July/August 2019

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Advanced technology, together with experience and a measure of sensitivity, enable pedodontists to provide the best possible care for their young patients.

Editor’s Note
Embracing Change

2019 ADSO Summit: A Huge Success with Members
Compliance, recruitment and retention, leadership and technology trends were just a few of the topics covered at this year’s Summit.

Dental Group Practice Meetings: An Overview
DSOs have year-round educational and networking opportunities

Kid-Friendly Dentistry
Treating young children requires a unique skill set

Improvements in implant technology are making them increasingly attractive to doctors and patients

All the Right Moves
For Eric Shirley, the best solutions lie beyond the obvious answers

The Dash to the 2019 Finish Line
4 steps to implementable success

The BISCO Dream Team
Best possible outcomes depend on the right mix of products

Engineering and Work Practice Controls
Key elements of Bloodborne Pathogens Standard are often overlooked

Safe Water, Safe Patients
Growing attention to the hazards of contaminated dental unit water has led more and more dental clinicians to take the necessary steps to protect their patients.

Instructions for Use: They’re Meant to be Read!
Assumption of knowledge is a dangerous thing

Your DSO Accelerator
How to maximize the tremendous value your hygiene team brings to the group practice


All the Right Moves

By Laura Thill

Eric Shirley

For Eric Shirley, the best solutions lie beyond the obvious answers.

When Eric Shirley joined Patterson Dental as president of the dental business unit earlier this year, he brought with him years of industry experience and perspective, as well as a fresh vision for the company and its business partners.

“Patterson has two critical and unique assets: our customers and our teammates,” says Shirley. “With that wonderful foundation, I am not here to solve huge problems. My role is to ask the right questions and challenge ourselves to think in ways that enable our teams to make our customers more successful.” Both distributors and manufacturers are tasked with increasing the value of oral healthcare, he points out. “It’s about empowering the clinical team to provide better and more efficient care, enabling the practice to adopt new technologies and products, and designing oral healthcare environments that do all of this more effectively and comfortably.”

“Distributors and manufacturers both have a role to play in that. If we each do our jobs really well, we’re going to increase the value of oral healthcare and help patients receive better care. Ultimately, we’re going to help the practices become more successful.”

From manufacturing to distribution
Shirley’s career took root in dental manufacturing when he joined Kavo Kerr (currently part of Danaher) in 1991 as the Southern California territory manager, as well as a product and marketing manager. He remained with the company for seven years, after which he joined Dentsply as the director of marketing for preventive care. For the next six years, he assumed various sales and marketing roles at Dentsply. In 2004, he joined Midmark Corp. as vice president of sales and marketing for the company’s dental business, later transitioning to general manager of both the dental and animal health divisions. Afterward, he was appointed Midmark’s chief commercial officer and directed the customer-facing efforts for all three of the company’s businesses: Medical, Dental and Animal Health.

“Midmark utilized the Toyota Production System in all of its manufacturing facilities and office environments – an experience that was very educational and eye-opening,” says Shirley. “Working on the manufacturing side taught me a great deal about process, operations and product development. I learned to look beyond answers to the questions and to really search for new ways to solve problems that the customer or clinical team couldn’t necessarily articulate. The discovery of unmet needs is critical on the manufacturing side, as is the ability to utilize real, established processes within those business units to achieve goals.” It’s precisely this experience, he adds, that he hopes to offer Patterson.

Meeting the need
For Shirley, the reasons for joining Patterson were clear. “Patterson has always impressed me as an organization that truly understands the dynamics of the dental practice, including how to bring real value-added expertise to help the practice team achieve its goals,” he explains. “I worked with Patterson as a supplier partner for many years and have gotten to know the organization’s values very well. I’ve long been fascinated with how deeply Patterson knows the practice mechanics of its customers.”

As newly appointed president of Patterson Dental, Shirley embraces the opportunity to bring new insight to dental practices, including practice owners and the clinical team, ultimately improving the care patients receive. It’s becoming increasingly important to provide dental practices with the data and insights necessary to achieve their goals, he points out. “Whether we offer new services, integrate technology, design dental practices, facilitate transitions, or use our data to find new sources of revenue for the practice, I think it’s critical for us to understand how we can evolve and change as a partner to help our customers achieve these goals,” he says.

“It’s important to understand what our dental customers need from a distribution partner, and to realize that these needs are changing – needs that are unique to each customer,” he continues. “Our customers’ needs are not the same as they were 10 or 15 years ago, and they will continue to change over the next 10 or 15 years. Our goal at Patterson is to understand our customers’ needs and position ourselves as the one company that can address those needs.”

Shirley couldn’t have joined Patterson at a more opportune time. Today more than ever, the company works to understand its dental customers’ needs and address the unique goals and objectives of each practice. “We are focusing on what makes the Patterson difference impactful to a dental practice,” he says. “It’s about the data and insights we bring to this conversation and getting to know what each practice really wants to accomplish.” This can vary widely from practice to practice, depending on whether it’s a large dental service organization, a regional group practice or a smaller solo practice, he adds.

Sometimes dental practices are looking to design better operatories or acquire other practices, Shirley continues. In some cases, their goal may be to add new services, procedures and technologies. What sets Patterson apart is “its ability to have those kinds of deep, one-on-one conversations with practices,” he points out. “We are becoming a stronger partner to dental practices, bringing business and clinical solutions to help each practice accomplish their individual goals.” In turn, Patterson’s dental customers are placing greater trust in the distributor by installing its software, equipment and technology offerings, helping to fuel its leadership position in the dental industry.

A look to the future
In Shirley’s experience, not only will the needs of dental professionals continue to change in years to come, so, too, will the industry landscape. In fact, he expects the industry to expand, making room for both large and small players. “We will continue to see the role of Dental Service Organizations (DSOs) grow and new models emerge,” he says, adding that these organizations will look very different in three or five years. “We’ll see new models emerge in size and scope,” he says. “We’ll also see new and changing ownership models. For instance, we may see more medium-sized regional service organizations that are made up of practices with the same consistent values and core concepts.”

At the same time, Shirley anticipates the re-emergence of the small practice environment. “I’m really encouraged by what I see with the sole practice model,” he says. “Solo practices want to be more relevant and provide better care and a different patient experience. They are clearly asking themselves some tough questions about how they can compete in the new world; I’m encouraged by what I see in all areas.”

In addition, he has great confidence in today’s millennial dental graduates, who as a group appear eager to begin their careers and give back to their community. “I have the pleasure of working with a lot of dental school graduates, [many] who are eager to own several practices,” he points out. “I also see dental school graduates who are interested in public dentistry and giving back to the community, and I think that’s great too. I’m encouraged by what I see in the graduating classes of dental schools; I think it’s going to be exciting for the future.

“I’ve fallen into an industry that is really [fantastic] to be a part of,” says Shirley. “Everybody wants to do the right thing and improve the oral healthcare of the patients that we all serve.” That said, he credits the people in his life – family, friends and colleagues – who have inspired him to try to make the world a better place. “I’m lucky to have a very supportive family and so many wonderful friends and colleagues in this industry who have helped me so much,” he says. “My parents and grandparents have been an inspiration to me, and I feel like I’m trying to bring their legacy forward. They have worked so hard over the years, and I am grateful for their example of work ethic and love.”

A history of philanthropy

Eric Shirley, newly appointed president of Patterson Dental’s dental business unit, has long been involved in a number of philanthropic efforts, including TeamSmile and the Dental Lifeline Network. So, it’s no surprise he feels at home at Patterson Dental. “Since 2004, the Patterson Foundation has given $3.2 million in scholarships to 415 students from Patterson families and $7.6 million in grants to 140 nonprofit organizations,” he points out. “So, I know how strongly the Patterson team feels about the mission and the work of the Foundation, and they’ve already encouraged me to continue the philanthropic work that I do.

“The TeamSmile work is what I’m most proud of because I’ve seen how the organization has grown in the years I’ve been a part of the Board of Directors,” Shirley continues. “The passion of Dr. Bill Busch and the many people who work with TeamSmile to provide free dental care to children all over the country – including partnering with professional sports teams – has been so inspiring. I’m really proud of what they do. We began 13 years ago with a single event with the Kansas City Chiefs; today, the program has mushroomed into 40 annual events with 40 professional sports teams!”

Kid-Friendly Dentistry

Treating young children requires a unique skill set.

A few generations back, the general consensus was that children should be seen but not heard. Fortunately, by today’s standards, not only should children be seen and heard, they should be afforded the best possible healthcare, including oral care. Indeed, the recent drive to educate families on the importance of early oral care and the need to make treatment more accessible has paid off, both for pediatric patients and the pedodontists treating them. Overall, this is great news for dental professionals. At the same time, many dental owners are challenged with making their waiting rooms more child-friendly, investing in newer technology and providing their teams with more and better training.

Outreach and education
Rolando Mia, vice president of customer success at Zyris, has seen a definite rise in pediatric dental visits among the company’s pedodontist customers. “We believe the increasing population of children in the United States[1] is helping fuel growth among our pediatric customers, many who are expanding – adding operatories, personnel and even offices,” he says. “We also hear that more families are realizing the importance of bringing their children to the dentists’ office; This is reinforced by our pediatric and community health center customers via additional and ongoing educational programs, as well as dental education outreach in their local communities. For instance, many dentists today offer on-site visits to schools and provide free dental packs (e.g., toothbrushes, toothpaste, floss, etc.) for the children.

“It appears that more children and their families are taking advantage of insurance coverage, as well as special pediatric-focused dental outreach programs for preventative dental care, (e.g., the American Dental Foundation’s Give Kids a Smile, America’s Tooth Fairy, etc.),” he continues. “It’s been especially helpful as dental associations have come together to develop a successful ad council awareness campaign promoting the importance of managing children’s oral hygiene (e.g., 2 Min – 2X/Day, which involves brushing one’s teeth for 2 minutes, twice daily). As a result, more children are receiving higher quality oral healthcare today.”

Addressing the need
As more and more children are scheduled for dental visits, pedodontists and general dentists who perform basic pediatric care (e.g., checkups and cleaning, preventive care, caries treatment, sealants, education, etc.) are tasked with adopting new technology, remodeling their waiting rooms and offering reward programs to motivate their younger patients.

“We’ve observed that many of our customers recognize the need to make their offices an inviting, fun and safe place for children to visit,” Mia points out, noting it’s common for dentists to rely on themes to make their offices less intimidating. So, for instance, the office may feature a beach theme or a tropical, jungle, ocean or zoo theme. It’s also becoming more common to have digital or board games available in the waiting room, children’s programming playing on a television and interactive iPads available in waiting rooms, operatories and recovery rooms. Some practices have begun sponsoring special events, such as field trips to the dental office to give children the opportunity to use the instruments, see the operatories and learn about dentistry, he adds.

“We also see different engagement and reward systems for children who are successfully performing preventative oral care, such as the Brush DJ app, a no-cavity club or movie passes, awards or toys,” says Mia.

Not surprisingly, with an increase in patient visits comes a handful of administrative responsibilities, including recruiting qualified doctors and staff, managing the business and working with parents and caregivers – some who can be overbearing! “Pediatric dentists must be effective in consistently managing issues related to profitability, staffing, expense control, maintaining a high quality of care and managing the team,” says Mia. And, it’s not always easy to secure qualified or experienced dentists, he adds. Many dental school graduates are opting to join DSOs over solo practices. “In addition, we’ve learned from working with our pediatric customers there is a special patience and focus required to work with children,” he points out. “There is a level of communication and patience required to be effective with children, and not all doctors and clinicians have the capacity or talent to do so.

“Children are especially difficult to treat due to their decreased understanding of the procedure, short attention span and smaller mouth,” he continues. “Pediatric dentists have a small window of opportunity to treat a child before the patient becomes tired, distracted or simply upset during the procedure.” Sometimes, it’s a matter of working with a difficult parent or caregiver, he notes. “We continually hear that parents can make or break a dental procedure visit. When parents do not cooperate, or they feel compelled to question everything a clinician is doing, we’ve been told this can upset the child and compromise the clinician’s ability to effectively treat the patient. In addition, children key off their parents/caregivers during a procedure. If a parent is nervous, impatient, fearful, etc., the effect on the child can be negative.

“As technology and materials continue to improve, procedures are easier and quicker to perform,” says Mia. That said, incorporating and using new technology, equipment and materials can be challenging, he adds. “We’ve been told the proliferation of computer and digital systems is especially daunting. The challenge is to find clinicians, hygienists and dental assistants with the skills and ability to operate and use these systems once they are trained.” Examples of newer pediatric technology includes silver diamine fluoride (SDF) for caries prevention and treatment, digital X-rays, digital and laser cavity detection devices and aids, hard and soft tissue laser designed to painlessly treat cavities and decay, CAD/CAM impression technology, painless injection systems and improved isolation and retraction devices, such as the Isolite System. At the same time, pediatric dentists today must be comfortable with sedation dentistry, which is now used more routinely.

“We’ve heard a number of concerns from our dental customers regarding these newer technologies,” says Mia. For one, there’s an ongoing cost involved in adopting new technology, some of which may quickly become obsolete as next generation systems become available. “Our customers also tell us that new technology can be disruptive to clinicians,” he says. Naturally, there’s a learning curve involved and it takes time for clinicians to become comfortable using new technology. The dental team must also keep up with software updates and on-going training and support. “It requires a dedicated effort, and when technology is set aside and forgotten, it’s a wasted investment.”

Training and education
Even as dental care becomes more accessible to many children, some community health clinics continue to face a huge patient backlog, notes Mia. “According to one community health clinic we work with, some pediatric patients have wait times of one to two years to be seen by a clinician,” he says. “The majority of recent dental school graduates are trained to perform procedures primarily on adults,” he explains. “They often have limited education or expertise when it comes to working with younger children.

“Pedodontists must participate in a graduate education program that is focused specifically on treating and managing younger children,” says Mia, noting this requires a much different skill set from working with adult patients. “When a child is experiencing more complex oral health issues or severe conditions, it is imperative that he or she is treated by a specialist – one that is specifically educated and experienced in treating young children and special needs patients.”

[1] https://www.childstats.gov/americaschildren/tables/pop1.asp


Advanced technology, together with experience and a measure of sensitivity, enable pedodontists to provide the best possible care for their young patients.

For pediatric dentists, patient care can be a fine balance between treating a child’s oral health and creating a safe, welcoming environment. The recommended age for a child’s first dental visit has dropped from three years to 12 months in recent years, making it more important than ever before for pedodontists to determine a treatment plan tailored to each patient’s needs.

Indeed, pedodontists must approach their patients with a unique level of clinical experience that enables them to manage each child’s behavior while also assessing his or her growth and development. “It is important that we meet each child to determine his or her needs for behavioral management, and put together a treatment plan that best suits that child,” says Kim Hansford, DMD, a pediatric dentist at Middletown, Kentucky-based Kid’s Dentistree, a Mortenson Dental Partners partner. “We see ourselves as primary care providers, much like pediatricians. Our goal is to provide a dental home for each child.”

The battle against tooth decay
Pediatric healthcare can be frustrating, both for parents who wish for immediate results for their children, and clinicians who are always in a position to deliver. “Dental caries is still the most prevalent childhood disease we see, even in our affluent society,” says Hansford. Most people’s diet includes processed foods, with lots of refined carbohydrates, she points out. “Even crackers break down on the teeth into simple sugars, which can cause decay.

“Parents become frustrated,” she continues. They feel they are doing everything they can to protect their child’s teeth, but to no avail, she notes. While good nutrition helps children avoid tooth decay, there often are overlooked culprits that impact oral health. Medications are a prime example, she points out. “A liquid allergy medicine taken every night by a child has sugar in it,” she says. “Gummy vitamins are made with sugar and stick to the teeth.

“Grazing or snacking – and not letting the mouth have time in between snacks or drinks to normalize – can place children at high risk, due to repeated exposure. It is my job to provide parents with the tools they need to avoid these easy traps, and teach them to care for their child’s teeth at home.

Exceptional technology
“Unfortunately, there is no magic bullet for treating children,” says Hansford, noting she makes a point to put herself in these parents’ shoes and be sensitive to their expectations.  That said, pedodontists today have some exceptional technology at their disposal for treating patients, she adds.

For many years, nitrous oxide has proved itself invaluable in many dental settings, but particularly in pediatric practices. “Nitrous oxide sedation continues to be the safest and most predictable way to provide an easier experience for most children,” says Hansford. “We use it for patients of all ages; it can make or break a child’s experience under the right circumstances.” She advises dental professionals against using the term sedation too freely. There are a number of options for pediatric patients, and the pedodontist can determine the best method for each patient. “Some children may do great in a pediatric dental setting without any additional medications,” she points out.

Equipment such as digital imaging/radiographs are another must-have for pedodontists. “Developments in digital imaging greatly reduce children’s exposure to radiation while delivering excellent clinical X-rays,” she explains. “We make a commitment to image gently in our office.” Without radiographs, pedodontists cannot determine an exact number of cavities, she adds. “Hidden interproximal decay can be a big surprise to parents!”

Hands-free dental vacuum suction and isolation systems have “totally changed the way I practice pediatric dentistry,” says Hansford. “In the past 20 years, this technology has allowed pedodontists to provide treatment on one whole side of the mouth safely and comfortably, with less local anesthetic than in the past when we relied more on rubber dam isolation.

“Dental materials have also come far, allowing pedodontists to provide more esthetic options, in more instances than in the past. Glass ionomer restorations in children provide fluoride release, good esthetics and are more tolerant in moist environments, where perfect isolation may not be achieved.

“General public awareness of the importance of early evaluation is key in helping children get established in a dental home and hopefully lowering their risks of oral health issues,” Hansford continues. Children may always have caries, she adds. But, with new treatments like silver diamine fluoride as an adjunct therapy to delay treatment, or decrease need in times where it may not be practical due to the patient’s medical status or very young age, pediatric dental practices should have greater opportunity to take a preventive stance to oral healthcare.

Safe Water, Safe Patients

Growing attention to the hazards of contaminated dental unit water has led more and more dental clinicians to take the necessary steps to protect their patients.

There are no shortcuts to obtaining compliant dental water. Without the right products and protocols, however, dental practices will not be able to meet the acceptable standard for water delivered to patients during non-surgical procedures.

What’s more, even though compliance with water safety standards in the United States has not been required by law, that is changing.

“A dental practice simply will not achieve compliance without effective, EPA-validated products used in accordance with the correct protocols,” says Jerod Mendolia, marketing assistant, Sterisil, Inc. “At Sterisil, our philosophy is embodied in the acronym, PPC: Products + protocols = compliance. We have applied this methodology with great success in various settings, from mid-sized five-chair clinics to Ivy League dental schools.” New technology is important, he adds. But unless clinicians are educated on the appropriate protocols and develop a conscientious attitude, “we are setting them up for failure.”

A serious business
Because dental water is used as an irrigant solution in conjunction with high-speed rotary handpieces, potentially contaminated aerosols and spatter can carry waterborne pathogens through the air, increasing the potential for infections. Unwanted health implications associated with contaminated dental unit coolants range from the exacerbation of existing asthma symptoms due to endotoxin exposure to complex bacterial infections, such as Legionnaires’ disease, according to the Organization for Safety and Asepsis Prevention (OSAP). In recent years, two high-profile cases have linked dental unit water to serious infections, notes Mendolia. The first incident occurred at Dentistry for Children in Jonesboro, Georgia. A second incident occurred at Children’s Dental Group in Anaheim, California. In both cases, Mycobacterium were isolated as the cause of infections in pediatric patients who received a pulpotomy procedure with contaminated dental unit water, he points out.

Although the Centers for Disease Control and Prevention (CDC) has recommended that water delivered to patients during non-surgical dental procedures meet Environmental Protection Agency (EPA) standards for drinking water (<500CFU), some question whether this is sufficient in a clinical environment. “In 1995, the American Dental Association challenged dental unit manufacturers to develop the equipment necessary to deliver effluent handpiece water with <200CFU,” says Mendolia. That standard has since been raised to the <500CFU/ml drinking water standard. “Currently, there are many products on the market validated to deliver levels of disinfection well below 200CFU. I don’t think it is unreasonable to expect dental professionals to meet this higher standard considering the number of products and protocols available with advertised effectiveness claims at =10CFU.”

The right solution
For many dental professionals, the importance of delivering safe water during patient treatment is clear. Navigating their options, however, can sometimes be tricky. There are several methods available for treating water, notes Mendolia, and clinicians must stay informed in order to best serve their patients. There are advantages and disadvantages to each.

There are many filter options capable of removing some level of microbial contaminants, but without the presence of a residual disinfectant, filtration alone is insufficient to consistently maintain and prevent microbial growth downstream from the filter, according to Mendolia. For best results, filtration should be paired with an ion exchange-based product for shock and residual disinfection. “Clinicians should steer clear of filtration methods that require water storage in a tank,” he says. “Unless the practice has something like a UV light after the tank, water storage can lead to incubation of existing bacteria in the tank to >500CFU. Most waterline treatment products will have some sort of disclaimer stating for use with potable water. So, contaminated storage tank water would be unsuitable for use with many chemical treatments based on this alone.

“Since the introduction of the independent bottle reservoir, chemical treatments have become a viable and convenient method for reducing effluent dental water microbes,” he continues. “When dental clinicians follow the instructions for use (IFUs), they can expect good results. However, when using municipal tap water, they must do so with caution. Municipal contaminants like chlorine and copper can interfere with the efficacy of some chemical treatments. The best regimens will always feature both shock and maintenance treatments that are compatible with one another. Whenever possible, clinicians should use distilled water in their bottle reservoirs for the best results.”

In theory, in-office distillers are a viable solution, notes Mendolia. However, they are often associated with water test failures. “The machinery of distilling demands regular cleaning and disinfection to ensure the water purity and microbial viability,” he explains. “Once water has been heated into a gas and condensed back into liquid, it no doubt will be above room temperature. This increases the likelihood you are incubating bacteria as it’s stored. Without a residual disinfectant or some sort of shock treatment prior to introduction to the chair, it’s unlikely the 500CFU drinking water standard will be met, and the practice risks violating the manufacturer’s labeling.

“Don’t get me wrong,” he says, “distilled water is much better than municipal tap water in just about every way. But physically distilling water is not the most effective method. Deionized water is essentially the same thing, and the process by which it is created does not increase the bacterial content. It is for this reason, all Sterisil systems employ this technology as the final purification step. Now you have a very pure base water to which a residual disinfectant can be introduced, with minimal interference from microbes or chemical contaminates.”

Pre-sterilized water is clean enough for any dental procedure, says Mendolia. “However, once it is introduced into a dental chair, it is unlikely to meet the <500CFU standard,” he points out. “Unless the dentist intends to irrigate with single-use pipettes or purchase a very expensive sterile water generator, this will not be a viable option.” And, the cost of purchasing sterile water makes this an unaffordable option for many dental practices, he adds.

Mendolia recommends that dental practices use their bottle reservoirs for their intended purpose. “The independent bottle reservoir was designed to isolate the dental unit from municipal tap water and provide a conduit through which antimicrobial treatments could be introduced,” he says. “Tap water is not suitable for the dental setting for many reasons, but particularly due to the infinite variability in water chemistry. If clinicians are using residual disinfectants to control microbes in a dental chair, these details matter. Distilled water will always save the dental practice a lot of headaches in the end, trust me.

“Dental practices should always consult with their dental unit manufacturers and their waterline treatment providers about water testing,” Mendolia continues. “Minimum standards for water testing should be followed whenever possible, even though they are recommendations rather than requirements. If the dental practice’s protocols are in line with these standards, it is off to great start.”

A passing water test verifies the absence of bacteria and validates the dental practice’s disinfection efforts, he points out. “According to OSAP, dental practices should be testing within 30 days of introducing a new product or new protocols, and then every 30 days thereafter,” he says. “The initial test validates the product and protocol’s efficacy, and subsequent tests validate the protocol execution throughout the product’s lifespan (assuming the product did not expire prematurely). If both tests pass, the practice can begin testing every six months. If there is a test failure, the clinician should shock immediately and retest per the waterline treatment manufacturer’s IFU. I personally recommend testing through a third-party lab that specializes in dental water microbes, like Agenics. They offer HPC counts and many other water chemistry metrics that help diagnose problems should they arise.”

Legal precedent
Compliance with water safety standards in the United States has not been required by law. But, that’s quickly changing. “Water compliance may not have been the law in 2016, when 73 pediatric patients contracted Mycobacterium infections from contaminated dental water at Children’s Dental Group in Orange County, California,” says Mendolia. However, in 2019, it will become a law in California, he points out, noting that eventually much of the country will likely follow suit.

“What I try to impress on people is that this issue isn’t going away,” he says. “Now that there are legal precedents associated with patient vs. clinicians, and manufacturers vs. clinicians, with regard to this topic, it will be difficult for dental clinicians to prove in court that they are not responsible for any infections related to dental water in their practice, even if they weren’t legally required to take action.”

That said, for some dental professionals, cost will always be an obstacle. “We must focus on the relative cost per liter differences among the various products, relative to their overall need for water,” says Mendolia. “If a large practice intends to confront this problem head on, it would serve them well to go with the option that has the lowest cost per liter. That’s not always the lowest initial cost, but the purchase will pay for itself with time.

Sometimes dental practices just want to get their toes wet, so to speak. “Low cost options like Citrisil tablets are a good place to start, with the same great treatment you get from the higher end products,” he says. But, they’re not as convenient as a long-term solution. “The low-cost options in this category always leave something to be desired when it comes to efficiency and cost per liter.”

As more practitioners are on board with the need for waterline treatment, they are looking for solutions that provide enhanced efficiency and require less staff involvement, notes Mendolia. “We are here to help,” he adds.

Instructions for Use: They’re Meant to be Read!

By Laura Thill

Assumption of knowledge is a dangerous thing.

If you don’t read the instructions that accompany your new iPhone, chances are you – or your teenage son or daughter – will figure it out. When it comes to dental equipment, however, assuming you know how to use a new product can lead to detrimental – even life threatening – consequences for your staff, your patients and your practice.

Particularly in the case of waterline treatment, noncompliance can lead to serious infection outbreaks, according to Leann Keefer, RDH, MSM, director, clinical services and education, Crosstex, a Cantel Medical Company. Nevertheless, dental professionals commonly refer to manufacturer instructions for use (IFUs) only on a need-to-know basis, they point out.

“In order to get the most effective and efficient use of any product, compliance with IFUs is critical,” says Keefer. “With regard to documentation and training, everyone in the office needs to be on the same page with the technology, not just the person who does the ordering. Procedures and policies of water management are an integral part of the office’s infection control manual, and the IFUs are critical to use in protocol development.” Unfortunately, many dental offices set aside the IFUs, referring to them when they have a specific question. In fact, after adopting new technology, some dental teams assume they can transfer knowledge from previous clinical experiences, she adds. But, they do so “without necessarily being aware of the differences and nuances in science, procedure or technique. Assumption of knowledge is a dangerous thing.”

Vigilance and caution
When adopting new waterline treatment technology, dental professionals are tasked with being extra cautious. For instance, it’s not unheard of for a manufacturer of a validated water treatment system to omit providing a monitoring protocol in their IFU, notes Keefer. In this case, the dental practice should reach out to the manufacturer for a best-practice recommendation, she points out. In addition, the dental team must be aware of discrepancies in directions for use from one manufacturer to the next. “Dental offices need to be aware of the differences in instructions for use from both dental chair manufacturers and waterline treatment manufacturers and reach out to these manufacturers when IFUs provide conflicting information,” she says. “For example, a dental chair manufacturer may recommend the use of a hypochlorite solution as an intermediate shock for bacterial reduction in the dental waterlines. However, use of this chlorine-based product may conflict with best practices for other automated dental waterline products that may be in use.

“OSAP issued a white paper in September 2018 specific to waterlines that speaks to the importance of contacting dental chair manufacturers and waterline treatment manufacturers for specific guidance and instructions on methods to improve and maintain the quality of dental procedure water,” says Keefer.

“Per FDA [guidelines], dental practitioners should consult with the dental unit manufacturer’s instructions for the recommended maintenance schedule of the dental unit waterlines,” she continues. “Dental practitioners should adopt appropriate infection control procedures for dental unit water lines (DUWLs) based on the manufacturer’s instruction for use. This should include infection control measures such as (but not limited to) monitoring water quality. The water management plan should include specific testing locations and frequencies, and actions to take (e.g., remediation, retesting at shorter intervals) based on test results. [Practitioners] should follow the manufacturer’s instructions for cleaning and disinfecting the dental unit at recommended intervals. They should contact the manufacturer of the dental unit to obtain the most up-to-date instructions or direction for reprocessing of the dental unit.”

Risks and realities
It can’t be said enough: When dental practitioners ignore DUWL treatment protocols, it places the staff, patients and, ultimately, the practice at risk. “Whether using a DUWL treatment like Crosstex DentaPure™ Cartridges or Liquid Ultra™ Solution, or a different DUWL treatment method, it is imperative that dental offices follow the instructions for use to ensure the chosen waterline treatment meets the product-approved claims for CFU/mL reduction to meet EPA standards of <500 CFU/mL,” says Keefer. “We frequently overlook the risk of the staff’s constant exposure to contaminated bioaerosol. Clinicians work between 14-16 inches from a patient’s mouth, and aerosol can carry over three feet. Studies have shown that occupational asthma is triggered due to endotoxins contained in aerosols.” (https://cdn.ymaws.com/www.osap.org/resource/resmgr/Docs/2_SADJFebruary_2009_REVIEWOc.pdf.)

In a few widely publicized cases, it was the patients who suffered the most. In In 2015, contaminated dental treatment water at a Georgia Pediatric dental clinic led to at least 23 children becoming infected after pulpotomies. Their ages ranged from 3 to 11, according to the Centers for Disease Control and Prevention. They had all been infected with Mycobacterium abscessus, a rapidly-growing bacterium known to contaminate waterlines in dental offices. (https://www.ajc.com/news/local/georgia-didn-sanction-dental-chain-accused-infecting-children/5501Ebv2D27LyuerW1ywdI/.)

In 2016, an Anaheim, California, pediatric dental clinic’s water system became infected with Mycobacterium, causing over 70 children to be hospitalized following pulpotomies.

In early 2011, an 82-year-old woman in Italy contracted Legionnaires’ disease, which was traced to equipment in a dental surgery she attended shortly before being hospitalized. Despite treatment and antibiotics administered at the hospital, she developed rapid and irreversible septic shock and died two days after being admitted. (https://www.eurekalert.org/pub_releases/2012-02/l-dow021412.php)

“At Crosstex, we provide a selection of literature that includes procedural guidance for following our DWUL IFUs after purchase, while addressing the evidence-based science behind why treatment is so important,” says Ilene Russo, Crosstex waterline product manager. “We also provide live CE programs, as well as on-demand webinars covering the science, treatment choices and implementation (www.crosstexlearning.com).” In addition, Crosstex sales representatives refer dental offices to the CDC Summary of Infection Prevention Practices in Dental Settings: Basic expectations for self-care (https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf).

“Following IFUs is not a standalone issue for waterlines,” says Keefer. “It’s a standalone mindset for how we approach overall infection prevention and control in the dental setting.  This becomes both an ethical and a clinical choice when patient safety is in question. It should not take tragic headlines to ensure compliance. However, if reminding clinicians of the risks and realities associated with noncompliance shifts the paradigm, Crosstex will continue to keep these preventable incidents top-of-mind.”

Engineering and Work Practice Controls

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.

By Dr. Katherine Schrubbe, RDH, BS, MEd, PhD.

Key elements of Bloodborne Pathogens Standard are often overlooked.

For all dental practice settings, OSHA’s Bloodborne Pathogens (BBP) Standard (29 CFR 1910.1030) provides the fundamentals for a safe workplace, prescribing safeguards to protect workers against health hazards caused by bloodborne pathogens. The Standard places requirements on employers whose workers can be reasonably anticipated to contact blood or other potentially infectious materials (OPIM), such as unfixed human tissues and certain body fluids.1

All of the elements of the BBP Standard are important and work together to provide a comprehensive plan for dental healthcare worker safety. Most dental team members are familiar with several points, such as requirements for an exposure control plan and personal protective equipment (PPE), the opportunity to obtain a hepatitis B vaccination and the implementation of universal precautions.2,3

Some elements of the BBP Standard, however, are often overlooked. Based on personal anecdotal and field observation, the concepts of engineering controls and work practice controls are not always assigned the importance – or the attention – they deserve. Dental healthcare workers not only are exposed to human bloodborne pathogens, but also to toxic chemicals in the workplace. But OSHA makes it clear: Engineering controls, as well as work practice controls, are vital to overall safety.2,4

OSHA’s longstanding policy is that engineering and work practice controls must be the primary means used to reduce employee exposure. Wherever possible, elimination or substitution of a hazard is most desirable, followed by engineering controls.  Administrative or work practice controls may be appropriate in some cases where engineering controls cannot be implemented, or when different procedures are needed after the implementation of the new engineering controls. Personal protection equipment is the least desirable, but may still be effective.5 The pyramid chart below illustrates least effective to most effective methods for reducing occupational exposure.

With regard to all healthcare, including dentistry, engineering controls refer to controls (e.g., sharps disposal containers, self-sheathing needles and safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace, according to OSHA. Work practice controls refer to controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).3 In other words, it’s product versus process. Engineering controls are products or devices that have been made or manufactured to help reduce the risk of injury; work practice controls are strategies or processes that dental team members should implement to reduce the risk of injury and practice as safely as possible.

Engineering controls
According to C.H. Miller, engineering controls isolate or remove the hazard from the workplace. In dentistry, this means the use of devices that eliminate or reduce chances of exposure to blood and saliva. These include sharps containers, needle safety devices, red-bags, rubber dams, high-volume evacuation, instrument cassettes and mechanical instrument cleaners. The controls used must be examined and maintained or replaced on a scheduled basis.4,6

Although the requirement to utilize engineering controls has been in effect since the 1992 BBP standard, because occupational exposure to bloodborne pathogens from accidental sharps injuries in healthcare and other occupational settings continued to be a serious problem, Congress required modification of the BBP standard. As such, the Needlestick Safety and Prevention Act was signed into law on November 6, 2000, to ensure that OSHA’s BBP standard set forth in greater detail OSHA’s requirement for employers to identify, evaluate and implement safer medical devices, such as needleless systems and sharps with engineered sharps protections.1,7

The Needlestick Safety and Prevention Act took effect on April 18, 2001, and mandated additional requirements for maintaining a sharps injury log and for involving non-managerial healthcare workers in identifying, evaluating and choosing effective engineering and work practice controls.1,7 In dental practice settings, this is a sound strategy to promote safety and team involvement. As new sharps safety devices become available in the dental marketplace, team members should bring them into their practice and test them out. They should trial the new device for a period of time, ask for feedback from one another, document the safety trial and determine if the device is something that could be implemented to promote a safer workplace.

Work Practice Controls
Miller points out that work practices can be used to reduce the likelihood of exposure by altering the manner in which a task is performed; all procedures must be performed in such a manner as to minimize the spraying and spattering of oral fluids.4,6 Also, work practice controls assist in carrying out tasks in a safe manner to reduce the possibility of a sharps injury. Miller provides the following list of work practice controls, although it is not all-inclusive:

  • Flush mucous membranes as soon as feasible if contaminated with infectious materials.
  • Recap dental needles by a mechanical means, such as forceps or another cap-holding device, or by using a one-handed “scoop” technique.
  • Prohibit the cutting, bending or breaking of contaminated needles prior to disposal.
  • Discard contaminated needles and other disposable sharps in proper sharps containers.
  • Prohibit the overfilling of sharps containers.
  • Place contaminated reusable sharp instruments in containers that are puncture-resistant, leak-proof, colored red or labeled with the biohazard symbol, until properly processed.
  • Eliminate hand-to-hand passing of contaminated sharp instruments.
  • Prohibit eating, drinking, smoking, applying cosmetics and handling contact lenses in areas where there is occupational exposure, such as the dental operatory or instrument processing areas.
  • Eliminate the storage of food and drink in refrigerators and cabinets, on shelves or on countertops where blood or saliva may be present.
  • Store, transport or ship blood and saliva, as well as items contaminated with blood or saliva (extracted teeth, tissue, impressions that have not been decontaminated), in containers that are closed, prevent leakage, colored red or labeled with a biohazard symbol.3,4

OSHA’s mission is to assure safe and healthful working conditions for all working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.8 When OSHA standards are followed, job-related injuries, illnesses and fatalities decrease dramatically. At times, dental team members may complain that doing so is cumbersome, overwhelming and challenging, but OSHA has made a significant difference in a positive way. Worker deaths in America are down on average, from about 38 worker deaths a day in 1970 to 14 a day in 2017; and worker injuries and illnesses are down – from 10.9 incidents per 100 workers in 1972 to 2.8 per 100 in 2017.9

It is important for all dental healthcare workers to comply with all of the elements of the OSHA standards, and it is imperative that practice owners and management teams are committed to implementing all aspects of the OSHA standards. This is the only way to ensure that dental team members can carry out their duties safely in the practice and that the dental facility is a safe place to work and care for patients.


  1. U.S. Department of Labor. Occupational Safety and Health Administration. Quick Reference Guide to the Bloodborne Pathogens Standard. Available at https://www.osha.gov/SLTC/bloodbornepathogens/bloodborne_quickref.html. Accessed May 19, 2019.
  2. U.S. Department of Labor. Occupational Safety and Health Administration. OSHA Bloodborne Pathogens fact sheet. Available at https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf. Accessed May 19, 2019.
  3. U.S. Department of Labor. Occupational Safety and Health Administration. OSHA Bloodborne Pathogens Standard. Available at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Accessed May 19, 2019.
  4. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 5th ed. St. Louis: Mosby Elsevier; 2013; 247.
  5. U.S. Department of Labor. Occupational Safety and Health Administration. Chemical Hazards and Toxic Substances. Available at https://www.osha.gov/SLTC/hazardoustoxicsubstances/control.html.  Accessed May 20, 2019.
  6. Miller CH. RDH. Isolate or remove bloodborne pathogen hazards. Available at https://www.rdhmag.com/infection-control/sterilization/article/16405576/isolate-or-remove-bloodborne-pathogen-hazards. Accessed May 20, 2019.
  7. U.S. Department of Labor. Occupational Safety and Health Administration. Frequently asked questions. Available at https://www.osha.gov/needlesticks/needlefaq.html. Accessed May 20, 2019.
  8. U.S. Department of Labor. Occupational Safety and Health Administration. About OSHA. Available at https://www.osha.gov/about.html. Accessed May 21, 2019.
  9. U.S. Department of Labor. Occupational Safety and Health Administration. Commonly used statistics. Available at https://www.osha.gov/oshstats/commonstats.html. Accessed May 21, 2019.

Editor’s note: 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.

The Dash to the 2019 Finish Line

Kristine Berry

By Kristine Berry, RDH, MSEC

4 steps to implementable success

Where are you regarding reaching your year-end goals? I invite you to pause and take stock of your successes from the last two quarters. This article focuses on the support you need in planning for the months ahead.

Looking backwards to the first two quarters of the year:

  • What successes did your team have?
  • What major accomplishments did your team have?
  • What were the key lessons learned?
  • What habits or practices helped you?
  • What role did you play in planning?
  • What systems and practices supported your focus and planning?
  • What got in the way?
  • What do you NOT want to carry forward into the coming seasons?

What’s this you say? You have yet to lay out your goals for this year? If a poll was taken of most people, it would reveal that the life they lead is a result of happenstance and not planning. The same goes for business. It’s my belief – and the belief of many business and professional coaches – that the business solvency of the companies we lead is more often a result of lack of planning, rather than over-planning or having the wrong plan.

Perhaps you dread making or tracking key metrics, or you never planned what your income will be, or you never decided how many patients you want to have. Perhaps you are at a point where you wish your team would just listen to you, so that you only have to say things once and it’s done! Or you are feeling like you’ve been on a treadmill the first half of the year and are ready to bust through the brick wall of running your business so that you can grow. Or perhaps you feel the people around you just don’t care. Or maybe you don’t care anymore!

Effectiveness in business requires a focus on both results and relationships. One without the other is not enough. This article offers tools and a roadmap to make your dash to the 2019 finish line more focused, effective and without carnage.

In order to establish and achieve your goals, you must follow these 4 steps:

  • Discover your direction.
  • Identify your gaps.
  • Pack your practice with meaningful purpose.
  • Create sustainable results.

Discover your direction
This is where the rubber meets the road. “Where is the road?” you ask. My answer: “Where do you want it to be?” Whether or not you set goals for your practice in January, yesterday or you commit to doing it after reading this article, Step 1 is to create space.

You must clarify and specify the future you want for your business, where you want to go or what you want to have. Some people do not even know what’s possible for their businesses; you may need someone to help you get a clear vision of how you want your office to be. At dental practice management firm Next Level Practice, our community sets goals considering the following divisions: leadership, management, administration, marketing, case acceptance, finance and quality assurance.

With these divisions in mind, you can begin to create specific destinations for your business. For example, one of my clients took the quality assurance division and set monthly calibrations with the clinical teams to ensure everyone was working to their highest standard of care. In the leadership department, a doctor who owned multiple locations shared that she kept encountering the same obstacle: Her team did not want to implement anything 100 percent. During one of our coaching sessions, she was willing to explore why this kept happening. She discovered that her team did not trust her to keep and honor her word about the changes, or to hold anyone accountable; she was known for not following through. Her team was playing the waiting game – always waiting for her to go on to the next idea. So, the doctor’s end game was to implement a system to interrupt that pattern. She realized it started with her leadership and that she needed to develop this first.

Identify your gaps
Once you have identified where you want to go, the next step is to identify the gaps between what you want for your business and where you are now. For example, if you want to work three days a week and take four weeks off a year, and you are currently working five days a week with two weeks of vacation, those gaps begin the process of awareness.

People do not particularly like gaps. Once identified, we instinctively want to close them. Some of this is the result of cognitive dissonance. People in general want to be consistent in their attitudes, beliefs, values and actions/behaviors. They want to act in accordance with their attitudes, beliefs, values and goals. When their actions contradict them, they experience dissonance.

This dissonance is uncomfortable, and people naturally want to reduce it. The dissonance gap creates a vacuum in which the solution starts to unfold. This strategy is one competency that I implement with my client teams. We discover what the owner/doctor/CEO/team leader, etc., wants to create with regard to time and dollars, and then we walk them through a process called reverse engineering. Reverse engineering is a proven implementation strategy or process for goals, systems and engaging teams.

Leaders with effective communication structures, team leaders, morning huddles and other key practice success methodologies will not find themselves in the position of being a hall monitor and policing or micromanaging people. Rather, they can do what they love to do: Practice dentistry and monitor outcomes.

Pack your practice with meaningful purpose
Perhaps some readers of this article are members of the drill-and-fill PPO club. Your culture and standards crank out transactional dentistry and experience the daily challenge of outrunning the expenses of your practices. That’s not good, bad, right or wrong; it just is. On the other side of the spectrum, there are practices that deliver complete health dentistry that have a high value proposition and embrace the triple win. The triple win is a culture that embodies agreements and systems to ensure the patient, team and practice all win.

These triple-win practices are playing a different game; they understand whole-body health and the mouth’s role in preventing chronic inflammatory and brain disorders. Doctors and teams go to work every day with an abundance mindset. They believe there are more than enough patients who value health, and they love to serve them.

You may find you are somewhere in the middle. It’s important to identify where you are on the purpose spectrum. No position is good or bad. And, if you want to finish every year strong, you cannot get there alone. Your team wants meaningful careers and workplaces. In order for you to achieve your goals, your team must align their values and passions with your vision, philosophy and/or guiding principles.

Create sustainable results
To create happy teams that implement sustainable results, you as a leader must locate your authentic leadership style. If you are not breaking even and/or have not consistently hit your financial goals, I invite you to take a deep dive into your leadership style. At Next Level Practice, we have worked with 6,000 practices and researched the personas of thousands of doctors.

Communicating solely from your dominant persona often results in your team not understanding you; their personas cannot yet hear yours. The following are four personalities we identify within doctors and teams: methodical, humorist, competitive and spontaneous. Seventy-five percent of dentists we researched fall into the category of introvert methodical, meaning they know the steps, but they might find it challenging to articulate their ideas. As you read the descriptors below, which one resonates with you?

  • Methodical. Paralysis analysis, likes step-by-steps, might not consider relationships while focusing on the finish line.
  • Competitive. Needs it done yesterday; get to the bottom line; you are not moving fast enough.
  • People pleaser, listens to how any strategy will influence relationships, acquiesces decisions.
  • Spontaneous. Likes to have fun and, if it is too much work, they won’t do it!

Identify which category best describes you. In order to achieve the goals you set and the freedom you deserve, you may need to disrupt your current modus operandi. You can do so by becoming aware of the way you see yourself and the manner you customarily use to relate to everyone around you. Dr. Marshall Goldsmith, preeminent executive coach and author of What Got You Here Won’t Get You There, believes that leaders need “guidelines to help eliminate dysfunctions and move to where you want to go.” He adds, “Often our own success delusion stands in our way and causes us to resist change.” In order to reach your goals, you may need to move out of your comfort zone.

The doctor’s persona overlays the practice’s communication system. Think about what can happen when a competitive doctor/owner wants to talk to his 80 percent humanistic team about numbers. The team is most likely going to view any metrics-and-measurements conversation as the doctor being obsessed with production. They may suspect he only cares about the money. Unless the owner knows how to set the context for his or her humanist team, and understands that KPIs are a way of tracking how they are living their standard of care or helping their community become healthier, the team will disengage. It only takes one person to derail the team. Leaders must be aware of whether or not their automatic leadership (and hence communication style) is alienating team members. The truth is, a team’s perception is their reality!

Another way to determine whether some team members aren’t engaged in your mission, and to better understand your style, is to look at team meeting agendas for 2009 and 2019. If the same items are on both agendas, you need to be open to leadership development. Think about hiring a coach to support your expansion as a leader. Once clear leadership and effective communication style are in place, you are in a better position to lead a happy team that get consistent results.

Now turn to the remainder of the year’s planning and set your group practice up to finish strong:

  • What are your goals for quarters three and four?
  • Narrowing it down, what are your top three to five priorities?
  • What time is earmarked for planning?
  • What time is earmarked for team training and development?
  • What new habits and practices do you want to put in place?
  • What relationships do you want to focus on?
  • What is the one thing you can do on a daily basis to move your goals forward?
  • What needs clearing up?
  • Where can you get accountability, support and mentorship?

Successful practices require dedication and strategy. Consider the four strategic steps to implementing effective results and relationships in your practice. Think about which of these areas is the weakest in your practice, and start there. Coaching can be a powerful ally in moving forward to a healthy, thriving practice. Be in touch if I can assist you in making a dash to the 2019 finish line!

Kristine Berry is an international speaker and executive business coach, specializing in enhancing group practices. If you are looking for a speaker or coach, she invites you to email her at kristine@nextlevelpractice.com, or visit www.nextlevelpractice.com.


Improvements in implant technology are making them increasingly attractive to doctors and patients.

Twenty years ago, patients who were missing one or more teeth did not have many options when it came to replacing them; often, they had to go to a specialist for treatment. That is not the case today.

Dental implants have become increasingly popular among patients, not only because they offer a number of advantages over traditional bridges, but because they have become much more routine to place. In fact, in most parts of the world, typically it is the general dentist who now places the implant, according to Madhu Mahadevan, DDS, clinical director for Tru Family Dental.

Indeed, improvements in implant technology are making them increasingly attractive to doctors and patients alike, notes Mahadevan. “Implant manufacturers have improved surface treatment, exterior design and connection type, all which have led to better implant integration and reduced bone loss,” he says. Now, too, dentists have access to a great variety of implant sizes, enabling them to customize the implant to fit the amount of bone available in the patient’s mouth.

“As more adjunct services become available – including cone beam computed tomography (CBCT) X-rays, surgical stents for guided surgeries, bone grafting, sinus augmentation and platelet-rich fibrin (PRF) membrane placement – implant surgeries are much more successful,” says Mahadevan. “Advances in CBCT imaging have allowed implant surgeons to view bone levels and density in a 3D radiographic rendering. Vital structures, such as nerves and vessels, can be seen on the CBCT, which may not be clear on a traditional panoramic radiograph. And advances in bone grafting, sinus augmentation and PRF membrane placement have led to more customizable options for implant placement, better healing and faster recovery times for patients.”

The pros and the cons
All that said, placing an implant is still considered a surgical procedure and, as such, dentists should discuss their patients’ options with them. On the plus side, placing an implant does not require the adjacent teeth to be altered in any way. By comparison, bridgework necessitates the two teeth adjacent to the missing space be irreversibly altered, which can sometimes lead to further issues, notes Mahadevan. In fact, implants can be placed even when the adjacent teeth are unhealthy, whereas a bridge cannot. Also, with an implant, patients can floss more easily than with a bridge. Implants help maintain healthy bone levels, are more functionable and typically look nicer than bridges.

On the other hand, implants take more time to place than a bridge, according to Mahadevan. “Implants can take as long as a year to complete, whereas a bridge can sometimes be completed in two weeks,” he points out. Common risks include fracture or overloading of the implant, infection or peri-implantitis, damage to the surrounding nerves, blood vessels or teeth, poor positioning of the dental implant, poor bone quality and more. And, unlike bridges, implants aren’t always fully covered by insurance plans. Nor is every patient a candidate, he adds. “Heavy smokers, unstable diabetics and patients who take bisphosphonates typically are not good candidates for implant therapy.

“Much of the risk associated with placing dental implants can be avoided with proper patient selection or by taking a detailed medical history, reviewing a CBCT of the patient’s jaw before planning the surgery, understanding proper occlusion when restoring the implant and thoroughly educating the patient about proper oral hygiene,” he continues.

Implantologists who work in a large group setting are at an advantage, he points out. “The implantologist at a large group practice or dental service organization typically has a restoring dentist on hand at the time of surgery,” he explains. “The restoring dentist can provide feedback regarding the placement of the implant, which most certainly will lead to a better end result for the patient.”

Endosteal vs. subperiosteal

Dentists can select from two types of implants: endosteal, which are placed in the patient’s bone, and subperiosteal, which are placed between the patient’s gum tissue and bone. “Endosteal implants are most commonly used,” says Madhu Mahadevan, DDS, clinical director for Tru Family Dental. “Given the recent advances in bone augmentation, implant design and zygomatic implant techniques, subperiosteal implants tend not to be a dentist’s first choice.

“Subperiosteal implants should be placed when the patient’s bone in the maxilla or mandible is atrophied and limited,” he continues. “Using a subperiosteal implant for these patients helps them avoid bone grafting.” And, since the implant sits on top of the bone rather than within it, the healing process tends to be faster, he notes.

Whenever possible, however, Mahadevan recommends the use of an endosteal implant. “The advantage of the endosteal implant is that it is much more stable and has a very low failure rate compared to subperiosteal implants,” he says.


Your DSO Accelerator

Heidi graduated from the University of Minnesota with a Bachelor of Science in Dental Hygiene. In 2002, Heidi started working for a large dental group in Minneapolis as a clinical hygienist and a hygiene mentor before she was promoted to the National Director of Dental Hygiene. In 2011, Heidi started Enhanced Hygiene. In January 2019, Heidi sold Enhanced Hygiene to Ascension Dental. Ascension Dental administers dental membership plans for dental groups and practice across the country. She is currently serving as their Chief Operating Officer.

By Heidi Arndt

How to maximize the tremendous value your hygiene team brings to the group practice

Did you realize that 83% of the patient experience is with the hygienist? Or that 74% of the doctor’s revenue is treatment planned in the hygiene chair?

Did you know that the average annual revenue of a full-time hygienist is $250,000/year? Although, the hygiene team is responsible for 30% of the DSO’s revenue, they provide tremendous value beyond the 30% revenue you have been monitoring for years.

With training, development and support, your dental hygiene team provides your biggest growth opportunity, and can accelerate same-store growth immediately in your practices.

There are many dental practices and dental groups that do not take the time to invest in the training and development of their hygiene teams as they still see hygiene as a loss leader, or have had limited success in the past with hygiene-focused initiatives.

After years of training, coaching and mentoring dental hygiene teams, I can attest that this can be a hard needle to move. However, with focused and dedicated attention, you can experience huge — and sustainable — gains.

Where are groups achieving these gains? Here are two big opportunities that exist in almost every dental group I have analyzed in the past 5 years.

Focus on same-day treatment
One of the most frequent questions I hear in the industry is: “How do you deal with schedule fall out?”  With the average schedule utilization running between 70% to 75%, each practice has an opportunity to create same-day treatment opportunities for their patients. By creating same-day treatment opportunities you’re turning down time into productive time, and your patients appreciate the convenience.

Same-day treatment has brought amazing results to several DSOs. In hygiene only, I’ve seen a group increase their same-day hygiene revenue by 1331%. Yes, you read that correctly. This same-day treatment fueled a 72% increase in their product per visit, and a 92% increase in hygiene revenue.

In order for same-day treatment to work in your group, the team must agree to be flexible, strong communicators and team focused throughout the day. They must also embrace the phrase, “we can start today.”

The hygienist as true treatment advocates
When you realize that 74% of the doctor’s treatment revenue is developed in the hygiene chair, you’ll see why it’s imperative to have your hygiene team focused on comprehensive treatment planning skills. Yes, the dental hygienist cannot diagnose or treatment plan but they can move the patient toward ideal treatment when they understand and support their doctor’s treatment philosophy. Remember, your hygienist spends more time with the patient than any other person in your practice. The hygienist has an incredible influence on the patient.

The doctor exam in the hygiene room usually takes 5 to 8 minutes. If the hygienist is not teeing up treatment for the doctor, it will be a very difficult for the doctor to adequately diagnose, provide a treatment plan and “sell” the patient on the treatment. The doctor and hygienist must work as a team to support the patient, and to optimize the practice.

Don’t allow your hygiene team to work in a silo. The partnership between the hygiene and doctor team is crucial to the success of your group, and supports quality patient care.

It is time to expand your groups horizons by looking beyond the 30% your hygiene team brings to your group revenue. Their value can be recognized in every level of your group; but only when you take the time to invest in them.