t make things better for the doctors and their team, or the patients, then adoption will be very challenging. It must make things easier.”

Heartland Dental is currently evaluating numerous AI companies and products, and is working on pilots of different concepts, says Dr. Gibree. “We are evaluating AI and how it can potentially assist our supported doctors and their teams as they deliver the highest quality dental care and experiences.

“I think it’s important to understand that this is still emerging technology,” he concludes. “Yes, there is lots of growth and possibility, but it is still early. We are working to understand the landscape at a high level, along with evaluating real-world applications and potential best practices for implementation. Finding strategic partners will be critical for long-term success and acceptance.”

Sidebar 1:

Terms to know

Artificial Intelligence. The science and engineering of making intelligent machines, especially intelligent computer programs. Artificial intelligence can use different techniques, including models based on statistical analysis of data, expert systems that primarily rely on if-then statements, and machine learning.

Machine Learning. An artificial intelligence technique that can be used to design and train software algorithms to learn from and act on data.

“Locked” algorithms. Algorithms that don’t continually adapt or learn every time they are used.

Algorithm Change Protocol, or “Predetermined Change Control Plan.” Proposed plan by FDA that would include the types of anticipated modifications—referred to as the “Software as a Medical Device Pre-Specifications”—being used to implement changes in a controlled manner that manages risks to patients. In this approach, the FDA would expect a commitment on transparency and real-world performance monitoring for artificial intelligence and machine learning-based software as a medical device, as well as periodic updates to the FDA on what changes were implemented as part of the approved pre-specifications and the algorithm change protocol.

“Adaptive” or “continuously learning” algorithms. Machine-learning algorithms that can learn from new user data presented through real-world use. They don’t need manual modification to incorporate learning or updates.

Software as a Medical Device. Software intended to be used for one or more medical purposes that are not part of a hardware medical device. It can be used across a broad range of technology platforms, including medical device platforms, commercial “off-the-shelf” platforms, and virtual networks, to name a few.

Source: U.S. Food and Drug Administration

Sidebar 2:

AI: Something new for FDA

Dental providers aren’t alone in their questions about artificial intelligence. The U.S. Food and Drug Administration has a few of its own.

That’s because the old rules for medical and dental device regulation – which have been around since the 1970s – don’t apply anymore, says Zach Rothstein, vice president, technology and regulatory affairs, Advanced Medical Technology Association, or AdvaMed.

“In terms of regulation, the most unique aspect of AI, or machine learning, is that it can continuously learn,” he points out. “The inputs it receives in the field inform future outputs. The question is, ‘How do you truly allow for that continuous learning aspect of the device to occur?’”

Thus far, the FDA has handled the question by granting marketing clearance for AI-based products that are essentially “locked,” says Rothstein. Their algorithms are typically based on thousands of data points – which make them very smart indeed. But they haven’t been FDA-cleared to get any “smarter” in the field. In other words, they are prevented from continuously learning.

FDA is trying to re-imagine its approach to AI-based devices by adopting a “change management protocol,” which would establish parameters that would allow devices to continuously learn in the field. “Without that, things have to be locked,” says Rothstein. “If a developer wants to update the software of an AI device based on input received from the real world, the developer has to go back to the FDA for marketing clearance.”

In April 2019, then-FDA Commissioner Scott Gottlieb announced that FDA was exploring a framework that would allow for modifications to algorithms to be made from real-world learning and adaptation.

The agency is probably a few years away from figuring all this out, says Rothstein. Congressional legislation may be required for some of the changes being considered.

The overwhelming majority of dental practices work very hard to ensure their patients’ safety and health during treatment, according to Organization for Safety, Asepsis and Prevention (OSAP) – a community of clinicians, educators, policy makers, consultants and industry representatives who advocate for the Safest Dental Visit™ OSAP – and it’s important for doctors and team members to convey that to their patients.

By discussing the following points, which are based on current dental infection control recommendations from the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA) and OSAP, the dental team can reassure patients they are in a safe environment, protected from the spread of infection.

• We sterilize all dental instruments, including handpieces, between patients. In keeping with Centers for Disease Control and Prevention, American Dental Association, and OSAP recommendations, dental professionals should be heat-sterilizing all instruments that penetrate or contact a patient’s oral tissues. Although autoclaves are most commonly used to sterilize dental instruments, some offices may have other types of heat sterilizers. Chemical-vapor sterilizers (chemiclaves) and dry-heat sterilizers also are appropriate for sterilizing dental instruments. Instruments that have been used on a patient should be heat-sterilized before they are introduced to treat the next patient. Most dental instruments are designed to withstand repeated heat sterilization.
• We take steps to ensure our sterilizer is working properly. Most practices use a variety of methods to ensure the office sterilizer is doing its job. In addition to monitoring the sterilizer’s gauges and readouts for proper temperature and (for autoclaves and chemical-vapor sterilizers) pressure, the dental team should wrap and seal instruments in packaging equipped with color-change indicators, which help identify instrument packages that have been sterilized, so there’s no chance that contaminated instruments could inadvertently be selected to treat the next patient. In addition, the dental team should routinely test their sterilizer using a vial or envelope containing spores. Referred to as biologic monitoring, subjecting commercially prepared, sealed spore strips or vials to a sterilization cycle, then culturing the spores to ensure they have been killed, is the highest guarantee that a sterilizer is functioning and being utilized properly. Most practices use biologic monitoring weekly or monthly in combination with color-change indicators on each instrument packet and monitoring of the sterilizer gauges and readouts.
• We change our gloves for every patient. Every dental care provider should use new gloves for each and every patient. For procedures that are likely to involve splash or spatter, the dental team should also don a new mask, as well as wear protective eyewear and apparel (possibly a gown or clinic jacket).
• We disinfect the surfaces in the operatory between patients. Between patients, the dental team should disinfect all the surfaces they are likely to touch during treatment. This eliminates the possibility of a dentist or auxiliary dental care provider transferring germs from a contaminated surface to the patient. To save time in preparing the treatment room for the next patient (and hopefully minimize time in the waiting area), many practices choose to cover surfaces, such as light handles, tubing and chair controls, with a plastic barrier film that keeps the surface underneath free of debris. Instead of disinfecting these surfaces between patients, the dentist or dental team member simply removes and discards the barrier and places a new, clean barrier on the surface for the next patient.

Most practices choose to cover some surfaces and disinfect others between patients. Some practices disinfect all surfaces between patients; others use protective barriers for all surfaces in the treatment room.

Editor’s note: OSAP focuses on strategies to improve compliance with safe practices and on building a strong network of recognized infection control experts. The organization offers an online collection of resources, publications, FAQs, checklists and toolkits that help dental professionals deliver the Safest Dental Visit for their patients. Plus, online and live courses help advance the level of knowledge and skill for every member of the dental team. For additional information, visit www.osap.org.

By Kristine Berry, RDH, MSEC

Dental industry disruption: As dental communities and individuals, we have moved into the 21st century in a world of developing technologies, disruption and VUCA. VUCA is a concept that originated with students at the U.S. Army War College to describe the volatility, uncertainty, complexity and ambiguity of the world:

• Volatile. Rapid, sudden, constant change.
• Uncertain. Unclear information and outcomes.
• Complex. Multiplicity of variable and unknowns.
• Ambiguous. Lack of clarity about meaning of event.

VUCA is gaining new relevance in health and wellness, and as leaders and providers, you are being called on to successfully navigate this concept to promote your values, vision and purpose, the evolving need of patients and your organization’s bottom line. We are at a turning point of discovery, confronting a moment when the traditional practice models are up for grabs and new models are developing. Innovation is required, as well as the ability to be flexible.

This article will outline an example of positive complexity: telehealth and teledentistry. It will provide a fundamental backdrop of considerations of teledentistry and describe how –by integrating steps and reframing conventional delivery of services – we have an opportunity to create certainty in our practices and organizations.

What is telehealth?

According to the Center for Connected Health Policy, “telehealth is a collection of means or methods for enhancing healthcare, public health and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical health, health coaching and education services.” Telehealth is not a specific service, but a collection of means to enhance care, coaching and education delivered from a distance (remotely), such as: 

• Live-video teleconference appointments, either scheduled or on demand (synchronous).

• Store-and-forward (asynchronous) transmission of radiographs, photographs, video and digital impressions through a secure electronic communications system to a practitioner. (This information is then used to diagnose or provide a service.)

• Remote patient monitoring (RPM). Collecting personal health, medical and dental data from a single individual via electronic medical devices and dental technologies. (The data is transmitted to a different location – sometimes via a data processing service – where the provider can access it for monitoring conditions and supporting care delivery.)

• Mobile health (mHealth), or health and oral care education, health coaching, practice and delivery provided via mobile communication devices, such as cell phones, tablet computers and personal digital assistants (PDA).

The American Teledentistry Association defines teledentistry as:

… the use of electronic information, imaging and communication technologies, including interactive audio, video and data communications, as well as store and forward technologies to provide and support dental care delivery, diagnosis, consultation, treatment, transfer of dental information and education.

An example of a teledental visit is a videoconference between a provider and a patient regarding an urgent dental or oral health problem. A teledental visit can give patients improved access to information about the importance of oral health and extensive education opportunities. In a value-based world, additional uses include teaching, mentoring, calibration, research, patient screenings, specialty consultations, pre- and post-operative care, follow-up and distance learning and coaching. In addition, teledentistry eliminates geographical barriers by bringing many providers together and allows for new collaborative care between providers/specialists. With regard to evidence-based modalities, telehealth applications have been shown to be highly beneficial for the management of chronic diseases and their awareness of health. 

Implementation and sustainability

If you foresee incorporating teledentistry into your existing model, it’s necessary to ensure your choices of telehealth programs are in line with your strategic goals and objectives. To ensure sustainability and financial and clinical success, it is essential that teledentistry is fully integrated into your existing clinical processes. Ask yourself the following:

• Will your choices reflect your values, purpose and vision?
• Do you support developing partnerships with other healthcare providers
  and organizations?
• Do you believe in – and are you committed to – teledentistry as a process to improve patient outcomes and provide increased access to care outside your brick and mortar locations(s)?
• Do you value continuing development, such that providers can develop added knowledge, skills and abilities by learning from specialists and collaborating with healthcare providers?
• Is care management and technology a value proposition?
• What services are most needed in your organization?
• Have you performed organizational assessments to determine your readiness in the adoption of telehealth technologies, as well as the leadership’s and team’s readiness to change?

• Is there buy-in or commitment to the additional work involved in developing a telehealth line of business?

• Do you understand what your state licensure permits, as well as any legal or regulatory issues?

• Have you appointed a point-person or consultant who understands the role as an agent of change for developing a sustainable model?

With a solid framework and implementation strategy, your organization can realize the full potential of teledentistry. Whether you adopt a synchronous or asynchronous method, you can apply different clinical teledentistry delivery systems. In a value-based world, telehealth and teledentistry will be important models for improving quality access to care and maintaining your organization’s top – and bottom – line.

Resources:

Kopycka-Kedzierawski DT, Billings RJ, McConnochie KM. “Dental screening of preschool children using teledentistry: a feasibility study”. Pediatr Dent. 2007; 29(3): 209-13.

2017 U.S. Telemedicine Benchmark Survey – REACH.

Finger Lakes Community Health, Teledentistry, Reaching out with Technology, Anthony Mendicino, DDA. https://localcommunityhealth.com/sodus-providers/

Kristine Berry RDH, MSEC is an international speaker and executive coach, specializing in enhancing group practices. Looking for a speaker or coach? She invites you to contact her via email at kristine@kristineberry.com or visit her website www.kristineberry.com.

Collaboration between team members drives quality patient care and continuous growth within the practice.

When Park Dental welcomed its first patients nearly 50 years ago, the group practice concept was newly evolving. Through team collaboration, however, the Minnesota- and Wisconsin-based dental practice has established itself as a high-quality provider of a wide range of patient services. Today, Park Dental boasts 51 offices and is home to over 950 doctors and team members.

“There’s no question that Park Dental has benefitted from the collaboration between our doctors and team members, ultimately driving consistent, quality patient care and service,” says Christopher E. Steele, DDS, president. “Our teams and doctors truly enjoy working together within a group setting, which also provides a network of general dentists and specialty clinicians who can provide a wide range of care procedures for our patients.”

Collaboration has also helped foster engaging external relationships in the dental industry, he continues. “The significant opportunities found in a group environment allow for professional development and continuous learning for our doctors and team members,” he says. “For example, our dentists and clinical team members undergo continuous peer review to ensure our standard of care excellence is upheld. In addition, leveraging our scale creates opportunities for practice acquisitions and the ability to reduce expenses, whether capital, technology or basic supplies.”

Park Dental is accredited through the AAAHC, ensuring it is compliant with regulatory and quality control measures of care, notes Dr. Steele. “Our doctors, team members and patients also appreciate the consistent care culture; our doctors and team members can provide clinical care at multiple Park Dental locations, whether assigned or substituting for another team member.” And the fact that all of the group’s offices have Park Dental as part of their name has made it substantially easier for new patients to recognize them, which is critical in expanding markets, he points out.

“Each year, we receive feedback from over 30,000 Park Dental patients and the results are approaching a 98 percent patient satisfaction rating,” says Dr. Steele. “We have found that our patients especially value Park Dental’s consistency of quality care (including comprehensive services), a conservative care-model and the ability to transfer within practices based on home-work geography. Patients also value building relationships with their clinical care team members who communicate effectively; our patients understand their dental health and are offered a full suite of preventative and restorative service.”

Efficiency in Group Practice: How has being part of a group practice impacted the responsibilities of your support staff?

Christopher E. Steele, DDS, President, Park Dental: There is strength in expertise. As a dental group, our doctors and clinical team members can focus on providing the best care for our patients. Park Dental doctors and patients benefit from standardized patient records, patient care protocols and state-of-the-art facilities and equipment. We also have dedicated support teams providing clinical training/mentoring and development, and improving the patient experience. All activities indirectly related to patient care, such as marketing, finance, facilities, team relations and talent acquisition, are addressed separately by teams within our group. By focusing our responsibilities, we feel the overall talent of our teams continues to improve.

Efficiency in Group Practice: How does your practice implement new technology efficiently and effectively?

Dr. Steele: Park Dental, like many practices, identifies new technology through our doctors, team members and management team interactions. Prior to total organizational implementation and appropriate training, we evaluate the viability of the technology – first with a technology workgroup, followed by pilot testing at a limited number of our practices. (A doctor lead verifies function.) The group practice concept allows us to truly assess technology and how it will improve our care prior to purchase.

Individual preferences and strengths vary within the group, and this is one of our biggest obstacles. Ultimately, all decisions are made for the group as a whole, which may also push the timeline for a workgroup to evaluate a new technology versus one individual’s decision. However, we can leverage our purchasing scale to reduce our technology costs so we can balance the best technologies against the resulting care improvements. With our state-of-the-art technology, such as CBCT, scanning, lasers, milling and digital radiographs, we can perform a wider range of procedures in-house or with an adjoining Park Dental practice, which provides efficient care for our patients.

Efficiency in Group Practice: How does Park Dental attract – and retain – top notch clinicians and team members?

Dr. Steele: Our group practice model has helped us understand, recruit and retain new doctors and team members. We realize our success is completely dependent on attracting talented individuals who will assimilate into our culture, while maintaining their generational value system, work patterns and communication preferences. Our goal is to gain their appreciation and trust in the value of consistent, high-quality, patient-centered care. Our reciprocal duty is to recognize their value system and provide an environment that suits their needs clinically, socially and, with regard to Millennials, financially given their respective student loan debts.

Since Park Dental is a group practice, we have the scale to offer sponsored CEs to our doctors and clinical team members. Our continuing education program is aimed at clinical excellence for our doctors/team members and represents areas of clinical need within our group and that of the dental industry. We provide extensive internal CE, as well as a yearly stipend to help reduce the debt burden for millennial dental students in particular. Another benefit of segregated responsibilities is that it allows better work/life balance. Our doctors and clinical team members can focus on providing patient-centered care, while support teams such as finance, marketing, IT, talent acquisition, patient experience and team relations focus on their respective subject matter. As with most groups, there is always a support structure for dentists, including a shared on-call schedule.

Efficiency in Group Practice: How has the connection between oral and physical health impacted the way your clinicians, hygienists and assistants work with patients?

Dr. Steele: The link between oral health and overall health continues to evolve. Park Dental has historically tracked systemic health during our patient visits. We continue to develop systems within our electronic dental record to recognize the health benefits of comprehensive oral health with improved systemic health. One recent example would be our implementation of sleep screening into our exam protocol. Our doctors, hygienists and assistants continue to have important conversations with patients about the oral-systemic connection, which is driven by continuing education and mentoring. One recent change is that overall health conversations are driven by a more informed patient base.

Efficiency in Group Practice: Has being part of a group practice given you better tools to provide more holistic patient care?

Dr. Steele: Without question, being part of a group practice has given us better tools to leverage our scale to provide a focus on holistic patient care with respect to coordinated training, mentoring, data collection within our electronic dental record and, finally, the application of data to patient health improvement. Connecting the dots is critical for our patients’ health and their perception of our care.

While the large group practice model has worked very well for the doctors and team members at Park Dental, Dr. Steele recognizes that there is not a one-size-fits-all model. “Dentists’ and team members’ decision where they practice should be based on their preferences and what works best for them,” he explains. “At Park Dental, our group practice is doctor-owned and led, so our focus starts with appropriate patient care and service. The group practice model, and Park Dental’s culture, provides a wonderful environment for our respective team members to thrive and develop their careers in a rewarding manner. We understand that either model (solo versus group) can provide care and service to all patients, and ultimately that’s what the profession is all about. Yet, our belief is that group practice is a model that affords multiple rewards to patients, doctors and team members, which exemplifies the profession.

Let patients know what and why you do the things you do to keep them healthy and safe.

By Patti DiGangi, RDH, BS

Holiday time is family time and joy for most everyone. Yet most of us have a dysfunctional family in some way or another. Dysfunction can be understood by thinking of a wind-chime. If one piece starts moving, it moves other pieces. Sometimes the sound is harmonious but often becomes a horrid clang of dysfunction.

A family is a system. Every day in your work, you probably interact with dozens of systems. Dentistry is filled with systems. Some effective, some whose time has come and gone but are still being used. One very important area in dentistry needing a systems approach is infection protection. A functional family of related products can help everyone in the practice family get it right without guessing.

The Centers for Disease Control (CDC) Summary of Infection Prevention Practices in Dental Settings and the Infection Prevention Checklist for Dental Settings state, “Infection prevention must be made a priority in any dental health care setting. At least one individual with training in infection prevention—the infection prevention coordinator—should be responsible for developing written infection prevention policies… appropriate training and education of dental health care personnel (DHCP) on infection prevention practices, and adequate supplies to allow DHCP to provide safe care and a safe working environment.’

That sounds great and is important. At the same time, anyone who worked in a dental practice more than a half-hour knows, the ideal isn’t the way a practice necessarily or often works. Those working in a dental practice become a family and act as a system. It can be a dysfunctional family. Starting the day with a team huddle gets the team on the same page each day. Huddles aim to refocus everyone’s attention after the morning rush. They enable the team to dial in together before breaking for the day. In other words, the best of plans can still get derailed.

The first patient comes late for their hygiene appointment. The other hygiene patient needs an extensive conversation with the dentist. The computers aren’t booting. So many issues arise that take precedence that pulls every person in the practice. With hygiene running so far behind, one of the assistants is asked to turn over the room and seating the next person. Yet the assistant can’t because the dentist has something more pressing for her to do. The business assistant is feeling the pressure because a patient who has been waiting for his appointment comes to back to ask when he can be seated. She is pulled in to turn over the room. She is in a bit of hurry because the dentist’s patient is being released and she needs to set up the financial plan. And of course, three phone lines are ringing.

All of this can lead to rushing through the important infection protection procedures. The business assistant isn’t as clear as others about the procedures or even the products just because she doesn’t perform the procedures as often as others. Or think if it got crazy enough for the dentist to need to perform the room turnover! Again, if you have worked in a dental practice more than a half-hour, you are seeing and even reliving the scenario.

It can all be made easier. How? Systems thinking with a functional family of products. The Monarch line of infection prevention products provide that system. It’s color-coded to make it easier even for those less practiced at infection protection. From surface cleaning and disinfection, instrument cleaning, equipment maintenance to personal skin and hand protection, the Monarch family of Infection Prevention merchandise makes it easier to make the right choices for the right surfaces at the right time.

• Green: The Monarch Surface Disinfectant products provide broad spectrum kill of 25 pathogens in one minute. These wipes and sprays have green lids and identification so anyone in the practice can know these are safe and compatible to for use hard surfaces in the dental office. The vinyl upholstery cleaner is also identified by the green color cleans and cares our chairs without leaving any residue; giving a silky gloss finish.

• Blue: The blue color products for Instrument Cleaning starts with Monarch Safety Tray that facilitates easy and safe instrument processing. This is particularly important for those less familiar with the room turn-over process though it is equally important to those who perform it routinely. Monarch Enzymatic Cleaner is an effective multi-enzymatic cleaning concentrate formula using five synergistic enzymes for complete instrument cleaning prior to sterilization.

• Yellow: The products that are yellow are very important to the office long term functioning of equipment-a major investment in most practices. Monarch CleanStream is designed for use with Air Techniques and all other vacuum systems, wet or dry. It removes and prevents future line build-up, increasing vacuum performance and suction and cleans and deodorizes evacuation lines. Monarch Lines Cleaner is the perfect solution to remove microbial build-up in tubing lines without the use of harsh chemical. For daily use in water bottle, weekly cleaning, and intermittent treatment to clear deposits from waterlines. Ready to use; no mixing or diluting is required.

• Pink: Finally, the pink products for protection of the person performing the infection protection procedures. Monarch Hydrating Instant Hand Sanitizer formula kills 99.99% of widespread germs. It is a waterless, alcohol-based gel that contains Aloe Vera for smooth application and silky feel. The Monarch Revitalizing Hand Lotion contains a special wax formulation makes donning gloves easier. It is enriched with Aloe, Vitamin E and B complex and leaves hands smooth and silky; never oily. It provides long-lasting moisturizing effect, even after several hand washes.

With more than 50 million Americans experiencing various types of allergies each year and allergies as the sixth leading cause of chronic illness in the U.S., the choice made every moment by every person in a dental practice is important to protect our patients.

Those working in a dental practice become a family and act as a system. Using systems for infection protection that coordinate and function together can give the best outcome. The Monarch family of functional Infection Protection merchandize help practice families make the best choice creating beautiful music of health and safety together.

Patti believes dentistry is no longer just about fixing teeth; dentistry is oral medicine. AND its time we got around to truly practicing it. Her new brand: Beyond Oral Health challenges us do so. Patti’s specialty is coding-medically necessary coding. Her efforts have assisted thousands of professionals to code more accurately and efficiently. She teaches the why behind the codes. Patti holds publishing and speaking licenses with ADA for Current Dental Terminology©2020. Patti’s passion for infection protection is based on her personal health and allergies. She wants everyone to be protected.

One clinician’s treatment journey with the Invisalign system 

Allison Walker

Digital technology and workflows bring a new level of efficiency and ease to a growing number of dental practices. Dr. Shorouq Sahawneh, lead dentist with Smile Brands Inc. (SBI), and Clinical Director and Professional Corporation (PC) President of all southern California offices, knows this well.

Throughout her 12-year career, Dr. Sahawneh has been fascinated with technology. Embracing new digital innovations has allowed her to save time, enhance patient communication, and see Smile Brands, Inc. continue to expand. “We have almost 72 offices in southern California and we’re growing,” she says. “It’s been an amazing journey and I’m very grateful.”

When Align Technology introduced the Invisalign Go system to Smile Brands and their general dentists in 2017, Dr. Sahawneh was given the opportunity to practice in orthodontics, an area of longtime interest. “I loved that Invisalign treatment helped me offer more comprehensive care. It helped me take advantage of a new area of untapped potential to help my patients.”

Dr. Sahawneh prescribed everything from restorative dentistry, extractions, and implants to her patients but had to refer all of her orthodontic cases to a specialist. “With Invisalign Go, I was able to provide my patients with orthodontic treatment. Achieving a straighter smile was a helpful first step in planning future restorative work more effectively and achieving better overall results for my patients,” she explains.

Dr. Sahawneh points out that incorporating Invisalign treatment into the practice workflow is a team effort. The training and support provided by Align Technology are critical to getting up to speed and mastering the different components of the Invisalign Go System – from the Invisalign Photo Uploader through the intuitive ClinCheck treatment planning software.  “Align Technology’s Invisalign Pro course, featuring one-on-one tutoring, was a tremendous opportunity to learn from an expert orthodontist while going at my own pace. It helped me become who I am and built so much confidence in my ability.”

Today, an orthodontic assessment is part of every patient’s evaluation and oral examination at Dr. Sahawneh’s practice. “I’m connecting the position of the patient’s teeth, their occlusion and misalignment, to the conditions that they complain about,” Dr. Sahawneh explains. “We are educating patients during periodic appointments that filling a chip or recession with composite is just a temporary fix and we need to treat the cause or the root of the problem—the malocclusion.”

Dr. Sahawneh started her Invisalign journey through utilizing the Case Assessment tool in the Invisalign Go system, which gave her a sense of assurance and confidence to assist her in determining if the patient was a candidate for the Invisalign Go treatment. After about a year, though, Dr. Sahawneh felt confident enough to do her own case assessments. “By this point, my practice was the top office in the whole company based on our number of Invisalign Go cases. But I felt limited and that there where situations where I could provide a more ideal outcome for my patients,” she recalls.

Dr. Sahawneh had been relying on standard impressions to start her Invisalign Go cases. She believed that starting the digital journey with a digital scan would further streamline the process for her team and for her patients. “Smile Brands’ leadership team was supportive, so we added an iTero intraoral scanner to my office,” she says.

Combining her advanced knowledge of Invisalign treatment options while utilizing the enhanced visualization tools, such as the Outcome Simulator available on the iTero scanner, gave her more confidence in case selection and efficient treatment planning. “Now we have more knowledge and can see the bigger picture of what to expect at the end of the case,” she explained.

The iTero scanner helped Dr. Sahawneh tap into something even more important than cost savings and efficiency. The Outcome Simulation feature helped her connect with her patients on a real and powerful emotional level. “Patients know from looking in the mirror that they have crowding or malocclusion,” she noted. “But looking at a 3D image on a screen tells a completely different story. It opens up their eyes. They often say they didn’t know it was that bad. Even just looking at their scans before getting to the simulation step is really helpful for them,” she explains.

 “One great thing is the iTero allows us to email them the simulation we created so they can look at it again and show it to their family. That is really awesome! It gives patients more confidence in their decision making and usually leads to a better outcome for case acceptance.”

Dr. Sahawneh uses the iTero scanner for 100% of her restorative cases. “No more impressions!” she exclaims. “It has reduced my percentage of crown and bridge re-dos. In addition, don’t forget that at the end of the day, it enhances patient experience.”

In fact, Dr. Sahawneh and her team have been discussing the need for a second iTero scanner. “We’re using it on every single patient—restorative, prosthetic, Invisalign treatment, all new patients, and for progress assessment in recurring patients.”

Dr. Sahawneh finds these digital technologies reinvigorating. She admits that in the past, she had gotten to a point where she felt “capped out” with regard to both dental procedures and production. “However, adding the Invisalign system and the iTero scanner to my practice created so many opportunities and took my office to the next level. It’s been amazing.”

In her opinion, connecting the iTero scanner to Invisalign treatments has added an additional line of business to her practice. “It took my revenue and production through the roof,” she says. “We’re literally hitting our goals every single month and offering Invisalign treatment to our patients is a big part of that success.” 

Uniformity, efficiency, productivity and competence

By Katherine Schrubbe, RDH, BS, M.Ed, PhD

The military, business and medical literature is filled with information on the creation and utilization of Standard Operating Procedures (SOPs).  Designed to create uniformity, efficiency, productivity and competence in the workplace, SOPs are crucial to infection prevention. According to the U.S. Army, an SOP is “a clearly written set of instructions for methods detailing the procedures for carrying out a routine or recurring task or study.”¹ In the business world, an SOP may be described as “a step by step guide on how an employee’s work process should run providing detailed guides or guidelines for an employee.”² In medicine, SOPs can be defined as “a specific set of practices that are required to be initiated and followed when specific circumstances arise. For example, emergency room physicians have SOPs for patients who are brought in an unconscious state; nurses in an operating theater have SOPs for the forceps and swabs they hand to surgeons; and laboratory technicians have SOPs for handling, testing, and subsequently discarding body fluids obtained from patients.”³

SOPs are critical to infection control and prevention in dentistry as well. They create a foundation for team training and effective, site-specific procedures, which have a positive impact on the safety of dental team members and patients.   

Where to begin?

The Occupational Safety and Health Administration (OSHA) states that each practice must have an individual designated as the safety manager, while the Centers for Disease Control and Prevention (CDC) states that one person in the dental practice who is trained in infection prevention be designated as the infection prevention coordinator.^4,5,6 In some cases, this is the same individual, but not always, as the roles outline varying responsibilities. For the purposes of this article, the focus will be on the role of the Infection Prevention Coordinator, also referred to as the Infection Control Coordinator (ICC). 

According to the CDC, one duty of the ICC is to develop written infection prevention policies and procedures based on evidence-based guidelines, regulations or standards – in other words, infection prevention SOPs. The CDC goes on to say that these policies and procedures should be tailored to the dental setting and reassessed annually.⁶ An example of this could be an SOP
for operatory cleaning and disinfection. This SOP creates a standard process in the specific practice for all team members and leaves no room for question around how to achieve compliance. The job of the ICC is extremely important to the practice and should be delegated to a team member who is truly willing to be committed to the position. The dentist or management team should really assess their team to determine who is best suited and will be dedicated to the ICC position. The ICC is also responsible for providing supplies necessary for adherence to Standard Precautions (e.g., hand hygiene products, safer devices to reduce percutaneous injuries, personal protective equipment).⁶

In a recent article by Eklund, she cites the Organization for Safety Asepsis and Prevention (OSAP) sample job description for the ICC, which includes a number of tasks, including:

• Review existing policies and SOPs to identify gaps and outdated information.
• Act as a resource for dental team personnel.
• Maintain relevant documentation, including records, permits and licenses.
• Provide infection prevention education and training for new and existing personnel.
• Monitor compliance with written policies and procedures through observation, checklists and other evaluation methods.⁷

The role of the ICC is to manage and provide oversight of the infection control program in the dental practice. Although this team member is the key person for infection control, it is vital for the doctor/employer to promote a culture of safety and support the efforts of the ICC so the entire team is focused on infection prevention, a safe workplace and compliance to set SOPs. 

Resources for the ICC

Almost any team member who has been designated as the practice ICC will say it is not an easy job. Whether new to the position or not, it may be overwhelming to review the assigned tasks for infection control and determine where and how to find resources. Fortunately, there is no need to try and re-invent the wheel, as there are some key organizations that can assist in developing written SOPs for the practice. 

The Organization for Safety, Asepsis and Prevention (OSAP)

• OSAP’s mission is to be the world’s leading provider of education that supports safe dental visits. The organization focuses both on strategies to improve compliance with safe practices and on building a strong network of recognized infection control experts. OSAP offers an extensive online collection of resources, publications, FAQs, checklists and toolkits to help dental professionals deliver the safest dental visit possible for their patients.⁸ The toolkits and checklists are current and science-based and can be used to form the foundation of the practice’s infection control SOPs.

CDC

• The Summary of Infection Prevention Practices in Dental Settings; Basic Expectations for Safe Care is filled with evidence-based sound information, key recommendations and best of all, two checklists. These checklists can be used as self-audit tools to guide dental team members through a practice evaluation of their infection control protocols and compliance to CDC guidelines. More specifically, the checklists were developed to 1) ensure the dental healthcare setting has appropriate infection prevention policies and practices in place, and 2) to systematically assess personnel compliance with expected infection prevention practices and to provide feedback to dental healthcare personnel regarding performance.⁶ Although site-specific written SOPs are needed for each individual practice, group practice or DSO, these checklists can be used as a tool to serve as the basis for developing and implementing the necessary SOPs.

Greenlight Dental Compliance Center by Hu-Friedy

• This online resource helps the ICC create site-specific, customized infection prevention protocols by providing templates and methods to import required materials, such as instructions for use (IFU) for equipment or products. Having prepared, ready-to-go templates that incorporate CDC, state regulations and OSHA (pertaining to infection control), simplifies the overwhelming task of creating the necessary infection control SOPs for the practice. Greenlight also provides the ICC and facility with access to online continuing education on OSHA and other topics, regulatory standards and state requirements, training and resources designed specifically for the ICC, regular online infection prevention self- assessment, breach response resources and tools and complimentary consultation for new members. Once SOPs are created via Greenlight, they can be updated as needed, used for training of new and existing team members and to monitor compliance to the protocols.^9,10

Benefits of SOPs

Cameron lists five business benefits of SOPs, which can easily be applied to the dental setting¹¹:

• SOPs maintain quality control and help ensure everyone is on the same page regarding how to get the job done. In the dental setting, infection control tasks are often completed because that’s the way it’s always been done. Creating and using written infection control SOPs will instill a sense of accountability and ensure that best practices are maintained over time.^9,11
• SOPs help ensure everything runs properly, like clockwork. In the dental setting (particularly with regard to DSOs and large groups) schedules and patient care need to run like clockwork to ensure a positive patient experience and staff satisfaction. If dental team members do not have SOPs to follow, there can be inefficiencies in workflow that could have a negative impact on both. Imagine not knowing the office procedures for disinfection and sterilization of dental instruments. Not only can mistakes cause injury or illness to patients or team members, there is a potential for lost revenue as well.¹¹
• SOPs are invaluable for training purposes. Having procedures in writing means that employees are trained on how to do things via a step by step process that is easily referenced by anyone who needs to look things up.¹¹ There is a saying that old habits die hard. In dentistry, SOPs that reflect evidence-based guidelines for infection prevention and safety help divert possible bad behaviors that may accompany new employees.⁹ For existing team members, SOPs aim to continually calibrate protocols and procedures.
• SOPs are in place to maintain compliance. In any business, including dentistry, certain procedures related to safety must be done a specified way because of regulatory or government standards such as OSHA. SOPs help protect the practice from potential disciplinary action, citations or fines related to non-compliance.^9,11
• SOPs are helpful during crisis management. When things go wrong, people don’t think clearly. In the case of a fire, a medical emergency or an occupational exposure accident, it’s essential to have systems in place and SOPs to follow. If team members can jump into action on auto pilot because they’ve been trained how to handle specific emergencies, it can save the day.¹¹

Standard Operating Procedures for infection prevention are vital to the dental practice to ensure consistency, efficiency and safety and there are good resources that can simplify the process. Regardless of the dental setting, management can’t always be around to issue instructions to team members, and that’s where SOPs shine. Knowing the step-by-step procedure for each task in infection prevention means that the team is empowered to act without waiting for directives. Infection prevention impacts both patient and team safety. SOPs can reduce the chance of errors and the potential for situations where team members might claim they didn’t know how to react because there wasn’t a written procedure to follow.¹¹  

References

1. U.S. Army Public Health Command. Writing and operating a standard operating procedure. October 2010. Available at https://phc.amedd.army.mil/PHC%20Resource%20Library/TG%20176%20Writing%20and%20Managing%20a%20Standing%20Operating%20Procedure.pdf. Accessed March 6, 2020.

2. Time Clock Wizard. The benefits of standard operating procedures in 2019. December 2018. Available at https://www.timeclockwizard.com/benefits-of-standard-operating-procedures. Accessed March 6, 2020.

3. Rao TS, Radhakrishnan R, Andrade C. Standard operating procedures for clinical practice. Indian J Psychiatry. 2011;53(1):1–3. doi:10.4103/0019-5545.75542. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056180/. Accessed March 6, 2020.

4. U.S. Department of Labor. Occupational Safety and Health Administration. Bloodborne Pathogens. Available at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Accessed March 6, 2020.

5. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-care Settings – 2003. MMWR 2003;52(No. RR-17):(6).

6. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, March 2016.

7. Eklund K. Role of the Infection Prevention Coordinator. Decisions in Dentistry; Feb 2020:23-25.

8. Organization for Safety Asepsis and Prevention.  About OSAP. Available at https://www.osap.org/page/AboutOSAP.  Accessed March 8, 2020.

9. Wilson J. Five reasons why every practice needs a written infection prevention protocol. Efficiency in Group Practice; Nov-Dec 2019:40-41.

10. Hu-Friedy. Infection Prevention – Is Your Practice Doing Enough? Available at https://www.hu-friedy.com/blog/greenlight-dental-compliance-center. Accessed March 8, 2020.

11. Cameron S. What are the benefits of SOPs? Bizfluent; Business Operations: May 31, 2019. Available at https://bizfluent.com/info-8416973-benefits-sops.html. Accessed March 8, 2020.

Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent compliance consultant with expertise in OSHA, dental infection control, quality assurance and risk management.  She is an invited speaker for continuing education and training programs for local and national dental organizations, schools of dentistry and private dental groups. She has held positions in corporate as well as academic dentistry and continues to contribute to the scientific literature. Dr. Schrubbe can be reached at kathy@schrubbecompliance.com.