March/April 2018


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Growing Efficient Practices

From The Publisher
Clinical Advances

2018 Annual Summit

The Changing Face of Pediatric Dentistry
Clinical advances help DSOs and their pediatric dentists address the needs of a growing patient base.

2018 OSAP Dental Infection Control Boot Camp ™
Record breaking attendance reveals excitement for dental safety.

Compliance a Must
Waterline disinfection helps ensure a safe patient visit.

Safe dental water……should be a priority at every practice

Evacuation Line Maintenance

Dental Unit Waterlines:
Municipal Tap Water and Why it Should be Avoided

A Look at OSHA
The Occupational Safety and Health Administration (OSHA) plays an important role in the dental industry

Measuring Up
Despite a rise in patient visits, dental services account for a small percentage of healthcare spending.

How to Win Other People Over

Enhanced Hygiene hosts Dental Group Evolution conference

Enhanced Hygiene hosts Dental Group Evolution conference

By Enhanced Hygiene staff

Leading dental coach, consultant and CEO and Founder of Enhanced Hygiene, Heidi Arndt hosted the second annual Dental Group Evolution conference and announced the highly anticipated launch of Enhanced Hygiene’s sister company, Enhanced Practices – along with an invitation to join her in The Boardroom, a year-long mastermind program.

Dental Group Evolution, held January 12 – 13, 2018 in Austin, Texas, was specifically designed for new and emerging mid-size dental groups to gather together and get inspired by listening and learning from the country’s most successful health practitioners and clinical experts.

Heidi Arndt

During these two exclusive days, the 200+ attendees experienced cutting-edge and practical strategies and solutions based upon proven evidence to help them grow their dental group practices. Through general sessions, panel discussions and a wide array of breakout session choices, attendees customized their conference experience – including being up close and personal with hand-picked, amazing sponsors and networking with the country’s best.

In addition to the content, Arndt took the stage at the end of Day 1 to unveil her new company, Enhanced Practices – as well as to invite attendees to enroll in its year-long, exclusive inner circle program, The Boardroom. Arndt explained that Enhanced Practices is the answer to the broader struggles practices face while trying to grow, such as misalignment, multiple philosophies and no consistency between providers and locations. Whereas The Boardroom is the opportunity to address those issues on-demand and work closely with experts who are able to give guidance along the way to growth and success.

From start to finish, Dental Group Evolution was full of ground-breaking concepts and opportunities, in which no one else is offering in the industry.

If you’re interested in connecting with Heidi or learning about or working within her companies, or joining The Boardroom, please reach out to

Raising the Bar

Newer products, such as Universal Adhesives, help large group practices provide optimal patient care.

Patients continue to be more and more informed, thanks to the wealth of information available to them online. In turn, their expectations are higher than ever before, raising the bar for large group practices to provide the best service and treatment possible.

Without access to the newest technology, group practices may struggle to meet patients’ increased expectations, notes Russ Perlman, executive director of marketing & communication, VOCO America, Inc. “Manufacturers can assist their group practice customers with these new advancements by being an active participant in the processes of education, adaptation and implementation,” he says. “Together, group practices can maximize the opportunity to successfully leverage these new advancements that can provide positive results, both on the clinical side and the business side, impacting the level of quality patient care and business efficiency.”

A prime example is universal adhesives, he continues. “From a product perspective, the advancement in adhesives – in particular, the introduction of universal adhesives – has made a significant impact on group practices,” he points out. “For instance, VOCO’s Futurabond U Universal Adhesive impacts group practices on multiple levels, including procurement, inventory management and, of course, clinical dentistry.

“From a purchasing perspective, universal adhesives allow the dental management team to streamline purchasing and reduce adhesive inventories, as well as some secondary product inventories that universal adhesives now share indications with, lowering overall costs,” says Perlman. Clinically, universal adhesives provide the quality and flexibility to meet the various preferences of multiple practitioners within a group practice. “Universal adhesives work in all cure modes and etch modes, as well as with all substrates, delivering very similar bond strength levels and overall performance quality,” he says. “This allows practitioners who differ in preference to use one single adhesive for all clinical situations, which in turn reduces variables and increases consistency on multiple levels, creating more predictable results for both the practitioner and the practice.”

Supporting the dental team
Not only must the dental practice have access to new technology to offer optimal patient care, it must be educated on manufacturer guidelines for proper use. VOCO partners with its group practice customers to ensure they are aware of the company’s new products, including the technology behind these products, notes Perlman. Additionally, VOCO educates its customers to ensure they can “harness and leverage the value of these products and underlying technologies to realize a return on investment on both the business and clinical sides of their practices,” he adds.

“We provide our group practice customers with continuing education programs and work with our media partners to create online continuing education opportunities through portals such as,” Perlman continues. “Furthermore, our dedicated special market sales team works closely with our local and regional reps to ensure our group practice customers have the necessary resources to educate their practitioners and implement these new advancements so that the intended benefits are realized at the corporate, practitioner and patient levels.

“With a fully developed product consultant team, in addition to our in house Clinical Education team, VOCO has been – and will continue to be – a part of the support team that our group practice customers turn to.”

The Full Impact

DSOs and clinicians must work together to ensure new technologies are used to their full potential.

Newer technologies, such as digital radiography and 3D imaging/Cone Beam Computed Tomography (CBCT) have contributed to better, more efficient patient care. And, doctors who are slow to adopt the latest tools risk losing their competitive edge, according to David Vieth, DDS, chief dental officer of Kool Smiles. “By not continually adding new tools and technology in their practices, an organization runs several risks,” he points out. “One such risk is to potentially lose the ability to recruit and retain doctors who have been exposed to newer, cutting-edge tools. Additionally, with media and social media so widespread, consumers are educated and savvy about what’s available in the market, and they expect practices to offer those things, as well as be competitive on pricing, convenience and a high-quality experience.”

Indeed, few consumers would turn down the opportunity to have a crown placed in one visit, rather than making several return visits, notes Vieth. “Simply put, practices that are behind the curve on advancements and new technology stand to lose business,” he says.

The impact of technology
In addition to digital radiography and CBCT, digital scanning technology has also impacted clinicians’ ability to provide better results than ever before. “The use of digital scanning technology can reduce costs, while increasing efficiency and accuracy over traditional impression taking,” Vieth explains. “This scanning process reduces errors by eliminating the impression errors, as well as the model being poured in stone and subsequent handling of the poured models. The result is greater efficiency, speed, cost reduction and a tremendous increase in accuracy.” The quality of care also improves dramatically, he adds. For example, scanning for, say, impressions can be done in fewer steps, reducing the potential for error, he points out.

That said, ensuring that the right technology is incorporated into a multi-site practice and that all clinicians are trained to properly use it requires collaboration on the part of the DSO and the clinicians. On one hand, a large DSO like Kool Smiles, which has more than 100 offices, “has a lot of leverage in terms of procuring the latest technology at more attractive prices and spreading the costs,” says Vieth.  “Because we’re a large group practice, we’re in a position to test-pilot the latest and greatest at an office, or at a few offices, experiment with it, and then make a decision to offer that particular tool or technology at all our offices. Smaller practices might not have the ability to do this. In addition, DSOs tend to have their own IT departments, with expertise and resources to help clinicians evaluate and test new technologies.”

However, the DSO alone doesn’t drive advancements or the latest technology, notes Vieth. “We collaborate with our doctors and clinical leaders to understand and identify what’s best for our dentists and our patients,” he says. “In other words, the DSO isn’t pushing any technology but rather listening to – and partnering with – our doctors on what their needs and the needs of their patients are.

“We work hard to ensure that any implementation is as seamless as possible throughout our offices,” he continues. “We provide all training and ongoing support as needed. Once we implement any new tool or technology, the DSO is there to make sure everything is running smoothly so that our doctors can focus on patient care.”

Innovation in Group Practices

As patient expectations – and the need for greater efficiency in group practices – continue to impact dental technology, Ivoclar Vivadent focuses on research, education and training.

In a competitive industry such as dentistry, where patient expectations continue to drive office efficiency and productivity, group dental practices have come to depend on high quality products and technology. “We have observed significant changes in the dental industry in the last five years,” says Shashikant Singhal, BDS, MS, director of professional services, Ivoclar Vivadent, Inc. As patients raise their expectations for longer lasting, higher quality dental restorations, clinicians are changing their practice model to offer best treatments to their patients faster, efficiently and with options that are more economical, he points out. New, innovative products, together with the digitalization of the dental workflow process, have made this possible, he adds.

“Change can be observed both chairside in dental practices and in dental labs,” says Singhal – a prime example being computer-aided design/computer-aided manufacturing (CAD/CAM) systems. “Since the first chairside CAD/CAM system was introduced in the mid-1980s, this technology has improved significantly,” he explains. “Contemporary scanners are faster, smaller, efficient, accurate and user-friendly, making it easier for dental offices and labs to implement automation in their workflow.” At the same time, dental manufacturers now offer better restorative products, he adds. The result has been new treatment options for patients with regard to fixed and removable prosthodontics, dental implantology, orthodontics and oral surgery.

That said, like all new technology, CAD/CAM systems require initial investment, and group practices must determine the level of technology that best supports their business model. Additionally, the office team must be trained and a digital workflow established to meet the needs of the office, notes Singhal. Often, dentists must expand their business model to incorporate new technology and ensure it facilitates increased efficiency, patient comfort and profitability. In the end, though, patients have a more positive chairside experience. “Today, patients can view their treatment planning by utilizing virtual software,” he says. “They can be educated during various clinical steps and receive restorations in a single visit!” Furthermore, it’s a marketing opportunity for the dental practice, which can attract and retain more patients.

“In addition, compared to analogue techniques, digital technology is cost effective,” Singhal continues. “The dental office team can scan intra-orally, and design and mill restorations for single-appointment restoration. Alternatively, scanned files can be digitally sent to dental labs with the click of a button. The dentist can discuss a patient’s dental treatment with the lab and, in turn, offer the patient an ideal solution, reducing the need for remakes and increasing efficiency, productivity, patient acceptance and profitability. And, at multidisciplinary group practices, digital technology can be effectively utilized by various specialties for multiple treatment modalities for better patient care.”

A mission to serve and educate
Ivoclar Vivadent’s mission to serve dentistry through “innovation, quality products and value-added service,” together with its commitment to dentists and patients alike, has enabled the company to develop “reliable products that maximize a group practice’s efficiency,” says Scott Welch, director of national accounts, Ivoclar Vivadent, Inc. “We invest millions of dollars each year into research and development,” he says. “These clinical trials are paramount to real practice success and efficiency throughout the industry. That’s what we feel doctors and patients understand, expect and deserve.”

Indeed, in a busy group dental practice, where clinicians are continually evaluated on their performance and efficiency, office time is often limited. As a result, training and education – the foundation for providing successful clinical outcomes – don’t always take precedence. Ivoclar Vivadent provides a variety of solutions to successfully meet these challenges, says Welch.

“Education provides the platform for cutting-edge information on techniques, technology and clinical products within the market,” he continues. “Ivoclar Vivadent believes that education is the key component to success in helping dentists address the daily challenges they face within their practice.” Ultimately, this leads to optimal clinical outcomes, satisfied patients and overall self-esteem, he adds.

By providing innovation matched with educational support to as many dental clinicians as possible, Ivoclar Vivadent strives to “increase knowledge and awareness of the various challenges that dentists face in their practice,” Welch says. “Based on the type of structure of the DSO, the training will vary. Ivoclar Vivadent provides industry-leading educational speakers, webinars and online training, all of which are effective means to meet the variety of educational needs of DSO practitioners.”

Ivoclar Vivadent collaborates with major dental learning institutions across North America, in addition to its training facilities located in New York, Florida and Ontario, Canada, according to Welch. The company also hosts Open House programs for dentists and their key staff at its North American headquarters in Amherst, New York. These are distraction-free formats where attendees can become thoroughly acquainted with the benefits associated with the Ivoclar Vivadent product line. “It’s a wonderful opportunity for doctors to peek inside products and get to meet our people,” says Welch. It’s also an opportunity for Welch and his colleagues at Ivoclar Vivadent to learn from program attendees – including dentists, dental assistants and dental technicians – and to create “confidence and long-standing relationships” with them. “Our internal education team spends countless hours creating instructional videos and hosting webinars, enabling our doctors to learn remotely,” he adds.

For more information, visit the following online Ivoclar Vivadent apps:


Growing an Efficient Practice

By Laura Thill

Dental practices work hard to provide the best patient care possible. That said, today’s patients are better educated, and they expect more and better service. In turn, dental practices are under more pressure than ever before to meet their patients’ growing demands.

New products and technology provide multi-site practices with the tools to streamline services and deliver higher quality, more efficient patient care. Their ability to keep pace with continual advances in technology, however, depends on their working closely with their manufacturers to receive proper education and training to attain the best results.

Indeed, an industry that works together is most likely to achieve best practices and the greatest value – both for the group practice and their patients.


Greater Efficiency, Better Results

EGP/Clinical Advances

Continuous advancements in technology enable clinicians to deliver enhanced treatment outcomes.

As dental technology continues to advance rapidly, clinicians have come to rely on better, more efficient treatment outcomes. In fact, “not incorporating these advancements detracts from a DSO’s ability to deliver care in accordance with their mission to enhance patient outcome and exceed expectations,” says Dr. Robert Brody, chief clinical officer, Great Expressions Dental Centers.

Some of the biggest game changers have included advancements in dental materials (implants, zirconia, and universal bonding agents have expanded and improved treatment modalities), the refinement of digital intra-oral scanners and the ability of the practice management software system to link all practices across the organization, according to Brody. Intra-oral scanners provide a visual reference for patients, aiding in their understanding of the procedure, he points out. They also facilitate more precise and consistent preparations and impressions. “Digital intra-oral impressions are more accurate than traditional impressions, less time-consuming and less technique-sensitive,” he says. The result is an enhanced treatment outcome, as well as lower supply and lab costs, reduced chair time and greater patient comfort compared to traditional impressions.”

Likewise, improvements in practice management software have led to greater collaboration among clinicians, who can more easily share diagnostic data and discuss treatment plans. “Instant access to patient records leads to more efficient delivery of quality dental care,” says Brody. “The subsequent sharing of ideas leverages the skills of specialists and general dentists to enhance treatment outcome.” In turn, they can deliver more successful multi-phase treatment plans with fewer patient appointments, he adds.

Establishing guidelines
Successfully incorporating new technology throughout a large dental practice depends on solid communication between the DSO and its clinicians, as well as ongoing education and support. “GEDC utilizes a Doctor Panel that reviews best practices regarding cutting-edge advancements and develops guidelines to incorporate into the group’s delivery of care,” says Brody. “We rely on the experience and collaboration of the group’s doctors to establish the guidelines for the use of new technology.”

The DSO also provides continuing education (CE) on all new technologies, including lectures, office meetings with team members and hands-on mentorship. “Ongoing support is similar to implementation,” Brody explains. “In addition to continuing education and mentorship to our affiliated doctors, these doctors participate in group-sponsored study clubs that share best practices.” When clinicians are able to use new products to their full potential, they can achieve the best treatment results for their patients, he adds.

Dental Unit Waterlines: Municipal Tap Water and Why it Should be Avoided

Sponsored: Sterisil

By Jerod Mendolia, marketing assistant, and Reid Cowan, director of marketing, Sterisil

It’s no secret in 2018 that dental unit waterline (DUWL) cleanliness is important. Every trade publication, tradeshow and continuing education summit offers some sort of crash course on the subject. The bacteria problem is widespread and omnipresent regardless of the practice type or equipment employed. If it runs water, the potential to be a problem exists. Given their nature, dental waterlines will grow bacteria beyond the 500 colony forming units per milliliter drinking water standard without some level of shock and maintenance.

Opportunistic bacteria and the subsequent biofilm they produce are everywhere in the natural world. Every dental unit in use today employs a network of tubing to deliver both air and water to the handpieces. The typical tubing used in a dental chair is narrow in diameter and low in volume. This proportional relationship means the internal surface area is much greater relative to the volume of water flowing through the tubing. The smaller the tubing diameter, the larger the internal surface. This large volume of surface area gives bacteria and biofilm plenty of room to establish themselves.

Bacteria and pathogens are opportunists, and they will exploit the nature of dental tubing to their advantage. According to The Organization for Safety, Asepsis, and Prevention (OSAP), “This proportional increase in the amount of potential biofilm relative to a given water volume is one of the major factors influencing dental water quality in unrelated systems.[1]” Once biofilm are established, they can be difficult to eliminate. If left unchecked, biofilm will exhibit a resistance to common disinfectants, making the situation even more problematic[7]. Consider other growth factors unique to dental systems, such as water temperature, flow rates and frequent stretches of stagnation. The culmination of all these factors allows the bacterial load in the waterline to exceed the CDC and EPA drinking water standard of 500 CFU/ml.

So why is this a problem? According to OSAP, “As many as nine potentially pathogenic organisms associated with opportunistic wound and respiratory infections have been isolated from dental unit water systems.”[1] When coolant and irrigant water is used in conjunction with a high speed dental handpiece, the contaminated water is aerosolized along with the bacteria. Now you really have a problem! If patients or the dental team inhales these water droplets, they’ve now been exposed to whatever was growing in the dental unit. There’s also the good old fashioned way of exposed tissue (or dental pulp) being infected when the site is irrigated with contaminated water. Either way, serious infections can be the result of a contaminated DUWL. So how can clinicians mitigate these risks? They can start with the water being supplied to the dental practice.

Most clinicians are not aware that municipal tap water could be contributing to their bacteria problems. Public water works that deliver municipal tap water are prone to contamination and breaches in their own water quality standards. A common watermain break or leak presents an opportunity for pathogens to gain access to the public works. According to a 2012 report, these types of failures have been the cause of several bacterial and viral outbreaks of Salmonella, Campylobacter, Shigella, E. coli O157:H7, Cryptosporidium, Giardia and Norovirus[2,3].

As of 1971, the Centers for Disease Control and Prevention (CDC), U.S. Environmental Protection Agency (EPA) and the Council of State and Territorial Epidemiologists (CSTE) have been tracking and quantifying these waterborne disease outbreaks in the United States. The most interesting insight from the data they provide is that over the 36-year period from 1971 to 2007, “a trend analysis found a statistically significant decrease in the annual proportion of reported deficiencies that were associated with the inadequate or interrupted treatment of water by public water systems[4].” Conversely, the amount of outbreaks related to flaws in premise plumbing have increased in that time[4].

Privately managed water treatment – or premises treatment – are technically outside the jurisdiction of a water utility. The liability falls to building managers to implement a strategy for maintaining waterlines after the meter. According to the American Society for Microbiology, “Health care settings, such as hospitals and nursing homes, were the second most common outbreak location in community systems, highlighting the need for continued vigilance to ensure provision of safe water to locations that serve populations that are more vulnerable, such as hospitalized patients or nursing home residents with preexisting medical conditions.”[4] For dental professionals in large healthcare facilities, it is certainly worth speaking with building managers about the plans for water treatment within the building. Systems of water quality monitoring and intermittent testing should be in place where the consequences could be serious.

Maximum chemical control
In 2015, reports began to circulate that a cluster of Mycobacterium abscessus infections had been identified in Atlanta, Ga. after nine pediatric patients were hospitalized in the same facility. The CDC reported that the Georgia Department of Public Health (GDPH) initiated an investigation, which revealed that all of the patients (between the ages of 3-11) had previously undergone a pulpotomy procedure at the same dental clinic. Upon visiting the clinic to evaluate their infection control policies, GDPH staff indicated the practice used tap water for irrigation during the pulpotomies. The report also indicated the practice lacked any level of monitoring or disinfection efforts as directed by the chair manufacturer. The report concluded that all seven operatories had bacterial counts above the 500 colony forming unit (CFU) drinking water standard and M. abscessus was identified in all samples[5].

If a dentist intends to use their municipal water for dental water – and, yes, there is a difference – it would be advisable to have some level of water quality analysis before selecting the product. Variations in tap water quality are virtually infinite and, therefore, the dental practice should not rely on tap water for consistent disinfection results. The presence of municipal disinfectants and additives, such as chlorine and fluoride, complicates things further if the practice is trying to manage the chemistry, as it should to get the best results. By failing to do so, the dental practice has a concoction of different chemicals and additives mixing in the waterline. The byproduct of these unwanted mixtures is called precipitates, and their presence indicates the diminished effectiveness of whatever exists in the water to control microbes.

So what is the solution? To attain maximum chemical control, distilled quality water is best. That said, distilled water from a distiller is not always optimal for dental water. The nature of distillation requires that one heat the water to remove impurities. This hot distillate is now primed for recolonization by bacteria. Without immediate waterline treatment, this water will most assuredly be contaminated. Without the presence of a continuously present residual disinfectant, that water will most assuredly be a breeding ground for bacteria. Distillers themselves are often the source of contamination for many offices, as once the storage tank is contaminated the water is then distributed along with the bacteria to the entire office.

The best strategy is a point-of-use purification system using deionization to remove all the impurities without heating the water. Ultraviolet disinfection can then be employed to drastically lower the existing bacterial load with proven effectiveness [8]. The water would then receive a low concentration of a residual disinfectant. The final product is water that is neutral in pH, contains less than 10 ppm total dissolved solids, is disinfected and contains some variety of residual disinfectant.

Now the water is pure and bacteria free. So the treatment process is complete, right? Not even close! We haven’t gotten to the most important part – the dental water use protocols. Without sound operating protocols, everything the dental practice has done up to this point would be for not.

Dental water use protocols
Manufacturers spend unmentionable amounts of money on development, EPA registration and validation for their products. The EPA label will run down all the necessary steps needed to get the advertised disinfection level. Clinicians should not go rogue on these protocols! When it comes to quality assurance (QA), OSAP recommends procedures that flush out user error[6]. Let’s face it, people can make mistakes. Minor investments like TDS hand meters will allow some level of protocol QA. For example, when using distilled water in their bottles, clinicians should randomly check the TDS count and ensure the result is less than 20 ppm. If it’s greater than 20 ppm, they can assume the water in that bottle is not distilled and that someone has botched the procedure for refilling it. Protocol consistency and quality failsafes are fundamental to getting all of this waterline stuff done right. Consistency leaves nothing to chance. This is also important, as manufactures design their products to work within certain parameters. We’ve already discussed the variability in water chemistry across the spectrum. Deviations in protocol, like the example above, could mean the dental practice is no longer operating within those parameters and, subsequently, it may have contributed to contamination in the unit.

So what is compliance under the current standards? The acceptable standard set by the CDC and the ADA for bacterial content in a dental unit is ≤500 CFU/ml. Compliance is not a state of mind; it’s a state of being. The notion that purchasing a product and following the instructions puts one in compliance is just wishful thinking. A complete and thorough waterline assessment performed by a 3rd party lab specializing in dental water microbes will provide all the information necessary. TDS, pH, and HPC counts in CFU/ml are the general markers of waterline cleanliness. These test results can be used to make adjustments to the waterline protocol or confirm that clinician’s efforts are having the desired effect. It can be something as simple as a change in the daily staff use or as extensive as a complete overhaul of the regimen at large.

Contaminated dental unit waterlines are a real threat to patient and staff safety. Their design, the nature of dental procedures and the conditions within the dental operatory prime them for bacterial colonization. We know the problem can be exacerbated by using municipal water instead of purified or distilled water, and the case data proves this point. The most important takeaway from this piece is that whatever clinicians do, they should be consistent. They should read manufacturers guidelines and follow them, as there may be something they’ve been missing. When they feel like everything is going well, they shouldn’t assume it is. Rather, they should order a test and know for sure. If clinicians miss the mark, they should reevaluate their plan, retrain their staff and retest to confirm the change. Attaining the <500 CFU/ml standard in dental effluent water is the culmination of forethought, execution, consistency and vigilance. No excuses!


  1. Berdnash, Helene, et al. “Dental Unit Waterlines: Check Your Dental Unit Water IQ.” Dental Unit Waterlines – OSAP,
  2. Ingerson-Mahar, M.; Reid, A. Microbes in Pipes: The Microbiology of the Water Distribution System A Report on an American Academy of Microbiology Colloquium; ASM Academy: Boulder, CO, USA, 2012; p. 26.
  3. Ramírez-Castillo, Flor, et al. “Waterborne Pathogens: Detection Methods and Challenges.” Pathogens, vol. 4, no. 2, 2015, pp. 307–334., doi:10.3390/pathogens4020307.
  4. Craun, Gunther F., et al. “Welcome to CAB Direct.” CLINICAL MICROBIOLOGY REVIEWS, vol. 23, no. 3, July 2010, pp. 507–528.,
  5. Peralta, Gianna, et al. “Morbidity and Mortality Weekly Report (MMWR).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Aug. 2017, – Dental Unit Waterlines
  6. Bridier, R. Briandet, V. Thomas & F. Dubois-Brissonnet. “Resistance of bacterial biofilms to disinfectants: a reviewBiofouling Vol. 27 , Iss. 9,2011
  7. Chevrefils, Gabriel, et al. UV Dose Required to Achieve Incremental Log Inactivation of Bacteria, Protozoa and Viruses. UV Dose Required to Achieve Incremental Log Inactivation of Bacteria, Protozoa and Viruses, Trojan Technologies Inc., 2006.

A look at OSHA

The Occupational Safety and Health Administration (OSHA) plays an important role in the dental industry.

Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent consultant with expertise in OSHA, dental infection control, quality assurance and risk management.

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

OSHA: It’s an organization that many dental employers fear! In fact, some dentists do not fully understand the importance of OSHA regulations and believe they make if difficult to deliver high-quality dental care. However, non-compliance can lead to injury, illness or harm to employees. For that reason, large group practices and DSOs make it their business to remain compliant with OSHA standards, often hiring quality assurance individuals to oversee compliance. This team is frequently charged with ensuring that OSHA standards are in place and being met throughout the practice. Furthermore, as a federal regulatory body, OSHA inspectors may appear at a dental practice unannounced and can issue citations and monetary fines for noncompliance and repeated offenses. These fines have recently increased, and they can be substantial, not to mention the potential damage to the practice’s reputation and credibility as a safe workplace.

This article looks at OSHA’s history, inspection protocols and fees for noncompliance.

The history of OSHA
In response to dangerous working conditions across the nation, and as a culmination of decades of reform, the bipartisan Williams-Steiger Occupational Safety and Health Act of 1970 was signed into law by President Richard M. Nixon. This law led to the establishment of the Occupational Safety and Health Administration (OSHA) on April 28, 1971. Since then, OSHA – along with state partners and employers, safety and health professionals, unions and advocates – has had a dramatic effect on workplace safety, showing a dramatic drop in fatality and injury rates. OSHA’s mission is to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.1,2

According to history, accurate statistics were not kept early on, but it is estimated that in 1970 about 14,000 workers were killed on the job – a number that decreased to approximately 4,340 in 2009. At the same time, U.S. employment has almost doubled and now includes over 130 million workers at more than 8 million worksites. Since the passage of the OSHA Act, the rate of reported serious workplace injuries and illnesses has declined from 11 per 100 workers in 1972 to 3.6 per 100 workers in 2009. OSHA safety and health standards, including those for trenching, machine guarding, asbestos, benzene, lead and bloodborne pathogens, have prevented countless work-related injuries, illnesses and deaths.1

Federal OSHA is a small agency, but with the state partners there are approximately 2,100 inspectors responsible for the health and safety of 130 million workers, which translates to about one compliance officer for every 59,000 workers.1,3 OSHA cannot inspect all 8 million workplaces it covers each year. The agency seeks to focus its inspection resources on the most hazardous workplaces in the following order of priority:

  1. Imminent danger situations: Hazards that could cause death or serious physical harm receive top priority.
  2. Severe injuries and illnesses: Employers must report all work-related fatalities within eight hours, and all work-related inpatient hospitalizations, amputations or losses of an eye within 24 hours.
  3. Worker complaints: Allegations of hazards or violations also receive a high priority.
  4. Referrals of hazards from other federal, state or local agencies, individuals, organizations or the media receive consideration for inspection.
  5. Targeted inspections: Inspections aimed at specific high-hazard industries or individual workplaces that have experienced high rates of injuries and illnesses also receive priority.
  6. Follow-up inspections: Checks for abatement of violations cited during previous inspections are also conducted by the agency in certain circumstances.4

In dental practices, the most common trigger for an OSHA inspection is a worker complaint or referral. A current or former employee can call in a complaint and, depending on a number of circumstances, including inspection history, if any, and the gravity of the complaint, an inspection can be triggered by this one phone call.Thus, it is prudent to treat employee concerns seriously and make the necessary corrective action before the issue escalates into a formal complaint to OSHA. When dental staff feel that they are threatened in an unsafe workplace for any reason, management needs to take immediate action.

Usually, OSHA conducts inspections without advance notice. However, employers have the right to require compliance officers to obtain an inspection warrant before entering the worksite.4   According to a national news report, OSHA has lost 40 inspectors through attrition since President Trump took office in January 2017, and as of early October 2017, the federal agency had made no new hires to replace them. The 40 vacant positions represent 4 percent of OSHA’s total federal inspection force, which fell below 1,000 this past October.6,7

In 2015, Congress passed the Federal Civil Penalties Inflation Adjustment Act Improvements Act to advance the effectiveness of civil monetary penalties and to maintain their deterrent effect. This law directs agencies to adjust their penalties for inflation each year using a much more straightforward method than previously available, and requires agencies to publish catch-up rules to make up for lost time since the last adjustments.8

In August 2016, for the first time since 1990, OSHA increased its fines – by 78 percent. As of this date, the top penalty for serious violations rose from $7,000 to $12,471, and the maximum penalty for willful or repeated violations increased from $70,000 to $124,709.

Then, effective January 2 of this year, OSHA increased its penalties again by 2 percent to adjust for inflation (as required by the Federal Civil Penalties Inflation Adjustment Act), with a maximum fine of nearly $130,000. The new fines apply to all violations that have occurred since November 2, 2015, with penalties assessed after January 2, 2018.9.10 

Type of Violation Penalty

pre-August 2016

Penalty as of

August 1, 2016

Penalty as of

January 2, 2018

Posting Requirements
$7,000 per violation $12,471 per violation $12,934 per violation
Failure to Abate $7,000 per day beyond the abatement date $12,471 per day beyond the abatement date $12,934 per day beyond the abatement date
Willful or Repeated $70,000 per violation $124,709 per violation $129,336 per violation

Penalties such as these would have a significant financial impact on a dental practice of any size, including a large group practice or DSO. From October 2016 through September 2017, there were 87 citations from federal OSHA (state issued citations are not included in this number) to dental offices. Of those, 49 were related to the bloodborne pathogens standard and 21 were related to the hazard communication standard.11

Dental practices are busy places, but remember, the OSHA Act was put in place to protect all workers, including those in dental healthcare. A safe workplace is also an efficient workplace.  Implementation of – and compliance to – the required elements of the bloodborne pathogens and hazard communication standards must be in place to ensure dental healthcare worker safety.  Although there is a decrease in the number of OSHA inspectors, legitimate worker complaints will eventually be addressed. Dental employers should not risk the possibility of an inspection or a citation with the new fees. They should be proactive and follow the federal standards for providing and maintaining a high-quality, safe practice setting for all dental healthcare workers.


    1. US Department of Labor. Occupational Safety and Health Administration. Timeline of OSHA’s 40 Year History. Accessed January 17, 2018.
    2. US Department of Labor. Occupational Safety and Health Administration. OSHA Celebrates 40 years of accomplishments in the Workplace. Accessed January 17, 2018.
    3. US Department of Labor. Occupational Safety and Health Administration. Commonly used statistics. Accessed January 17, 2018.
    4. US Department of Labor. Occupational Safety and Health Administration. OSHA fact sheet. Accessed January 17, 2018.
    5. Garofolo R. OSHA compliance for the dental office. DentalTown; September 2014. Accessed January 17, 2018.
    6. NBC News. Accessed January 17, 2018.
    7. OSHA Healthcare Advisor. General health and safety. Accessed January 17, 2018.
    8. US Department of Labor. Occupational Safety and Health Administration. OSHA national new release. Accessed January 18, 2018.
    9. US Department of Labor. Occupational Safety and Health Administration. OSHA penalties. Accessed January 18, 2018.
    10. OSHA Healthcare Advisor. A rundown of new, increased OSHA penalties. Accessed January 18, 2018.
    11. US Department of Labor. Occupational Safety and Health Administration. NAICS Code: 621210 Offices of Dentists. Accessed January 18, 2018.

Editor’s note: Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent 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.

The changing face of pediatric dentistry

Clinical advances help DSOs and their pediatric dentists address the needs of a growing patient base.

Pediatric dental visits are on the rise, according to Marc A. Auerbach, DDS., Esq., a pediatric dentist with Kool Smiles. At the same time, access to care continues to be an issue.

The good news is that dentists – including pediatric dentists – have more and better tools available to treat their patients, including the following:

  • Silver Diamine Fluoride. Applying Silver Diamine Fluoride to the carious teeth of a young child allows dentists to delay definitive treatment until the child is older and better able to tolerate dental treatment.
  • Non-radiating fluorescent. The use of non-radiating fluorescent for caries diagnosis reduces the need for radiation.
  • Caries management by risk assessment (CAMBRA). CAMBRA enables dentists to develop a patient-specific preventive care plan. (Evidence-based dentistry further aids dentists in providing treatment shown to be scientifically effective.)
  • Zirconium crowns. Zirconium crowns for both anterior and posterior teeth result in a more natural looking tooth.
  • Innovative use of local anesthetic products, such as buffering of local anesthetic to make injections more comfortable and to facilitate faster anesthesia uptake.
  • Intranasal atomization of anesthetics for maxillary teeth, potentially eliminating the need for an anterior maxillary injection.
  • In-office general anesthesia for the uncooperative or pre-cooperative child with extensive dental needs. Using general anesthesia can help dentists complete treatment in one visit, reducing stress for both the child and parent.
  • Newer, in-office sedation techniques, utilizing safer and shorter-acting drugs, such as Midazolam.
  • Innovative isolation techniques. Traditionally the rubber dam has been used for tooth isolation. Today there are new, single-use systems designed to provide tooth isolation, as well as illumination, suction and jaw stabilization, in one device.
  • Advances in pulp therapy, such as the use of MTA for vital pulpotomies, which have reportedly led to successful results without the potentially toxic effects of formocresol.
  • Expanded use of sealants, which has helped prevent the development of caries on molars.
  • Newer and faster lasers designed to cut both hard and soft tissue.

The role of the DSO
Dental service organizations can play a substantial role in helping their pediatric dentists become more comfortable in large group dental practices, according to Auerbach. “The DSO can help integrate the pediatric dentist into the large group practice by facilitating the training of the referring doctors,” he says. “DSOs can locate and hire appropriate staff and provide adequate, appropriate equipment and supplies. They can interact with payors to aid in claims processing and to reduce denials.” At the end of the day, DSOs can make it possible for their pediatric dentists to remain focused on their patients, rather than be distracted with managing the office, he explains.

The Pediatric Dental Visit

Low-profile nasal masks make it easier for pediatric dentists to administer nitrous oxide and offer their patients a more enjoyable experience.

Pediatric dentists work with a range of patients – from infants and children to adolescents and special needs patients – many who are uncomfortable being treated and fear returning for their next appointment. By ensuring that pediatric patients have a comfortable experience through the use of nitrous oxide and scented masks, dentists can help make their visits more enjoyable, notes Deepti Sanjai, product manager for Crosstex/Accutron. Additionally, the use of nitrous oxide can facilitate more efficient patient scheduling. “It has been shown that offices that use nitrous oxide are able to have a higher turnover of patients, while increasing patient comfort,” she says. “This ultimately facilitates better patient care, since the pediatric dentist is able to focus on the treatment of the patient.”

“Crosstex/Accutron helps pediatric dentists and staff by assisting in patient comfort,” Sanjai continues. The company recently launched Axess®, a line of low-profile nasal masks available in pediatric sizes and designed for nitrous oxide sedation. “The design of these masks allows pediatric dentists to more easily access the oral cavity of the patient,” she explains. “In addition, the lightweight tubing fits neatly around the ears of the patient, so movement of the head during the procedure doesn’t disrupt the placement of the mask.”

“Crosstex/Accutron is committed to advancing the care of pediatric patients by launching single-use scented masks with a low-profile design, available in pediatric sizes. We continue to advance our nitrous oxide portfolio, with a focus on our core values of quality, safety, infection prevention and patient comfort.”