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Midlevel Providers-Changing the Face of Dentistry?

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The topic of mid-level providers in dentistry is one that has consistently gained popularity over the course of the past 15-20 years.  According to the Pew Center on the States, over 40 million Americans live in dental shortage areas (Wright, et al., 2009). With this shortage of dental providers, the need to fill the gap in access to care is pressuring states to look at changes to the way dentistry is currently practiced.  

  

New Zealand began utilizing the role of “dental therapist” in the 1920s, and the idea was tried in the United States as early as 1949 in Massachusetts (Bader, et al., 2013).  Recently, in 2009, Minnesota became the first state to license dental therapists, although Alaska had been using the dental health aide therapist model since 2008 for limited provision of care in tribal areas.  

 

Two states maintain schools of dental therapy, Alaska and Minnesota (Kavita, et al. 2008).  Dental therapists are individuals who are trained to provide basic dental services, specifically preventative services but also operative services, with the intent to serve rural, indigenous, and otherwise underserved populations.  Dental therapists usually work under indirect or general supervision of a licensed dentist and can perform different tasks based on their level of supervision.    

  

Another emerging issue in dentistry is the question of expanding functions for existing roles, such as dental hygienists and dental assistants.  Many states already allow for hygienists to be trained in the administration of anesthesia, and some states allow for indirect or general supervision of hygienists.  Specifically, Colorado has legislation which allows dental hygienists to set up and run their own, independent practices (Astroth, Cross-Poline, 1998).    

  

This issue has recently become a topic in Georgia, a state which has traditionally resisted attempts to expand hygienist functions, where legislation is pending that will increase the independence of hygienists to work under general supervision in areas up to 100 miles away from the authorizing dentist’s office (Domino, 2016).  The goal of this legislation is to increase access to oral healthcare in settings such as nursing homes, schools, hospitals, and nonprofit clinics and it has recently gained approval from the FTC.   

  

Midlevel providers in dentistry are here, and they are here to stay. From the creation of new roles and expanding functions of traditional roles, dentists should expect to work with midlevel providers in the future.  Future research should be focused on efficacy and proper utilization of midlevel providers, with focus on patient safety and access to care.    

  

Instead of fighting a change which is already taking place, dentists should embrace this opportunity to shape the future of midlevel providers in dentistry—if you aren’t at the table, you’re on the menu.   

  

References  

   

Astroth, DB, Cross-Poline, GN (1998). Pilot study of six Colorado dental hygiene independent practices. Journal of Dental Hygiene 1998: 72: 13-22.  


 
 

Bader JD, Lee JY, Shugars DA (2013, October 14).  Clinical technical performance of dental therapists in Alaska. JADA 2011;142(3):322-329. http://jada.ada.org/content/142/3/322.  


 
 

Domino, D. (2016, February 19). Georgia dental hygienist bill advances, with FTC support.  Retrieved from: http://www.drbicuspid.com/index.aspx?sec=sup&sub=hyg&pag=dis&item  

Id=319260. 

  

Kavita R. Mathu-Muju, DMD, MPH. (2011, May 08). Chronicling dental therapist movement in the United States. Journal of Public Health Dentistry. ISSN 0022-4006.  

  

Wright T, et al. (2013, October 7). A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. JADA 2013;144(1):75-91. http://jada.ada.org/ content/144/1/75.  

Beating the NBDE with This New Mobile App

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          There is one acronym that every dental student learns to associate with a sense of dread: NBDE. This past December, I too experienced the same apprehension that many others have before me when it came time to take Part 1 of the National Dental Board Examination. However, during the course of my exam preparation, I came across an invaluable study resource that not only improved my confidence going into the exam, but actually encouraged me to learn the material in a way that was conducive to my overall learning style and interests. This hidden study gem is the Dental Boards Mastery App, which is an application developed by the UICD (and others) for dental students taking the NBDE. The app is available for purchase on the iTunes App Store, and can even be accessed from an Internet browser. 

The aspect that I liked best about this application is its organization and user-friendly interface. The Dental Boards Mastery App has hundreds of practice questions that are divided up by category (dental anatomy and occlusion, anatomy and histology, pathology and microbiology, physiology and biochemistry, growth and development, and ethics). In addition, each category is divided into its own subcategories so you can customize your study questions based on where your own personal weaknesses lie. For example, the “dental anatomy and occlusion” category is further divided into subcategories such as general structure and tooth morphology, pulp and periodontium, primary tooth morphology, dental pathology, and occlusion.  

The application also allows you to sort each question you study into a “know,” “somewhat know,” and “don’t know” pile. This feature not only helped me quickly determine my personal strengths and weaknesses, but also made it easy for me to maximize my studying efficiency by targeting the topics that I needed to review the most.  

Another useful feature of the app is an extensive list of mnemonics. The mnemonics are creative, fun, and, more importantly, useful, especially when it comes to memorizing which nerves exit which foramina and which bacteria cause what disease. I even found myself reciting many of the mnemonics in my head when I was taking the exam. The app also includes practice quizzes and allows you to track your overall progress by setting daily study goals, which helped me to stay motivated and on track, even on the longest study days.  

We live in a world of constantly evolving technology. Study resources are shifting away from traditional hard copy textbooks to more online, digital resources such as THE NEXTDDS, which I hear is readying its own testing tool. The Dental Boards Mastery app appealed to me and many of my classmates because of its accessibility. With just a few clicks on my phone, I could bring up the app and instantly access the questions while waiting in line at the grocery store or at the library for quick, “on the go” studying. In fact, the study material being presented as an app made the process feel less tedious, and I even found myself running through 50 questions at a time without thinking twice about it.  

The actual return on investment came on exam day, when I found that I was able to retain much of the information that I had reviewed through the app. I highly recommend this study resource to any dental students taking the NBDE Part 1! 

Residency Process from a Fourth Year Dental Student Perspective

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This is a time of transition where fourth year students are planning out their futures and third year students are thinking more about a life after dental school. Having just finished the application process for a GPR (General Practice Residency) and successfully making it through MATCH day, I have been reflecting on the experience and have devised some recommendations for getting through the process. 

 

 

Get as much advice as possible. Each of the experiences I heard from my classmates have been unique. It is important to talk to more than one person about the process. Indeed, if the person is going through a path that you would like to follow, or has the same career goals, spend more time with them. Programs are usually willing to give you the contact information for their current residents, which can provide you advice as well. Use alumni to your advantage. I knew several residents from different programs I applied to that made the interview process much more comfortable.

 

Start to figure out what you want. I am a very indecisive person. Usually I need to experience things firsthand to determine if it is important to me and what I really want. This can work in the opposite way as well. For example, one of the hospitals I looked at was not in a safe part of the city. I did not realize until I was there how much of a deal breaker that was for me. If you can figure out what your priorities are sooner rather than later, this can be ideal. Making a list of certain points to different factors of a program can help you in this decision-making process. For example, if location is important, give it 5 points and score every other program based on that scale.

 

Start Early. This is something that I learned from my mistakes. I found that it’s really hard to think about your future when the present is already causing so much stress. I asked for letters of recommendation later in the summer, which, when it came to the faculty writing them, put me on the bottom of the list. You do not want the control of your application be contingent on a reference.

 

Prepare for the interview. This is another area that I felt was lacking in my application process. However, even some of the interviews that I prepared for still had unexpected questions. A question that I often had trouble with was, “Do you have any questions?” because I already had so much information about the program flying through my head.  

 

Be you. Yes, this is advice that has been given time and time again, but it’s true in this situation as well. Programs are looking for a good fit, not a flawless candidate. They want to see your personality, not your perfection. The interview for my matched program went smoothly because I realized that all they wanted was to get to know me. Remember that just like relationships, not all programs are going to be a perfect fit. Try not to shake off those experiences and move on to other programs.

My last piece of advice is remembering that the results of this process will not change the fact that you will have your DMD. Though I have seen others before me have disappointing results, they are still dentists and doing quite well. All this determines is your first step in your path as a dentist. 

The Non-Ideal Treatment Plan

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Often, as health professionals, we are faced with patients who hesitate, question, or flat out reject our plan for treatment. As frustrating as this situation may be, reality does not always allows for ideal treatment, and circumstances may arise in which your patient is not willing to go forward with the plan we propose. It can be easy to be discouraged and argumentative when there is a disagreement, but if we prepare ourselves for these patients ahead of time, knowing what to say, to propose, and to accept, our conversations with patients can become more constructive. A patient-provider relationship that could be damaged by argument can be instead strengthened by understanding and trust. Take, for example, the following scenarios of patients who aren’t willing to follow the advice of their dentists and think of what you might do and say to maintain a strong relationship without undermine backing away from your stance as their health care provider. 


A 95 year old woman presents to your office with ADA Class IV Periodontal disease, generalized severe bone loss in the maxilla, furcation involvement in the posterior, and class II mobility in many teeth. You alert the patient of her condition, insist that many of her teeth have an extremely low prognosis and that there is risk for a periodontal infection, and suggest that she have her teeth extracted and a complete denture fabricated. She looks at you baffled, questioning why she needs all of her teeth out when she isn’t experiencing pain. “I’m 95 years old; I don’t know how many years I have left. I don’t want to spend them struggling with a denture.”  

Tips for handling this situation: Many of your older patients will want to forego treatment because they don’t feel that the time that they have left in their lives merits the money and time that it would require to undergo your proposed plan. As their healthcare provider, your role in this situation is to 1) ensure that the patient is aware of their oral health quality of life and the effect it will have on their remaining years and 2) alert them of the risks and benefits of receiving vs foregoing treatment. It is important to respect your patients wishes, but they may also not have the all of the knowledge to make an informed decision that is right for them. It is your responsibility to pass on that knowledge and accept the choice they ultimately make. 


Your 33 year old male patient has no insurance coverage and presents with extensive decay in twelve teeth, many of them so broken down that they should be restored with crowns. When you suggest this he argues “I can’t pay for the crowns right now. My parents teeth all fell out before they were 50; I just want them pulled."

Tips for handling this situation: Finances are a huge problem when it comes to patient’s treatment plan compliance. Many patient’s do not value their oral healthy as much as you would like and its difficult to convince them otherwise. Your role in this situation should include: 1) making sure your patient realizes that losing their teeth is not a natural, inevitable situation, 2) helping your patient to make a long-term plan instead of a quick fix decision and 3) potentially setting up a payment plan to lessen the financial burden and allowing a more ideal course of treatment. Money can be an object for any patient in any socioeconomic class if they do not value their oral health and it is important to acknowledge this when forming a treatment plan for these patients. 

A 7 year old female is sitting in your chair, her mom observing the appointment in the corner of the room. On examination, she has facial caries in all anterior teeth and interproximal decay in almost every primary molar. You begin to explain your plan to her mom to restore these teeth, but she objects and says “why put fillings in all her teeth when they’re just going to fall out? I think we should just pull them out or leave them be and wait for her permanent teeth to come in.” 

When it comes to dealing with parents of your patient you should: 1) explain the role their child’s baby teeth have in ensuring their future oral health, including how abscesses may damage their forming permanent teeth and how the baby teeth maintain necessary space to prevent crowding and 2) insist that this decay is a future indicator of poor oral health, placing emphasis on the necessity of preventative appointments and good oral hygiene. Before treating your younger patients, you must first receive financial and treatment consent from their guardians. This will require you to educate a third party about the reasons for your proposed treatment and you must be able to be an advocate for the child while also respecting the parents wishes. 


If you understand your role as your patients’ healthcare advocate, you will be able to accept their wishes without dismissing them as foolish. Your job is to educate, inform, and direct their decisions without being overbearing or pushy. Prepare yourself ahead of time with the types of things to say to these patients and you will be well equipped to create a patient-provider relationship secured in understanding and trust. 

Embezzlement - An Unfortunate Topic to Discuss for Business Owners

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Embezzlement is something no business owner wants to encounter. Unfortunately, the reality is that some of us will go through the troubles associated with such an issue.  Embezzlement is when someone in a position of trust, typically staff but potentially others, steals from his or her employer. In dentistry, there are three types of embezzlement. Intramural stealing: when staff is stealing from the dentist or a dentist is stealing from another dentist in a group practice setting. Direct embezzlement: when staff is stealing from the practice. And finally, indirect embezzlement: when staff is stealing from insurance companies, where the doctor will be held financially responsible. Indirect embezzlement is also commonly referred to as “midnight dentistry.”

 

Frequency of Embezzlement

                How often does embezzlement happen? Is this a valid concern? According to ADA studies, dentists have a 52 to 60 percent chance of embezzlement happening to us in some form or another. The average theft from filed cases is $109k, however, according to the Association of Certified Fraud Examiners, this number actually rises to $140k. The biggest case known to date is $1.9 million, which occurred over a five-year span. These numbers reflect only the amount of money stolen—not the lost time, productivity, or investigation costs.

                Dentists are easy targets. During dental school training, we are not sufficiently trained in business, and therefore many areas of the business model are left to a "trusted" employee. As dentists, we pay little attention to the administration of the dental practice. The embezzler can be motivated to find weaknesses in the systems we implement in our practices. Commonly, it is the “needy,” having recently gone through a financial crisis, who resort to embezzling. They could be stealing to make a number of different payments in their personal lives. A mortgage, divorce or a spouse losing their job, and addiction are all possible triggering events to motivate someone to embezzle. The “greedy” people steal for their egos; smart people who feel underappreciated and believe that you, as a dentist, are successful due to them. 

                There are many red flags in staff behavior to be aware of if you suspect embezzlement has occurred to you.  They are:

1.       Staff who are suspiciously dedicated, especially working unusual hours or who never take vacation and/or sick days

2.       Territorial about work or workspace

3.       Control freaks who want to control communication between patients and the practice

4.       Conspicuous displays of honesty

5.       Resistance to practice management software upgrades

6.       Resistance to increased involvement of consultants/accountants

7.       Attempting to exert control over choice of practice advisors

8.       The receptionist’s BMW is new, and bigger, than yours!

 

Could you be facing embezzlement in the near future? As young dentists, we are a target for being ignorant. While so many other aspects of running a business and dentistry weigh heavily on our minds, staff members are able to know that we are preoccupied to be concerned with the tasks that they complete each day.  Go with your gut instinct, and if something doesn’t feel right, investigate further!

The Power of Organized Dentistry

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Coming into dental school, everyone always talks about the academics and the clinical side. However, we tend to forget about all the organizations that our dental schools take part in. These organizations are the ones that help schools develop a curriculum and policy. I recently just signed up to attend my second ASDA annual session, and it had me reminiscing back to my first ASDA annual session.

 

Now as many students ask, including me at one point, “What do these organizations even do for me? I’m just trying to graduate and become a dentist.” Even though this is true, we have to think of our job as a dentist more like its own profession. These organizations help make the rules, so we all stay up on specific standards that will help us, our staff, and our patients.

 

So what is the point of joining these groups or attending these conferences? By joining organized dentistry, you empower those out on the front lines. For example, by saying this organization represents 25% of dental students vs. 75% of dental students, which would people be more compelled to listen to? Obviously, we all know more members lead to a better impact.

 

When students hear about organized dentistry, the first thing that comes to mind is that it’s just another political field. However, politics are far from the extent of what organized dentistry does. Instead, the purpose of organized dentistry groups is researching products and techniques for the safety of ourselves and our patients. For example, the ADA creates standards of care and recommendations for us as providers and for our patients in order to promote oral health. In addition, these organizations also help create a network for, and of, dentists. This helps with contacts in the mentoring field for incoming dentists, or even just dentists to shadow as we are in school.

 

As you can see by now, organized dentistry is what helps us remember that we not just have jobs, we are part of a profession that has rules and ethics. By all of us working together, we can help improve our profession for ourselves, incoming dentists, and patients.

 

The importance of organized dentistry has become undervalued in recent years. Yet, we are living in a time where student debt is increasing, political change in health care is ongoing, and we are being introduced to new technologies. Being a member of organized dentistry strengthens our profession. In the end, we are the only ones that can protect our own field. Even though we all might not have the same morals and political views, there are core values that we all hold that brought us to dentistry.

 

So go ahead, join your school, local, or state chapter and begin learning. Think about what you could do for your education, career and your future practice. Just remember: Even if you don’t want to be an integral part of the organization, you can still be on our team and make a difference!

California’s Licensure by Portfolio Pathway

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The University of the Pacific Arthur A. Dugoni School of Dentistry was the first school in the state and country to have a DDS Class of 2015 graduate receive their licensure by portfolio. This licensure by portfolio is a pathway which came about in 2007, approved by California legislature in 2010. As of now, licensure by portfolio is currently only being offered in the state of California and only provides licensure to practice in-state as well.

                  Prior to the licensure by portfolio pathway, only two other ways to obtain a license in the state of California were available. The first was a clinical exam administered by the Western Regional Examining Board (WREB), which involves two and a half day clinical exams.  This exam demonstrates dental treatment competencies by performing the exam on a patient. The second pathway of licensure involves completing a postdoctoral residency program in an Advanced Education in General Dentistry (AEGD) or a General Practice Residency (GPR).

                  The new portfolio exam allows students to compile a portfolio based on their clinical experiences and competency exams performed while in school. The portfolio covers six subject areas: 1) Oral Diagnosis and Treatment Planning, 2) Direct Restoration, 3) Indirect Restoration, 4) Removable Prosthodontics, 5) Endodontics and 6) Periodontics. Students will be evaluated in these subject areas over their last year of dental school. Calibrated dental school faculty members will evaluate students in these six subject areas in accordance with criteria required by the Dental Board of California. Licensure by portfolio costs $350, in comparison to WREB examinations which run around $3,000.

                  Dentists and cosmetologists are currently the only two fields which still use licensure based on a live patient examination. Using a live patient-based examination can often present many challenges for dentists. A patient may not show up for an exam or can be bartered away by another candidate taking the exam. Not only can these unfortunate situations occur, but these exams also tend to be costly.  Overall, live patient exams are not the most ideal type of setting to practice dentistry, nor does it provide the highest standard of care to patients.

                  If dental students are thinking of staying within the state of California upon graduation for at least five years, they should think about licensure by portfolio. Oftentimes school requirements correlate closely with the portfolio requirements, making it very convenient for students to complete portfolio requirements. This type of licensure is the first step to break away from traditional live patient-based examinations and hopefully eliminating these types of exams all together.

Tips for Finding a Job After Dental School

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           As a fourth-year dental student, I can finally see the light at the end of the tunnel. Among the many stressors and responsibilities of this last semester, one of them includes finding an incredible job after graduation. Luckily, I have had many helpful hints and/or received valuable advice to guide me on my quest towards employment. I hope these tips are as helpful for you as they have been for me. 

Take advantage of ASDA lunch and learns, vendor fairs, and other socials at your school. State dental societies, dental vendors, and/or dental corporate groups will host many of these events, which allow dental students to learn more about their companies and employment opportunities. Dental support organizations (DSOs), such as Aspen Dental or Heartland Dental, will host events specifically for fourth-year dental students to initiate discussion about possible job opportunities in a DSO-supported practice. These events are great venues to build relationships with recruiters who can help you find a job in various regions across the United States and set up initial interviews. If you have a business card, be sure to take a few to the event to pass out to the recruiters. 

A state dental society is one of the best resources you can have during dental school. Not only do they support you throughout your dental school career, they are eager to help you transition into employment. Contact your state and local dental society to stay connected and up-to-date with their events. Get involved and get to know the doctors. Networking can open you to several job prospects that you may have otherwise missed. Furthermore, check out the classified section on the state dental societies’ websites. Many doctors will place advertisements in these classifieds hoping to find excellent doctors to join their practice, including recent graduates.  

Do not wait until the last minute to search for a job. Depending on the region you want to practice in, the area could be potentially competitive without a plethora of options. Making connections and networking early on can give you options and the ability to compare them and make an informed decision. Take the time to educate yourself on all prospective jobs, so you do not miss out on an incredible dental provider position.  

As you enter your fourth year of dental school, you will begin to look for job opportunities after graduation. Take the time to formulate a game plan, which will set you up for success. Attend events sponsored by ASDA and your school to connect with recruiters to help you obtain a job with a DSO group or private practice. Get involved with your local and state dental societies to meet established dentists who may be looking to sell their practice or hire an associate.  

Most importantly, start your job search early to give yourself the best opportunity for success. With these tips and an enthusiastic outlook, I am positive you will have an incredible journey transitioning from dental student to dentist after graduation!  


Attitude is Everything

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Attitude is everything in dentistry, just as it is in life. Personal relationships can make or break you. In a field where one of the most effective forms of advertisement is word of mouth, keeping everyone happy is the main objective. There are several qualities one must demonstrate in order to develop strong relationships and an even stronger business. 

 

 

 

Kindness 

Growing up, my mom always told me, “Kill them with kindness.” She couldn’t be more right. Kindness is one of the most important qualities one can possess. This especially applies to dentistry. Patients come to you seeking treatment, often afraid and possibly in pain. They are timid—letting a stranger perform a procedure they know nothing about in an intimate place. Comfort your patients. Treat them like you would your own family.  Show them love, kindness, and a gentle touch. Always smile regardless of how you are feeling. Educate them on what’s going on so they feel more comfortable in your hands.  

 

 

In order to have a successful business, you must also extend this kindness to colleagues and employees. In dentistry, everyone is connected. Be kind to your colleagues, whether they are classmates or future dentists. This will allow you to develop relationships within the community for referrals and possible mentors. Additionally, your employees should be shown kindness as you depend on them to keep your business running smoothly. 

 

 

Flexibility 

Flexibility is key in dentistry. Be prepared to take on anything. Things don’t always go as planned. Be adaptable, remain positive, and avoid getting frustrated. This also extends to your nonverbal communication. Body language can often convey more strongly than words. Your patient will pick up on everything.   

 

 

Being flexible can also apply to the technical side of dentistry. As you progress, don’t get stuck in your ways. Keep an open mind and try new technologies or ways of doing things. In a constantly evolving field, it is imperative that we keep up on education and remain aware of new methods. 

 

 

Humility 

There is a fine line between confidence and arrogance. No one wants a dentist, colleague or boss who thinks their you-know-what doesn’t stink. 

 

 

Be a team player. If you aren’t already, get used to it, because that’s your future, even if you are a sole practitioner. Learning to work with others is critical to perform procedures effectively and efficiently. This will translate to shorter appointments, happier patients and staff, and a more profitable business. 

 

 

Remember that mistakes happen, especially now as students. Instead of interpreting these mistakes as a blow to your ego, see them as a learning experience. Embrace mistakes: You’re human just like everyone else. It’s what you do after the mistake that truly matters. Try to maintain composure and think of a game plan to compensate. Once you have fixed the situation, learn from it.   

 

 

Respect 

Respect everyone. From your patients, to your receptionist, to the other dentist down the street. Everyone deserves respect.   

 

 

Patient respect is always the number one priority. Remember the ADA Code of Ethics principle: “Autonomy.” As professionals, it is our duty to listen to patient’s desires and treat them accordingly within the bounds of accepted treatment. We are to respect our patient’s right to choose their treatment by involving them in treatment decisions.   

 

 

In a field with many ways of performing the same treatment, respect that other dentists may not do it exactly like you. Some may choose to implement different materials and methods. It’s also important that this extends chairside. Avoid bad mouthing other dentists to patients. If a patient were to hear you comment on a poor margin or a bad filling as you review the radiographs of another doctor, they may immediately think, “Malpractice.” Remember that what you’re seeing on these radiographs is just a snapshot. You don’t know the movie. While it is important to recognize issues with current dental findings, however, respect other dentists by not talking negatively about their work. Instead, refer the patient back to that dentist to evaluate.   

 

 

Dentistry is all about who you know and the relationships you create. We’re a tight-knit community where everyone is tied together somehow. Personal accounts may make or break you down the road with jobs, residencies, and even patients. Dentistry is a healthcare but it’s also a business. If you want to keep patients, you need to have a good attitude. Remember to treat everyone with kindness, maintain flexibility, work humbly, and be respectful. At the end of the day, work with others the way you would like them to work with you. 
 

 

Preparing for medical emergencies

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Recently in our dental clinic, one of my fellow students was providing care for a patient who fell asleep during the appointment. This patient in particular tends to get drowsy each appointment and dozes off during her procedures. My friend finished the procedure and went to wake her and advise he was going to get a professor to examine his work.

 

Well, on this day, his patient did not wake up when he called her name. He called her name a little louder several times with no response so he then nudged her shoulder firmly in an attempt to wake her, but still received no response. After checking to make sure she was still breathing, he called a professor over and they administered smelling salts from the first aid kit. Again there was no response, other than a few sniffles and snorts as she remained asleep in the chair. They called for an emergency response team and checked her heart pressure, which was within normal limits.

 

The EMTs arrived and, as they were transferring the patient to the gurney, she started to awaken. After being checked by the physician at the hospital, she said she felt fine—was just very tired and had a hard time waking.

 

Needless to say this was quite an atypical ending to an appointment and, as I heard the news, it really made me reconsider my own preparation in the clinic for medical emergencies. As is standard policy at OHSU all students must receive Basic Life Support training and pass the course to become BLS-certified. We renew this certification every two years, I believe, and will do so through the remainder of our careers as dentists.

 

The reality is that these things happen, and will happen, and we as dentists will need to lead the response when they do. Reviewing the location, contents, and uses of the first aid kits that we have in our clinics is something we need to do often in order to ensure we are prepared to handle the situation professionally.

 

At OHSU, every so often we split up and have medical emergency “huddles” where we meet as a group of 20 to 30 students to do just that, and to discuss the uses of each item in our first aid arsenal.  In an emergency, response time is often critical and the only way to be prepared is by constantly reviewing the procedures for such situations.

 

In short, I hope my friend’s clinic experience can be a reminder (as it was to me) to anyone who hears it so he or she can be best prepared for emergencies. We can all agree that this is not the most exciting thing to do with our time--and understandably so--but when it comes time to use that knowledge in a real-world situation with a struggling patient in the chair, we will all be glad we spent the time to be prepared. 

What to Expect After Dental School

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    It’s difficult to know exactly what to expect after dental school, but there are aspects of life that you can begin to prepare for now. At the University of Maryland School of Dentistry, students were fortunate enough to be able to hear firsthand a recent graduate’s experience in the real world and the advice she wished she knew prior to graduating dental school. 

    Some students will start looking for a job right after graduation, and the first question that comes to mind may be, “Where do I start?” Talking to faculty, professional affiliations, and getting in contact with your state dental association are excellent starts that will serve as the foundation in the process. An upcoming dental graduate may also be wondering, “When do I start?” While it’s never too early to network, most hiring dentists are looking to add an associate to their practice immediately.  

    In addition to the traditional, necessary curriculum vitae (CV), it is also suggested that dental students put together a portfolio of their work completed throughout dental school. This will really give you an advantage when looking to join a practice. Making a portfolio of your work is also a good habit to get into while still in dental school. Not only can patient cases be used for documentation, but they will also inspire you to evaluate and improve your performance.  

    One of the most beneficial things I learned from the graduate student was what you will need before starting a job. The first and most obvious is a state dental license. In order to obtain your state license, you will need to obtain a letter from your dental school stating that you graduated and have fulfilled all of their requirements, as well as your board results and completed jurisprudence exam. You will also need a DEA number, which costs around $700 dollars, a CDS number, which costs about $300 dollars, and a NPI number, which can be obtained at no charge. Malpractice insurance is the last thing you will need before starting a job. Some dental practices request that you get a certain malpractice insurance, which will be outlined in the contract.  

    The graduate student closed with her brief experience in corporate dentistry. Her story really was an eye-opening insight into what it’s like to work in the corporate realm. Corporate dentistry is eagerly trying to lure recent graduates by offering benefits, vacation leave, financial support for licensure and continuing education, loan repayment programs (if it’s a Medicaid approved site), and no responsibility for scheduling or managing patients. Although these benefits may appeal to a recent graduate, it was beneficial to hear her opinion about the downsides of corporate dentistry, especially since she had experienced it firsthand. She told us that the workload in corporate dentistry is focused on high production, which can lead to being “burnt out.” This focus leads to a minimal emphasis on the dentist-patient relationship, which draws many of us into the field of dentistry to begin with. She also mentioned that if you work in corporate dentistry, you are not your own bosstreatment planning sales pitches become more important than your quality of work.  

    As dental students, we are so fortunate for the foresight and experience of this recent graduate’s story. With graduation not too far away, current dental students can only benefit from her insight.  

What I Learned During My Residency Journey

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It’s here. January 25: Match Day. All the time I’ve put into my CV, asking for letters of recommendation, going on interviews, and ranking the programs all comes down to this. Nervously, I click on the email from National Match Service. “Congratulations! You have been matched to…” Suddenly, that nervousness turns into an overwhelming joy. Getting into residency is a great accomplishment. It takes a lot of hard work and months of staying dedicating to the journey. Here are a few things I learned throughout my process:

Get organized early. Try to finish your CV and personal statement early in the spring of the year you apply. It’s hard to summarize four years of dental school into one page. Have your peers review it, since they have shared the experience with you. Almost everyone I asked for a letter of recommendation wanted a copy of these materials to help them. The biggest delay in my application process was waiting on these letters from my busy faculty members, so be sure you can provide them with your important documents EARLY!

Traveling to interviews. Most interviews start by 8am and flying in that same morning can be very hectic. The best thing you can do is arrive the night before and get familiar with parking or any possible public transit to the interview site. Pack yourself some breakfast so you are not stuck looking for a coffee shop in an unfamiliar city. It is a stressful time already, so avoid the additional pressure. On your plane ride, brush up about the program’s faculty members and their backgrounds. Take some time to prepare your questions for the interview.

During the interview. First impressions are key! Remember, you are expected to be professional with everyone, including the staff. Some of the most useful information I got about the program came from the dental staff, some of whom have been working there for more than 10 years. Don’t be intimated to talk to current residents in the programs. After all, they are your best source of information. Get the names and emails for the residents as contacts for any future questions. A good tip for a successful interview: be yourself! They are interested in seeing who YOU are so don’t deviate from your awesome personality.

Thank you cards/email. Write thank you emails or cards to the program directors, chairman, program coordinator, and the faculty who interviewed you. Send them immediately after the interview as well as 1-2 weeks before the rank deadline.

"Coffee, helpful or harmful to your dentition?"

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    A lesson to give our patients who state “Cavity?? I don’t eat candy, but I do drink 3 cups of coffee a day”  

Coffee is a brewed drink prepared from roasted coffee beans, which are the seeds of berries from the Coffea plant. Coffee is slightly acidic and can have a stimulating effect on humans because of its caffeine content. Coffee is one of the most popular drinks in the world, you can have it many ways, hot, cold, espresso, latte, whatever your heart desires. 

Coffee is most dental student’s best friend. Whether you drink it daily or only during finals, dental students consume coffee as a regular part of our diet. It is necessary at conferences, meetings and any event in order to keep everyone happy. So why do we ask our patients about their consumption during the caries risk assessment? Because as dental students we know the tools and measures we need to keep our teeth healthy and our patients may be unaware that their coffee drinking habits may be a factor in their caries development. Coffee, as I mentioned before has acid, which is hard on your teeth’s enamel. Drinking too many liquids that are high in acid, like coffee, can weaken your enamel. Your enamel is what protects your teeth, so if it is weakened or wears away, then your teeth become more vulnerable to decay. 

A way to lessen the negative effects of coffee is drinking your coffee with a meal, or a healthy snack that is high in fiber. The physical act of chewing produces saliva; this saliva neutralizes food acids to protect your teeth. Another option is drinking a glass of water after your coffee. The water will dilute the acid and wash it from your teeth, so that it doesn’t eat away at your enamel. There have been studies released that describe the “cavity fighting” properties of coffee. Before we all start jumping for joy, I think I would like to see more research done. But, if your patients do bring this up, one thing to remember is that the so-called “cavity fighting” property of coffee only applies to coffee with no additives. The study shows that the reduction in tooth decay was only for those people who take their coffee black with no sugar and that the alkaloids in the coffee are optimized when no sugar is added. So, if they are adding sweeteners and cream to their coffee, they are negating any of the dental health benefits. 

It is also well known that coffee stains your teeth. Coffee contains darks pigments that can attach to the enamel of your teeth, and after time, these pigments can yellow your teeth and darken your smile. Again, drinking water is a good practice to protect your teeth. If you drink water directly after your coffee, it will wash away the pigments and keep them from staining your teeth. Of course, brushing will help, too, but wait a while because the acid in coffee weakens the enamel to the point where brushing may actually damage your teeth. 

A Spotlight on the Advanced Dental Admission Test

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As dental students, we are no strangers to test taking. Testing anxiety, sweaty palms, the feeling like you are going to throw up become chronic problems in dental school. The #2 pencils, scantrons, multiple-choice tests, and the anxiety of missing one question can generate nightmares that haunt you for weeks leading up to a big exam. In addition to taking hundreds of exams required by our schools to graduate, we must pass the National Boards Parts I and II and a licensing exam to be able to practice dentistry. Countless sleepless nights are spent cramming Dental Decks, Mosby’s, Board Reprints, and other resources. Finally, when the end of testing is in sight, an additional, unexpected exam to apply for specialty training has been introduced. This exam is in the pilot phase, but it will be affecting all students in the graduating class of 2017 and beyond who are applying to specialty programs. Here is what you need to know.

 

The Advanced Dental Admission Test (ADAT) is an exam created to help residency directors be able to distinguish students and select highly competitive applicants. This change came about because many dental schools do not rank students or have pass/fail curricula. As of January 2012, the National Boards no longer reported candidate scores because the exams were never meant to distinguish students or be used as a comparison mechanism for advanced training programs. NBDE Parts I and II were designed for use by the state dental boards to determine if a candidate had the minimum competency to safely practice dentistry. The new ADAT exam will help identify the most highly competitive applicants for selection into advanced dental education programs.

 

In recent years over 300 advanced training programs have expressed interest in participation, including several oral surgery programs. As of now, oral surgery applicants still have to take the comprehensive basic science examination (CBSE). A list of programs that will require applicants to participate in the pilot examination will be listed on the ADA website in February 2016, so it will be advantageous to see if the programs you are interested in applying to will require this exam in 2016.

 

With this being a pilot year, expectations for the exam are still unclear. The ADA website posts updates on any changes that arise. The pilot ADAT exam will be held from May 16 to August 31. As of January 27, the ADAT testing fee for 2016 will be $250. In 2017 and beyond, the cost is expected to rise. At the time of exam, applicants may request to send their scores to programs at no cost. After the exam has been completed, a $35 charge will be assessed for each additional score report request.

 

The ADAT will assess Critical Thinking and Principles of Ethics & Patient Management in the form of a 200 question, 4.5 hour exam.  The ADAT exam will be scored on a range from 200 to 800, with a target mean of 500 and a target standard deviation of 100. Scores will be reported in increments of 10. Since this exam is in its pilot year, scores may fluctuate as more applicants participate. You can expect to see some changes in your score report as more applicants complete the exam up until September 15. A preliminary score result schedule can be found below.

 

ADAT SCORE REPORTING TIME TABLE

PRELIMINARY SCORE RESULTS

Test Administration Period

Results posted in ADAT Candidate "My Account"

Results sent to Advanced Dental Education Program Directors

May 16, 2016 to June 30, 2016

July 15, 2016

July 15, 2016

July 1, 2016 to July 31, 2016

August 12, 2016

August 12, 2016

August 1, 2016 to August 31, 2016

September 9, 2016

September 9, 2016

FINAL SCORE RESULTS

May 16, 2016 to August 31, 2016

September 15, 2016

September 15, 2016

May 16, 2016 to August 31, 2016

September 15, 2016

Final Score results available in DTS Hub (Advanced Dental Education Program Directors and Dental School Deans)

 

Taking another test, especially one with so many unknowns, personally gives me anxiety—but it’s here to stay. The ADAT will help our profession identify the most qualified candidates for specialty programs. Whether or not your program requires or recommends taking it in 2016, you can expect that programs look at a student’s initiative and willingness to take the exam more than the score itself.

 

Neither programs nor students know what to expect, so take the initiative. Buckle down and pull out the old study notes from your classes. There may not be decks or a quick study hack for this exam yet, but the ADA website does provide a list of sample questions to help guide you. Deep breath--this too is just another hurdle to reaching your ultimate career goal.

 

State Dental Societies: Why Should You Be An Active Member?

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    Our state representatives make decisions that affect us, the clinicians, and more importantly, our patients. The patients we serve sometimes have no one else but us keeping their best interest at heart. This is why it’s crucial to be an active member in your state dental society and keep informed of the issues of your area. 

As a first year, the legislative world seemed a galaxy away, but approaching my fourth and final year in dental school, I find myself immersed and sometimes flooded with questions from my patients, peers, and future colleagues. It can be overwhelming and disappointing when you’re unable to answer questions for them and a simple “I’ll find out for you” isn’t always good enough (sometimes embarrassing even, when it’s something you should be able to discuss right then and there). Sure, you can Google the topic and read up on it, but there’s more that goes into being truly informed. Being active in your state dental society is a way to make sure this doesn’t happen in the future. 

Being a dental student and ASDA member, we are automatically ADA members, and ASDA Chapters across the country do a great job of corresponding with their state societies. I believe this is the first step in a lifetime of commitment to involvement. I have friends who have made careers in government relations and, while they are some of the most intelligent people I’ve met, they don’t necessarily understand all the nuances of the dental profession or healthcare in general. They don’t see the patients that we do nor are they aware of the issues these patients face, such as access to care or affordability of care. 

A leader isn’t merely an elected official; as dental professionals we are leaders for our patients and communities. With this comes the responsibility of being a liaison between our state societies and our communities. Having active involvement with these societies will enable us to bring to the forefront the issues we care about. It can be a bit intimidating initially, but the state dental societies are always open to questions and are there to help guide you as you enter the world of practicing clinician.  

 

Change can bring wonderful differences to the profession, but we need to work as a team. As Helen Keller said, “Alone we can do so little; together we can do so much”. 

Disability and Malpractice Insurances

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As a practicing dentist, a myriad of insurances are necessary for comprehensive coverage encompassing every aspect of the profession. Two important among these are malpractice and disability insurances. Certain key concepts of malpractice and disability insurances must be understood in order for one to successfully obtain coverage for these aspects, and are discussed below.

 

Differentiating Between Coverage Options

First, malpractice insurance is essentially professional liability insurance; one of its key features, among others, is to protect from failure to diagnose. Coverage for malpractice insurance may either be “claims made coverage” or “occurrence coverage”. The main advantage of claims made coverage is affordability, while the main disadvantage is the possibility of needing a tail policy upon leaving the initial policy. Occurrence coverage covers claims that occur during the policy period regardless of the time at which they are reported. The main advantage of occurrence coverage is that no tail policy is required, while the main disadvantage is the higher cost of the policy. This higher cost is effectively pre-paying for the tail policy.

 

Next, it is crucial to remember that malpractice claims must meet two conditions. The first condition is that they must be reported while the coverage is still valid. The second condition is that they must occur subsequent to the retroactive date shown on the policy. Finally, in order to determine whether an insurance is the correct fit, the following are valid questions to ask an insurance agent:

1) What is the premium structure in subsequent years?

2) Are there discounts available for new graduates?

3) Does the policy cover legal defense for board investigations?

 

Disability insurance protects a dentist’s most valuable asset – the ability to earn a living. After numerous years of training, and often a substantial accumulation of debt, it is imperative to be able to earn a regular income. This is why disability insurance is so critical. Moreover, according to the ADA, about 1 in 4 dentists experience disability long enough to collect benefits at some point prior to quitting work. Therefore, it is not an issue limited to a negligible number of professionals in the field.

 

A few important things to consider with this insurance are whether the premium is level or graded, whether there is a future increase option, and whether there is guaranteed renewal. A level premium remains the same throughout the lifetime of the policy; on the other hand, a graded premium has lower premiums at a younger age and increases as age increases. Next, a future increase option allows you to increase insurance coverage as income increases, without any medical re-consultations. Last, guaranteed renewal is an important feature that ascertains the policy cannot be canceled as long as fees are paid. These details are crucial to understand before purchasing any disability insurance.

 

Conclusion

In conclusion, after securing basic insurances such as health insurance and life insurance, disability and malpractice insurances are two very important insurances for a practicing dentist. Given the nature of the profession, these two insurances are key towards achieving peace of mind throughout the span of one’s career.

 

 

References

1. Dental Professional Liability. (n.d.). Retrieved December 1, 2015, from http://www.fdaservices.com/insurance-programs/professional-liability/

 

2. Disability Insurance for Dentists | ADA-Sponsored Insurance Plans – Insurance for Dentists and Their Practices. (n.d.). Retrieved December 1, 2015, from https://www.insurance.ada.org/ada-insurance-plans/disability-insurance.aspx

 

3. Disability and Office Overhead. (n.d.). Retrieved December 1, 2015, from http://www.fdaservices.com/insurance-programs/disability-and-office-overhead/

An Ergonomically Friendly Dentist

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Practicing dentistry requires significant attentiveness and precision. All too often, the practice is also accompanied by awkward poses, repetitive actions, and a chronically strained back.

 

In fact, in a study done by the University of California, San Francisco School of Dentistry, forty-six to seventy-one percent of the student dental population reported having body pain across all four years of school, with more than seventy percent having pain by their third year. But this is probably just due to the fact that you are still trying to get a grasp of dentistry, trying to avoid indirect vision as much as possible, correct?

 

Wrong. A systematic review done by MJ Hayes shows that the prevalence of general musculoskeletal pain ranges between sixty-four and ninety-three percent in dental professionals, with the back and neck regions being the most prevalent for dentists. This in turn can result in a decrease in range in motion and strength, weakness and fatigue, and even possible numbness.

 

There is no doubt that it is easier to prevent bad habits than to break them. Therefore, what can we do now to decrease our risks for chronic musculoskeletal pain?

 

Be conscientious of your ergonomics. The more you continue to think about maintaining proper posture, properly positioning your patient, utilizing your magnification, and maintaining a neutral position now, the quicker it will become habit. Utilize gloves that fit well while maintaining the necessary equipment relatively close and in proper positioning.  

Purchase ergonomic equipment. If possible, use adjustable chairs that offer lumbar and thoracic support. The less bulky the equipment, the closer you can work to your body and the better your ergonomics will be.  

 

Take breaks. It is nearly inevitable that every so often, there will be a case where ergonomics just cannot be maintained. As a result, take a break. This will prevent the body from maintaining a static position and allow your muscles to relax. Even better, try utilizing some posture break exercises.

 

Reward yourself. Being a dental professional takes work. Getting a massage on a regular basis will definitely help ease your tensions and relax your muscles as well.

 

Start now. Personally, I find myself saying that I will fix my posture once I master the dental aspect, but this definitely is not the best way to go about it. I really encourage each and every one of you to master the dental aspect, but also master your ergonomics alongside it. They really do go hand in hand.

 

I hope that you can begin to make at least a few changes by incorporating some of the suggestions above into your regular daily routine. I’m confident that by doing so, you will experience less fatigue and pain by the end of the day, while continuing to provide valuable services to your patients. 

Raisin's role in oral health

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When counseling patients about nutrition and how diet can effect oral health, we often times discourage dried fruits due to their stickiness and high sugar content. The stickiness of a food can get lodged in the pits and fissures of a tooth, which is the most susceptible area for cavities. Additionally, the higher sugar content when a fruit is dried causes the pH of the saliva to drop due to the acid produced by the oral bacteria, therefore rendering the enamel surface more susceptible to demineralization. Lastly, the third bases of dried fruit such as raisins previously being thought to cause cavities was due to the fruit sugars inducing a bacterial biofilm on the surface which therefore exacerbates the sticking of additional food and bacteria to the tooth.

 

 

To the surprise of many, none of these caries-causing characteristics are true of the raisin. Eating raisins alone will not cause cavities. After testing was done by Dr. Wong of the University of Pacific Arthur Dugoni School of Dentistry, raisins do not stay stuck on the tooth long enough compared to other foods. Additionally, raisins do not cause a drop the pH of the saliva below 5.5, or low enough to cause caries.  Additionally, natural antioxidants found in the raisin were found to have antibacterial properties. Oleanolic Acid, amongst others, has antimicrobial properties that decreased the population of Streptococcus mutans bacteria, a leading culprit in caries development.

 

Another component of the research was comprised a study which measured the bioluminescence of the biofilm in plaque samples collected from different parts of the mouth. These samples showed activity in terms of bioluminescence in relative light units, the amount of energy produced by the bacteria’s ATP when mixed with a reagent that glows. Studies look at people who ate raisins, compared to those who did not. In compared with people who did not consume raisins or any other food, those who ate raisins, waited 15 minutes, then were swabbed in 6 different parts of their mouth showed 42% less bioluminescence compared to those who did not consume raisins.  However it is important to note that there was still some bioluminescence and therefore raisins to not completely rid the oral environment of cavity causing bacteria. Additionally, the amount of raisins consumed to show a notable effect needs more investigation.

 

Lastly, raisins mainly contain glucose and fructose, not sucrose, which is the main causation of tooth decay. Be weary though, in that many dried fruits besides raisins will be sweetened, and most likely contain sucrose. Because there is no added sugar to naturally sun dried raisins, they are actually healthier than many have believed. So, go out and snack on raisins at your leisure.

ADEX Exam in Dentistry

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How prepared are you for licensure, specifically the clinical exams? Independent from taking the NBDE Part I and II, there are other important steps to become licensed in the specific state where you decide to practice. The requirements vary per state, so it is important to check the licensure laws and regulations for the individual state you are interested in. Florida, for example, also requires the Florida Laws and Rules Examination and the ADEX Dental Licensing Exam.

The American Board of Dental Examiners (ADEX) dental examination is used to measure the candidate’s clinical competency for licensing purposes. The Commission on Dental Competency Assessments (CDCA), formerly known as NERB, is one of the five regional testing agencies that the state boards contract to administer the clinical exams. The CDCA administered examinations are accepted in 46 different US states/jurisdictions and Jamaica. Other agencies that administer the ADEX examination are CITA and SRTA.

The ADEX examination series consists of a computer simulation and clinical examinations. There are up to five clinical and simulated clinical sections included. The Diagnostic Skills Examination (DSE) section is computer-based. The two simulated clinical examinations are manikin-based and include Endodontics and Fixed Prosthodontics. The two clinical examination sections are performed on live patients, including Periodontal/Scaling and Restorative. All parts of the examination must be completed within 18 months of the first section taken.

To register for the ADEX examination, the candidate must visit the testing agency website, for example: https://cdcaexams.brighttrac.com/. Then, complete the candidate profile including school and expected graduation date. The candidate must also upload a photo following specific guidelines. It is important to know that uploading the photo is mandatory and the profile will not be verified until the photo has been uploaded. Once everything is complete and payment is submitted, the information is sent to the candidate’s school for confirmation. Profile verification usually takes 2-3 business days.

It is very important to familiarize yourself with the Examination Manual (http://www.cdcaexams.org/dental-exam-manual/) to know what to expect and to prepare accordingly for each section.  There is a mandatory orientation session preceding the clinical examination sessions, typically the evening before. An important white envelope will be disbursed with the candidate’s ID badge and paperwork. The candidate is required to bring two forms of ID on the day of the exam. They must supply their own instruments and provide their own patients in order to perform the diagnostic procedures and treatment. 

The candidate must score at least 75 percent in each section to pass the ADEX examination. Grading criteria is categorized as Acceptable and Marginally Substandard for passing, or Critically Deficient for failure. The candidate should try to achieve the parameters under Treatment Goals, which will result in Acceptable. Three calibrated independent examiners determine the scores and are different from the Clinic Floor Examiners.  

The Endodontics section consists of two procedures within a maximum of 3 hours: the access, canal preparation and obturation of a simulated anterior tooth and the access preparation and canal identification of a simulated posterior tooth. A separate isolation dam is required for each procedure. The placement of the access opening must reflect the position of the pulp chamber. Straight-line access to the root canal and complete debridement of the pulp chamber is expected to allow complete removal of all pulp horns. For the anterior tooth, the canal shape should taper to allow for debridement and instrumentation up to 0.5 mm from the anatomical apex. Obturation using gutta percha should extend up to 1 mm short of the root apex. The pulp chamber should be cleaned of all gutta percha and sealer material.  

The Prosthodontics section consists of three procedures within a maximum of 4 hours: preparation of a simulated maxillary incisor all ceramic crown, premolar for porcelain fused to metal bridge abutment crown, and molar for cast metal bridge abutment crown. Ideally, the crown margins should be 0.5 mm supragingival to the CEJ. The optimal occlusal reduction for the porcelain and PFM crowns is 2 mm and the reduction for the full cast metal crown should be 1.5 mm. Internal line angles and cusp tips should be rounded and the general occlusal anatomy should be maintained. Fabricating a reduction guide is recommended and helps to verify the second plane of reduction. Taking an impression and pouring a model of the preparation can be helpful to assess undercuts and path of insertion.

The Periodontics section is optional and only required in certain jurisdictions.  The candidate is evaluated for acceptability of the case for the examination, subgingival calculus detection, subgingival calculus removal, plaque and stain removal and treatment management. The candidate must remove subgingival and supragingival calculus and stain from 12 surfaces selected within 90 minutes.

The Restorative Dentistry section includes two separate sections: the preparation and restoration of a class III carious lesion on an anterior tooth using composite resin, and the preparation and restoration of a class II carious lesion on a posterior tooth using amalgam or composite resin. All lesions on the anterior tooth do not need to be treated by the end of the examination, but the candidate is expected, and will be evaluated, on the restoration of all existing lesions on the posterior tooth. An isolation dam is required during preparation and restoration of both teeth and can be removed later to adjust occlusion. There is a maximum time allowed of 7 hours for this section or a total of 9 hours if taking concurrently with the Periodontics section.

The DSE is the multiple-choice, computer-based portion administered at a testing center and is independent from the clinical sections. It assesses diagnostic and treatment planning knowledge. It consists of Patient Evaluation (PE), Comprehensive Treatment Planning (CTP), and Periodontics, Prosthodontics and Medical Considerations (PPMC) subsections. The test has 150 questions within 4 hours. A score of 75 percent is required to pass the DSE section.

My main recommendation is that you follow all the guidelines given and practice, practice, practice! I hope you find this information helpful and, if anything, it can at least be a starting point for you to ask questions about the subject. I encourage you to find more information regarding the ADEX examination and other requirements for licensing in your specific state.  Good luck!

Resources:

http://www.dentalboards.org/states/index.htm

http://www.cdcaexams.org/

https://cdcaexams.brighttrac.com/

http://www.cdcaexams.org/dental-exam-manual/

 

 

 

 

Policy Competence as Dental Professionals: Making a Difference

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    Longest (2010) defines policy competence as the “dual abilities to analyze the impact of public policies on one’s domain of interest or responsibility and exert influence in the public policymaking process” (p.28). DeBuono, Gonzalez and Rosenbaum (2007) take the definition even farther by stating that the United States won’t ever achieve optimal population health without public health practitioners embracing policy leadership. In other words, public health planners and practitioners need to contribute to the nation’s health policy or a significant improvement in overall health is unattainable. Policy competence involves understanding the policies that affect health services organizations, the process of policymaking, and the forces that affect those processes (Longest, 2004).  Longest (2010) describes how policy competence relates to dental professionals by stating, “Anyone professionally involved in the pursuit of health through any determinants has a vested interest in understanding how health policy is made at all levels of governments” (p.26).  I completely agree with the principle presented in this statement but I don’t know if every health professional displays policy competence. Every professional involved in healthcare should have a vested interest in understanding health policy but unfortunately that’s not always the case. The International Council of Nurses (2008) developed a 10-step advocacy framework to help health care professionals become more engaged in health policy. The 10 steps are as follows: take action, select an issue, understand the political context, build the evidence base, engage others, elaborate strategic plans, communicate messages and implement plans, seize opportunities, be accountable and catalyze health development. This advocacy guide is just one of the many tools available to help increase the policy competence of health care providers. 

       The Children’s Dental Health Project (CDHP, 2015) is an excellent example of how one policy-competent pediatric dentist can make large contributions to improved oral health. Dr. Burton Edelstein created the Children’s Dental Health Project in 1997 to be “the voice for children’s oral health” (para.3). The four main goals for the CDHP (2015) are: prevent childhood tooth decay, increase the number of children with meaningful dental coverage through Medicaid, CHIP and state insurance exchanges, build states’ capacity to improve oral health, and strengthen public awareness to encourage good health behaviors. These goals are only accomplished by working with policymakers and oral health advocates. Today, after a couple decades of hard work, the CDHP funded by several federal and state agencies, private foundations, and large corporations and organizations. If more public health and private dental practitioners were engaged in the policy making process that affects their every day jobs, then more people would be the recipients of improved access to and costs of dental care. 

References 

Children’s Dental Health Project (2015). Our story. Retrieved from https://www.cdhp.org/about/our-story 

Children’s Dental Health Project (2015). Mission and goals. Retrieved from https://www.cdhp.org/about/mission-and-goals

 Council of Nurses (2008). Advocacy guide for health professionals. Retrieved from  http://www.whpa.org/ppe_advocacy_guide.pdf 

 DeBuono, B., Gonzalez, A. R., & Rosenbaum, S. J. (2007). Moments in Leadership: Case Studies in Public Health Policy and Practice. 

 Longest, B. B. (2004). An international constant: the crucial role of policy competence in the effective strategic management of health services organizations. Health Services Management Research, 17(2), 71-78. 

 

Longest, B. B. (2010). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press. 

Pointers in maintaining successful periodontal tx

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Maintenance of periodontal health of the patient after treatment needs a program as important as the treatment to help the periodontal disease. Patients must understand the importance of maintenance program and the dental student must emphasize that preservation of the teeth depends on maintenance therapy. Patients who are not maintained in a supervised recall program regress back to recurrent periodontitis with increased pocket depth, bone loss or even tooth loss.

 

it is important in making sure that all subgingival plaque is removed during scaling and root planning for a successful periodontal tx. It is important to insure complete removal of subgingival plaque while treating periodontal disease to avoid any recurrent periodontal disease. If subgingival plaque is left behind during scaling, the bacteria regrows within the pocket. Inadequate subgingival plaque removal can lead to continued loss of attachment.

 

Continuous visit is necessary for meaningful long term maintenance prevention of periodontal disease. The visits are made up of of examination and evaluation of the patient’s current oral health, necessary maintenance treatment and oral hygiene reinforcement and restorative dental procedures.

 

Examination and evaluation – looking for any changes since the last visit, update of any changes in the medical history and evaluation of restoration, caries, occlusion, tooth mobility, gingival status, and periodontal and periimplant probing depths are some of the procedures done for recall appointments.

 

Checking plaque – patient should perform hygiene regimens regularly to minimize plaque. The recall visit should indicate the maintenance performed at home. If necessary additional instruction is given to improve the hygiene regimens. Continuous encouragements to reinforce the importance of the maintenance phase of treatment should be considered at this point.

 

The dentist or dental student should take a time out to explain to patients that oral hygiene is important in maintaining a healthy life style. Failing to take care of oral health can lead to many dental problems like bad breath, cavities, gum disease, sensitivities and even tooth loss. Also, adopting healthy life style, proper tooth brushing technique, flossing, and visiting the dental office regularly is key in successful periodontal tx.

 

 

 

 

 

Transition into Clinic

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The transition from didactic classes to seeing patients in the dental clinic is an especially exciting time, being that this is beginning of your lifelong career as a dentist. For most students, this transition occurs within the second or third year of dental school. I am currently a second year dental student, in the midst of balancing didactic classes and clinic once to twice per week. Seeing patients was something that I was initially very excited about, but I underestimated the amount of frustration and confusion that would come along with it. For those of you that will be starting this transition soon, here is some advice as to what to expect, and how to stay on top of your patients and requirements:

 

 

1. Keep organized. Organization is a key factor to accomplishing everything that you need to do in clinic. Have a plan for each patient ahead of time. Know what you will be doing during each appointment before the patient comes in.  By having a plan, this leaves no time wasted, and eliminates any scrambling to figure out what you need to do next before the appointment is over. Organization will allow you to be efficient with each appointment, and will help you reach your goal for each patient faster.

 

2. Keep up with your patients. When you are assigned a patient, it is important to call them, establish rapport, and let them know how long it will take to reach what they expect from you. This will eliminate any complications further down the road, as they will know what to expect in the dental clinic, and how long it will take. Establishing rapport is extremely important as well. You will be seeing these patients for numerous appointments, and having a positive relationship plays a role in treatment planning and performing treatment.

 

3. Be confident and stay calm. It is especially important to show confidence when speaking with your patients. A patient does not want a dental student to perform work on them if they are unsure of what they are doing. Be confident in the advice you give patients. Also, do not be intimidated by patients that are very forward. It is important not to let a patient boss you around. If a patient has certain demands that you cannot fulfill at the pace they expect, it is important to communicate properly. Sometimes setting “ground rules” may be necessary, so that the patient is aware of what to expect.

It is also important to stay calm. Treating your patient in the dental school will be a longer process than it would in private practice. If you tell your patients that from the beginning, this will reduce any anxiety or stress levels while they are in the chair. Keeping organized (as stated in #1) will also help reduce any stress, and keep you on track for what you need to complete for that appointment.

 

4. Do not be afraid to ask questions. Asking questions is critical to your learning process as a dental student. You are in dental school to learn, and are not expected to know everything. Asking questions helps you grow as a dental student. It is important to take the time to speak with faculty about any questions that you may have.  

 

 

What am I going to do after dental school?

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When graduating dental school you may have a feeling of mixed emotions. Although the fact that you will finally be a dentist is very exciting, if you aren’t sure about what career path you would like to choose you could end up feeling very overwhelmed and stressed. There are so many career path options these days it is sometime hard to decide which way to go, which is why it is important to begin thinking about it early. Some career options after graduation include: residency programs, Associateships, starting your own practice, buying out an older dentist, corporate dentistry, and group practice.

                If you are interested in pursuing a residency program, you really need to start thinking about it in the end of your second year. Most residency applications are due at the end of your third year and in order to get all your ducks in a row and become a competitive applicant you need to be ahead of the game. Residency programs alone have many options including AGD/AEGDs, Endodontics, Orthodontics, Prosthodontics, Oral Medicine, Oral Pathology, Oral Maxillofacial Surgery, Dental Radiology, Periodontology, and more. So knowing which one interests you early can help you to narrow down what you need to do to show that you are interested.

                If you are interested in going to work right out of dental school, so that you can start making some money, you have to start thinking about that early as well. As an associate you will be working in someone else’s practice seeing your own patients. The process of becoming an associate is very similar to the average job hunt. Most times you are not the only one applying for the position so the sooner you know who you are interested in working with, the better. If you want to open your own practice or buy out an older dentist you need to be ready to make some pretty big financial commitments. On the other hand, if you don’t really want to open up your own practice or don’t feel comfortable enough with the business side of dentistry to embark on an associateship, you may want to consider working in a corporate practice. When you work in a corporate practice you don’t have to worry so much about the business side of things. You simply show up, do your work, and go home. Payroll, ordering supplies, staffing, etc. is all handled by the corporate managers. However, a lot of dentist have said that corporate dentistry pushes the moral ethics of the practitioners working there in a less than ideal direction, as the pressure to produce in order to receive a good income gets to them.

In conclusion, you should really begin to seriously think about which direction you want to take your career in during the second year of dental school. Don’t wait until the last minute because you may not have the opportunities you would like as an option. Remember, “Early bird gets the worm!”

Writing a Clinical Note: The Basics And a Bit More

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Be concise. Document what you do or plan to do AND what you’ve discussed. Primary goals of a good note are to be in accordance with medicolegal standards, and be able to draw conclusions when reviewing past records. Find your own systematic way of documenting appointments early on, and always try to improve on it.

  • Start with date of tx and brief summary of tx being done
    • E.g. 1/31/16 #18 PFM crown preparation and final impression
  • If not done previously, have on record a consultation appt, patient’s C/C
    • Diagnose disease
    • Very important. Do Not just list tx plan, include reason for tx
    • Review proposed treatment – reason for tx (distal lesion present radiographically, nonrestorable lower molar, etc – This is the diagnosis)
    • Alternatives , including no tx 
    • Risk – including risk of no tx
    • Questions – All patient’s questions were answered
    • Include any concerns patient has that may be relevant in future
    • Informed consent – document that it is signed, patient given copy
  • Medical history
    • If already on file, include “Medical history reviewed and changes were updated”
    • Premedication required? Sedative, antibiotic, etc
  • VITALS VITALS VITALS 
    • Put BP, HR in note. If 2 recordings taken, include both, and time between
  • Local anesthesia, % used, # of carpules
    • Can mention topical if you want; type and % used (20% benzocaine)
    • Method of local anesthesia: IAN, buccal block
  • Describe tx done, but you do not need to list steps of tx like a how-to
    • E.g. #18 prepared for PFM using high speed and copious irrigation
    • Don’t need to be specific if tx is routine
  • Do include details of all materials being used
    • “Impression taken with Aquasil heavy and light body”
      • this is especially important when trying new materials. Good records allow you to look back and make conclusions on crown margin adaptation and material used for impression
    • Lab materials come with sticker, document these materials
  • Document post op instructions, and if you gave a written form
  • Post op medications
    • how much prescribed and how to take it
  • Briefly describe how patient did during appt
    • E.g. patient did well throughout appt, except during local anesthesia
  • If sedated, document condition upon leaving and who is escorting them
    • Patient left in ambulatory condition (i.e. able to walk)
  • Document follow up with patient, if applicable
    • Great practice builder to follow up with patients. Call them personally
    • Schedule surgeries (extractions, perio flaps, etc) on Fridays and develop habit of calling Friday night/Saturday morning

Impact of Increased Orphan Drug Growth on Payer Dynamics

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    During winter break I finally had a chance to catch up with a college buddy of mine who currently works in healthcare consulting. He's been learning a great deal about the pharmaceutical industry and insurance policy, much of which he was able to share with me. It was a nice change of pace to take a step back from the hard dental science and take a look at healthcare form a macro perspective. As providers we assess our patient’s medical histories and their current drug regimen with little regard to the economics behind them. We understand the basic science and interactions of the drugs we prescribe but little thought goes into the determinants of pricing, and the pharmaceutical giants behind them. This discussion prompted my research in orphan drugs and their impact on payer dynamics. 

  

    In 1983, the Orphan Drug Act (ODA) promoted the research and development of novel therapeutics aimed at treating those with rare diseases that impacted fewer than 200,000 people in the United States. At the time, and to this day, the ODA was seen as a major step forward in helping those with life-threatening diseases for which treatment had relied solely upon supportive therapies that didn’t alter the disease path or significantly relieve symptoms. The ODA encouraged heightened research and development by offering tax credits for the cost of clinical research, annual funding to help reduce the costs of research and development and, crucially, a seven-year period of exclusivity following orphan drug approval by the Food and Drug Administration (FDA).  

  

    In the following years, numerous pharmaceutical companies began to shift their focus toward orphan drug development given the increased profitability that resulted from the seven-year exclusivity period. Although the impact of the ODA was not immediate, its impact has become increasingly evident in recent years. Orphan drugs composed ~15%  ($176B) of all prescription drug costs in 2014, and the growth of orphan drugs from year to year currently doubles that of the remainder of the prescription drug market. Currently, large pharmaceutical companies, with extensive marketing capacities and price leveraging abilities, are responsible for the majority of orphan drug development.  

  

      Further contributing to the significant growth of orphan drugs has been the relatively unregulated pricing mechanisms for these therapies. Pharmaceutical companies have recognized that they receive no pushback from the FDA on behalf of the price of an orphan drug (the FDA does not consider drug pricing) and, historically, relatively minimal resistance from payers since these drugs are used to treat such a small population of patients. As a result, more orphan drugs were approved in 2015 than in any previous year, and their prices have reached extraordinary levels, with some “ultra orphan” therapies garnering $500,000 per year or more. 

  

      However, in more recent years, payers have begun to express greater concern regarding the rising costs and utilization of orphan drugs. These payers have also faced increasing difficulties as diagnoses for rare diseases have grown at faster rates. With the approval of greater quantities of orphan drugs has come the increased incentive for physicians to actively diagnose individuals, given that this diagnosis can now lead to a more successful treatment option. As such, a number of commercial payers have attempted to solve this problem by implementing 4th and 5th “specialty” and “orphan” tiers on the copayment structure of their insurance plans, under which patients are charged a greater percentage of the overall cost of each orphan drug prescription. Other private plans require patients to pay a set fee – potentially a few hundred dollars – each time they acquire an orphan drug from the pharmacy. While a number of the plans limit the amount that a patient is responsible to pay in a given year, patients can still be left paying $10,000 or more in a given year. Plans that do not implement patient payment ceilings can require patients to pay $50,000 or more each year for their therapies. 

  

    Moving forward, the increased growth of orphan drugs will increasingly become an area of intense focus for payers. Current views suggest that, in the short-term, payers will continue to shift more of the costs for these drugs onto the patients who are utilizing them, either through greater copayment and coinsurance rates for these specialty tiers or through increased annual patient payment ceilings. Payers will likely begin to more critically evaluate drug efficacy and safety on their own and determine which drugs they will choose to reimburse – some of them have already began to implement this formulary review process. While these efforts may alleviate the financial burden of orphan drugs in the short-term, they will not provide a long-term solution. Current opinions suggest that there will likely occur a breaking point – one in which insurance companies display significant resistance to these rising prices such that orphan drug manufactures are required to reevaluate their pricing mechanisms. However, this is likely to add another host of issues into current reimbursement dynamics, and it is unlikely that drug manufactures would continue to invest in orphan drug development to the same extent if their potential profits were reduced.