Expert panel updates imaging safety guidance

The American Dental Association no longer recommends using thyroid collars on patients during radiographic exams.

Before taking radiographs, dentists should also consider what diagnostic information they need from the images to benefit patient care or substantially improve clinical outcomes, according to updated recommendations developed by an expert panel established by the ADA Council on Scientific Affairs.

The recommendations, published online Feb. 1 by The Journal of the American Dental Association, aim to improve radiation protection in dental radiography and cone-beam computed tomography. Medical physicists with the U.S. Food and Drug Administration supported the development of the recommendations, which are also aligned with recent guidance from the American Academy of Oral and Maxillofacial Radiology. The recommendations are the first on dental imaging safety and radiation protection from the council since 2012.

After reviewing nearly 100 articles, guidance documents and regulations related to radiography, the expert panel determined thyroid and abdominal shielding during dental imaging is no longer recommended, and the use of these forms of protective shielding should be discontinued as routine practice. Evidence indicates modern digital radiography equipment and restricting the beam size only to the area that needs to be imaged better protect patients against radiation exposure to other parts of their body. Lead aprons and thyroid collars can also block the primary X-ray beam, preventing dentists from capturing the image they need.

“When this happens, more radiographs need to be taken, and unnecessary X-rays are what we want to avoid,” said Purnima Kumar, D.D.S., Ph.D., professor of dentistry and chair of the department of periodontology and oral medicine at the University of Michigan School of Dentistry and chair of the ADA Council on Scientific Affairs. “The central point of these recommendations is that clinicians should order radiographs in moderation to minimize both patients’ and dental professionals’ exposure to ionizing radiation.”

The recommendations — which apply to all patients, regardless of age or health status, such as pregnancy — also advise dentists to safeguard patients against unnecessary radiation exposure by:

• Ordering radiographs to optimize diagnostic information and enhance patient care outcomes and making every effort to use images acquired at previous dental exams.
• Using digital instead of conventional radiographic film for imaging.
• Restricting the beam size during a radiography exam to the area that needs to be assessed.
• Properly positioning patients so the best image can be taken.
• Incorporating CBCT only when lower-exposure options will not provide the necessary diagnostic information.
• Adhering to all applicable federal, state and local regulations on radiation safety.

“We encourage dentists and their teams to review these best-practice recommendations, comply with radiation protection regulations and talk with their patients about any questions or concerns before ordering dental imaging,” Dr. Kumar said.

There may be state laws or regulations mandating continued use of certain equipment. Dentists should abide by the laws and regulations where they practice.

To view the complete recommendations, visit JADA.ADA.org. They will appear in the April issue of JADA.

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Masooma Rizvi, RDH

Gingival recession, the apical shift of the gingival margins,^1,2 is the process in which the margin of the gingiva that surrounds the teeth wears away or pulls back, exposing surfaces of the tooth or the tooth’s root.^3-5 This common finding in clinical practice can lead to dentinal hypersensitivity among patients during dental hygiene visits.² To ensure patient compliance with their dental care and recare interval maintenance, it becomes imperative for practitioners to use desensitizing agents on patients to reduce dentinal hypersensitivity due to gingival recession. Various preventive measures can be taken during hygiene visits and at home for patients experiencing dentinal hypersensitivity associated to gingival recession.

Gingival recession is the result of a shift of the gingiva, positioned 0.5–2.0 mm coronal to the cementoenamel junction (CEJ) in a healthy periodontium, beyond the CEJ.⁶ Recession is a prevalent dental issue because of its gradual nature⁴ that affects most middle-aged and older people.^4,7

Masooma Rizvi, RDH, has been practicing clinical dental hygiene for five-and-a-half years in general practices across Halifax Regional Municipality in Nova Scotia, Canada. Her professional expertise caters to patients’ dental concerns relating to periodontal disease and orthodontic needs. Outside of work she likes to travel, read, and spend time with family and friends.

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The latest research from the Weizmann Institute of Science unveils a newly identified autoimmune disorder affecting tooth enamel development, providing valuable insights into the mysteries surrounding enamel irregularities. Headed by Professor Jakub Abramson, the study investigates a rare genetic syndrome named APS-1 and its correlation with impaired enamel production. Significantly, this disorder is also prevalent in children diagnosed with celiac disease, suggesting a broader link between autoimmune conditions and dental health.

Tooth enamel, acknowledged as the toughest and most mineral-rich substance in the human body, plays a vital role in safeguarding teeth. However, the study reveals that one in ten individuals and a third of children with celiac disease exhibit defective enamel, heightening sensitivity to temperature changes and accelerating decay. Despite the widespread occurrence of enamel issues, the specific causative factors remain elusive in many cases.

Published recently in Nature, the study delves into the autoimmune nature of enamel defects observed in APS-1 individuals. Given that APS-1 patients grapple with various autoimmune diseases, the researchers theorize that the enamel abnormalities may be autoimmune-related, indicating a potential immune system assault on proteins or cells crucial for enamel formation.

The investigation identifies a mutation in the autoimmune regulator (Aire) gene during the exploration of this mechanism. A key player in educating T cells, essential for averting autoimmune responses, the Aire gene mutation disrupts the critical process of instructing T cells to distinguish between the body’s own proteins and external substances. Consequently, T cells lacking proper education are released from the thymus gland, leading to the production of antibodies targeting enamel proteins.

The study intriguingly draws parallels between APS-1 and celiac disease, a prevalent autoimmune disorder affecting approximately 1% of the Western population. Significant numbers of celiac patients were found to possess autoantibodies targeting enamel proteins, akin to APS-1 cases. To comprehend this link, the study explores potential shared proteins between the intestine and dental tissue.

A noteworthy discovery arises from the focus on k-casein, a major component of dairy products. The study reveals that antibodies against k-casein, generated in response to specific food antigens in the intestines of celiac patients, may inflict collateral damage on enamel development. Considering the widespread use of k-casein in dairy products, the study’s implications extend to the food industry.

Professor Abramson underscores the common occurrence of impaired tooth enamel development for unknown reasons among individuals. The study not only enhances our understanding of this phenomenon but also suggests the potential for diagnosing this newfound disorder through blood or saliva tests. Early diagnosis, especially in children, holds the promise of enabling preventive treatment for tooth enamel issues, potentially revolutionizing dental healthcare practices.

In summary, this comprehensive study not only unravels the intricate connection between autoimmune disorders and tooth enamel defects but also carries implications for medical diagnosis and the broader food industry.

The study, “Autoimmune amelogenesis imperfecta in patients with APS-1 and coeliac disease,” was published November 2023 in Nature.

FEATURED IMAGE CREDIT: Markus Winkler on Unsplash.

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Even if you have a practice with 5-star customer service, you’ll still encounter patients who are deemed difficult—individuals who simply don’t cooperate in some way, shape, or form. Dealing with difficult patients can upset the staff, send negative reverberations throughout the practice, cause stress and frustration, and even lead to a loss of revenue due to their behaviors and the time needed to address them.

Here are 4 steps for effectively dealing with difficult patients:

1. Maintain Your Composure: The first step in handling a difficult patient is not to let it bother you. While this may sound easier said than done, it’s essential not to internalize the difficult patient’s behavior or comments. Instead of being shocked or surprised, expect occasional encounters with challenging patients. Try viewing it as a challenge or game to be won – find ways to relieve stress and possibly satisfy the patient.
2. Seek Understanding: Be curious enough to try to figure out why the patient is being difficult. Initially, it’s natural to perceive the patient as unfair, ridiculous, or annoying. However, there is usually an underlying reason that triggers the difficult behavior. It could be a minor inconvenience, financial concerns, personal preferences, or discomfort with a team member. Taking a moment to understand the root cause of their behavior can help you find a solution.
3. Ask for Feedback: Engage the patient by asking how you can make their experience better. This approach often disarms difficult patients because they may not expect someone to genuinely listen to their concerns. By simply asking what could enhance their appointment’s comfort, convenience, or enjoyment, you demonstrate a willingness to address their needs. This can help move the patient back into rational and logical behavior.
4. Offer Reasonable Solutions: Determine if the patient’s request or concern can be reasonably addressed. In some situations, offering a simple solution can alleviate the patient’s dissatisfaction. For instance, a restaurant might offer a free dessert to appease a customer unhappy with service. Similarly, in a dental setting, finding a practical solution, such as scheduling the patient for the first appointment of the day to avoid delays, can resolve their issue. Often, acknowledging the problem and taking steps to rectify it can significantly improve the patient’s attitude.

Dealing with difficult patients can be disruptive and challenging. They can create stress, tension, conflict, financial losses, and disrupt the practice’s daily operations. Following the general guidelines mentioned above can help you manage and satisfy most difficult patients effectively. However, in rare cases, you may need to consider whether it’s in the practice’s best interest to continue serving an extremely challenging patient.

Ultimately, the goal is to equip your team with the tools and principles to handle difficult patients professionally and skillfully, ensuring the best possible experience for both the patient and the practice.

ABOUT THE AUTHOR

Roger P. Levin, DDS, is the CEO and founder of Levin Group, a leading practice management consulting firm that has worked with over 30,000 clients to increase production. A recognized expert on dental practice management and marketing, he has written more than 60 books and over 4,000 articles and regularly presents seminars in the U.S. and around the world.

To contact Dr. Levin or to join the 40,000 dental professionals who receive his Practice Production Tip of the Day, visit www.levingroup.com or email rlevin@levingroup.com.

FEATURED IMAGE CREDIT: Vitalii Vodolazskyi/Shutterstock.com.

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The European Commission has published draft legislation to phase out dental amalgam in 2025. The revision of the EU Mercury Regulation has been expected since December 2022 and includes a ban on mercury-containing light bulbs and lamps.

Since there are viable mercury-free alternatives, dental amalgam shall no longer be used for dental treatments of any member of the population from January 1, 2025. The proposal also includes a ban on its manufacture and export, making an important contribution to reducing mercury emissions internationally.

The use of dental amalgam for children under the age of 15, as well as breastfeeding and pregnant women, has already been banned in the EU since 2018.

Amalgam consists of 50% mercury, one of the world’s most toxic substances. Despite all precautions taken in dentistry, mercury inevitably enters the environment, where it transforms into the even more toxic form methylmercury and contributes to mercury accumulation in the fish we eat.

Before the Commission’s proposal can take effect, it must be approved by the European Parliament and the Council. Given the delay, however, the Parliament will have to move fast to complete all the formalities before the 2024 parliamentary elections.

“This is a milestone. Finally, we get a regulation for dental amalgam, the largest remaining use of mercury in Europe and a serious threat to health and the environment,” says Florian Schulze, director of the European Network for Environmental Medicine, who has been pushing for the phase-out for years.

“Numerous countries, such as Sweden, Norway, Moldova, Lithuania, Switzerland, Bolivia, Ecuador, Indonesia, the Philippines, or Zambia, have already phased out the use of amalgam. Most recently, Poland had replaced amalgam with alternatives in the statutory health insurance,” explains Schulze.

FURTHER INFORMATION

Proposal for a REGULATION OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL amending Regulation (EU) 2017/852 of the European Parliament and of the Council of May 17, 2017, on mercury as regards dental amalgam and other mercury-added products subject to manufacturing, import, and export restrictions: https://ec.europa.eu/transparency/documents-register/detail?ref=SEC(2023)395&lang=en.

Global Overview of Countries Phasing Out Dental Amalgam: https://environmentalmedicine.eu/mercury-free-dentistry-for-planet-earth/.

FEATURED IMAGE CREDIT: Tobias Blad-Stahl/Shutterstock.com.

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Gordon J. Christensen, DDS, PhD, MSD

“I have been practicing for many years, and most of the indirect restorations I have placed in the past could be cemented with correct occlusion as they came from the laboratory. However, in recent years, I am seeing some crowns that are not even close to touching the opposing arch of teeth, and others are too high. These crowns come from my usual laboratory that has had near-optimal occlusion on the crowns in the past. Additionally, I still have some zirconia crowns coming off in service. What can I do about these challenges?”

Dr. Christensen: Both you and I are seeing the same problems, and I have several potential reasons and solutions to share.

Labs are making crowns out of contact with the opposing arch (figure 1). Some labs are making crowns up to 0.5 mm too low (500 microns or the thickness of at least 10 human hairs) as measured by Clinicians Report (CR) scientists. This reduction in crown height reduces the completed restoration occlusal thickness, potentially compromising crown strength and causing tooth extrusion of both the tooth being crowned and the opposing tooth, as well as stress on adjacent teeth.

Figure 1: Note the significant lack of occlusal contact on this zirconia crown example as sent from a large dental laboratory.

Why would technicians do this? Currently, the most popular crown types—zirconia and lithium disilicate—are very difficult to reduce in height and difficult to finish and polish smooth in the mouth, taking clinical time and frustrating the dentist and patient. The technician and the dentist would like to have the patient say the crown feels just right when closing the two arches together. Making the crown shorter with no occlusal contact avoids removal of ceramic on the occlusal/incisal surface when seating.

Most zirconia and lithium disilicate crowns are initially one color without significant translucence. Thus, most ceramic crowns have a layer of low-fusing ceramic fired over them to provide individual characterization of color and translucence on the crown. If the occlusal/incisal crown surface is adjusted, removing the superficial layer of low-fusing ceramic, the underlying zirconia or lithium disilicate is exposed and the restoration’s color and translucence are compromised.

In discussions with CR scientists and clinicians, they disagree with placement of superficial low-fusing ceramic. They have proven that the superficial glaze and stain wear off over time and wear the opposing teeth until worn off (personal communication, Rella Christensen, PhD).

Successful cementing of zirconia crowns: Still a problem

Zirconia crowns in dentistry: Uses, clinical challenges, and solutions

Some labs are spacing the intaglio (internal) surfaces of crowns to reduce seating difficulty as measured by the CR science team (figure 2). You have probably noticed that many current zirconia crowns do not have a definitive seating location and tend to be mobile on the tooth until cemented. This unfortunate situation is directly related to internal spacing. So, how much internal spacing is necessary for optimum seating?

Figure 2: This crown came off in service and is from one of CR’s in vivo zirconia studies. It was placed only a short time before the photo was taken. Note the thickness of the resin cements as observed in the void area on the occlusal intaglio surface of the crown and the staining on the margins that occurred after a very short time.

You may remember when stone dies were the norm. A layer of lacquer was painted on the dies to allow space for the cement and reduce hydraulic resistance caused by the cement during seating. That layer was about 25 microns thick, which is probably enough even for the digital needs of today. However, if there are undercuts on the prep, those undercuts need to be filled with some material to avoid the digital directed milling device automatically overspacing the digital prep model. CR scientists have measured up to 500 microns (one-half mm) of internal spacing.

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Elizabeth S. Leaver

Researchers have developed a method of restoring tooth enamel by adding a complex of amino acids to hydroxyapatite, a strategy they say has “huge potential for application” in dental practices.

Hydroxyapatite is a naturally occurring component of teeth and bones, comprising 97% of tooth enamel and 70% of tooth dentin, and mixing it with amino acids can create coating that replicates the composition and microstructure of natural tooth enamel.

According to the study, Engineering of biomimetic mineralized layer formed on the surface of natural dental enamel engineering, a biomimetic mineralized layer on the surface of native dental tissue (bio-template) was key to that replication. They achieved that mineralized layer with nanocrystalline carbonate-substituted calcium hydroxyapatite (HAp), calcium alkali, and a complex of polyfunctional organic and polar amino acids.

“By applying the set of structural and spectroscopic methods of analysis we have confirmed the formation of a mineralized biomimetic HAp layer on the surface of bio-template with properties resembling those of natural hard tissue … our work aimed to develop a concept for the engineering of a biomimetic mineralized layer on the surface of natural dental tissue as well as the study of its structural-spectroscopic features.”

Current restorative techniques involve acid etching of the enamel to increase the bonding effect, which sometimes leaves behind products that aren’t conducive to the bonding of enamel and synthetic materials.

The new method of using HAp can be used to reduce the sensitivity of teeth in case of enamel abrasion or to restore it after erosion. Overall, researchers said their strategy for biomimetic engineering and technique for enamel surface pre-treatment to provide tissue mineralization has a “huge potential for application in dental clinic practices.”

A growing cohort of dental professionals espouse HAp for its usefulness as a natural means of remineralization: “HAp should be a no-brainer when it comes to substances able to remineralize our teeth,” wrote Jacqueline Carcaramo in “Hydroxyapatite: A way to brush your teeth with their natural components?“ “The benefits of this ingredient being biomimetic are that once we place it on the teeth, the body knows what to do with it as it is already a familiar component. The small particles adhere to the tooth structure and fill in the weaker, demineralized areas, binding to the tooth and creating a stronger surface. This can also decrease sensitivity and give a whiter appearance to the teeth.”

Download the PDF: Engineering of biomimetic mineralized layer formed on the surface of natural dental enamel

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Roger P. Levin, DDS

No dentist wants to hear “work faster.” Those words typically create the image of rushing, stress, and even mistakes. However, as dentistry continues to evolve, one way to significantly increase production is to up your practice speed. There are many ways to increase the speed and flow of a typical day, but one of the best is to simply up the speed of the doctor or team members.

Enhancing skills increases speed

Large businesses understand they must provide significant training for their employees. Some companies even have the equivalent of training universities in their organization, with many types of courses and skill set developments designed to advance employee quality and efficiency. Most dental practices are small businesses that don’t have the advantage of a training university. But they can still enhance overall practice speed by identifying a specific skill set enhancement that will enable team members and doctors to work faster.

Keep in mind, avoid stress, rushing, or anxiety when upping your speed. The idea is to increase the speed of performance through advanced training rather than simply trying to work faster. Here are three ways to improve the speed of doctors and team members.

1. Engage in continuing education and training

Identify continuing education or advanced training that will allow everyone to do their job faster and more efficiently. A great example of this is to identify skills that dental assistants have not yet mastered. Advanced training for the assistants would allow the doctor to delegate more tasks to them. This helps doctors move between rooms more efficiently by using an accelerated scheduling model while increasing the number of patients seen and the number of procedures performed per day.

2. Use technology to your advantage

Technology can also increase speed. A good example is that many practices use text message confirmations rather than phone calls. Texting rather than calling to confirm at two weeks, two days, and two hours before appointments has a better chance of decreasing last-minute cancellations and no-shows. There are other workflow technologies that can also improve practice speed but be sure to carefully evaluate them before using.

3. Develop a schedule based on reaching a daily production goal

Your schedule can be mathematically calculated to ensure that treating the right volume of patients on any given day will achieve the daily production goal. For practices that operate far below their production potential, simply reevaluating and mathematically recalculating the schedule will allow them to comfortably increase production.

Speed counts

In any business, speed counts. For example, manufacturing companies work hard to find ways to increase the output of their products. Often, suggestions from workers are what lead to increased speed, therefore, dentists should be comfortable asking team members for their ideas. You can also talk to colleagues about how they’re performing certain procedures to determine if they take less time.

One of the fundamental challenges we see in many practices is the impact of existing habits. If a crown prep appointment has always been 90 minutes, it will continue to be 90 minutes if no one ever stops to think that it could be 80 minutes. Breaking your habit of spending 90 minutes on a crown prep to save 10 minutes on each of these treatments throughout a year adds up to a significant number of days of extra production.

Speed is important for many reasons. Use the recommendations here to help increase the speed in your office and you’ll start seeing an increase in production as well.

Editor’s note: This article appeared in the August 2022 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.

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Roger P. Levin, DDS

Like all businesses, dental practices go through stages of growth and development. The ultimate success of any dental practice depends on how well it navigates the essential phases of building and maintaining a highly successful practice. During the last 30 years, Levin Group has studied top 10% performing practices. We’ve identified 17 common principles in these practices, along with an understanding of their processes. This research has allowed us to identify four key phases that every practice must pass through to achieve superior results, continual improvement, and consistent growth.

• Phase 1: Capable and stable staff
• Phase 2: Proven business systems
• Phase 3: Leadership
• Phase 4: Relevant strategy

Each of these phases has a basic set of principles. It’s possible to build a highly successful practice without implementing every principal. The challenge is trying to figure out in advance which principles you can omit without impeding your march toward success. Therefore, we encourage each practice to examine each principle, evaluate how well they’ve implemented or not implemented that principle, and determine what needs to be done. It’s in the best interest of most practices to implement most of the principles.

Breaking down the phases

In phase 1 the practice is growing, and staff members are being added. In the current era it is very difficult to hire highly trained and experienced dental staff and many new or fairly new practices can’t afford highly trained staff. The reality is that many practices will have to hire for attitude over skill and then train new hires.

You must train the team in phase 2. Training, plain and simple, is best accomplished by implementing excellent step-by-step comprehensive business systems. For 37 years we’ve watched practices increase production and profit and we’ve learned that the absolute key factor is implementing the right systems. Scheduling, collections, hygiene production, managing no-shows and late patients, insurance management, and a host of other full and partial systems all contribute to team training. Implement your systems and the team will follow them. You’re giving them an exact playbook of what to do, how to handle their positions, and how to perform at superior levels.

You want to be a great leader in phase 3. In a nutshell, the first step of leadership is acting the way you want your team to act. The second step is delegating everything possible to the team, and I mean everything. I call it extreme delegation. A dentist should be doing what only a dentist is allowed to do. Somebody else in the practice should be responsible for everything else.

And guess what? Team members really like this. People like to know you trust them, and if they have great attitudes, they enjoy the challenge of increased responsibility. Don’t over-think and complicate leadership. Great leaders have compassion, care about their teams, and behave accordingly. You can go deeper and establish your core values, mission, and vision, but start by acting the way you want the team to act.

Phase 4 is very different from the others. It’s not about the team, attitude, training, or delegation, but about strategy, the future, and the five-year plan. It’s about knowing exactly what will be accomplished by what deadline and by whom during the next five years. Strategy is the backbone of every company and one of the most crucial factors in success. When we meet with practices that used to perform well but are now in decline, rarely do they have a strategic plan. They did a lot of things right, got to a plateau, and then didn’t change as the world changed, or they didn’t change in the right direction. Practices move back on track every time they develop a good strategic plan.

Dental practices are like organisms—always developing and changing. Is your practice ready to evolve and grow? I hope so. As one practice member told me recently, “We spend a lot of time here. We might as well make it a great place to be.” I wholeheartedly agree!

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Roger P. Levin, DDS

Dentistry, like all industries, is going through a continual and rapid transformation. As this change occurs, there are emerging trends and challenges that will have a direct effect on dental practices. Understanding what the trends are will allow practices to establish short- and long-term strategies to ensure a successful future.

The staffing crisis and shortage

Trend and challenge

Staffing is more than a challenge; it is a literal crisis for dental practices. In the Dental Economics/Levin Group Annual Practice Survey of 2021, we found that approximately 65% of practices were seeking at least one additional team member. We also estimate that up to 10% of full-time dental hygienists have left the profession. This is beginning to have a direct negative impact on practice production, day-to-day operations, and levels of stress and anxiety. Practices will need to be more proactive and rethink how they hire and manage the team.

Recommended solutions

While there are no magic bullets, there are several potential solutions for hiring new team members:

1. Regular online advertising. Make your ad stand out. Talk about the practice, purpose, fun, career opportunities, teamwork, and supportive environment. Be different and don’t look like every other ad.

2. Signing bonuses. Offer a signing bonus that is significant enough to attract attention. If a signing bonus helps you quickly hire an employee, it will save you from spending enormous amounts of time in the hiring process.

3. Cross-training your team. Turnover in dental practice staff is at an all-time high. If you don’t cross-train your team to perform all the responsibilities within the practice, you’ll be caught short if someone leaves and won’t be able to cover important practice tasks.

4. Longevity bonuses. Bonuses for five-, 10-, 15-, and 20-year longevity go a long way toward keeping people in the practice, and set a goal in their minds. We are now hearing team members say “Next year, I get my tenure bonus.” That’s a good thing!

5. Part-time employment. Reach out to former team members to see if anyone will come back, even on a part-time basis. Hiring part-time people or bringing back former staff members for part-time employment can help create the necessary coverage for a practice.

Dental insurance reimbursements

Trend and challenge

Dental insurance companies are typically lowering reimbursements as opposed to raising them. This happens differently in various regions of the country and for different dental insurers. In a time of inflation, when dental practices should be increasing fees simply to keep pace, dental insurance companies are not adding inflation adjustments to their reimbursements. If inflation rises and reimbursements remain stable, the only solution is to increase practice production to offset the effects of inflation.

Recommended solutions

The antidote to lower dental insurance reimbursements is to improve practice systems and efficiency.

1. Accelerated scheduling. Implement a true accelerated scheduling model where a doctor can work two or three rooms, with each room having its own highly skilled full-time assistant. As doctors move back and forth between rooms in a true accelerated scheduling model, they have the potential to increase their production immediately by 30% if there is sufficient patient flow. Willingness to delegate significantly to the dental assistant is a key factor, so assistants must be highly trained with ongoing education.

2. Longer appointments. Longer appointments that can handle multiple treatments often create high levels of practice efficiency. Overhead in certain long appointments can drop by as much as 20% after 90 minutes; as well, patients find longer appointments convenient, and longer appointments typically represent higher production.

3. Same-day treatment. Same-day treatment is now becoming essential for many practices to reach the daily production goal. Between dentists and hygienists, there are many opportunities to identify treatment and have the patient complete treatment that day, which is convenient for the patient and the practice and increases practice production toward the daily goal.

4. New patients. New patients, of course, are essential to production. But you may be surprised that the average new patient production in the first 12 months is 200%–300% higher than the average active patient. Also, scheduling new patients sooner increases practice production faster.

5. Emergency patients. Get emergencies in that day. The case acceptance on emergencies is typically extremely high, often as high as 97%. Emergencies add to production.

6. Procedural time studies. Consider performing procedural time studies to evaluate the scheduling system. Saving 10 minutes per hour in a dental practice amounts to the equivalent of two months a year of increase to doctor production based on a four-day week. In a 36-year career, this adds up to an extra six years of increased doctor production time.

Expansion of DSOs

Trend and challenge

Like it or not, DSOs are part of the dental profession. In recent years they have been growing and will continue to grow for many years to come. However, while it’s unknown at this time what percentage of practices will come under the DSO-style umbrella, private practice is still alive and well and will continue.

Admittedly, DSOs do offer advantages. They have strong marketing power that can benefit several affiliated practices in a geographic area. They have the purchasing power to procure supplies, materials, equipment, and technology at lower cost. Some DSOs even have in-house training and offer multiple specialty services.

For independent private practice dentists, DSOs represent a legitimate competitive factor that has emerged in dentistry in recent years. However, there are many opportunities for dental practices to address DSOs, including joining buying groups, participating in study clubs for continuing education, hiring expert trainers, and attending clinical institutes.

One question we are often asked is whether a practice should sell to a DSO. This decision is individual for each practice based on several different parameters. Questions that should be asked include:

• How will it affect a pathway to financial independence?
• Is the dentist ready and willing to be an employee?
• How much change will a DSO insist on for the practice?
• What percentage of the purchase price will be held back based on production over the next few years?
• What are the DSO’s culture, values, and vision?

Recommended solutions

The recommended solution is to build and maintain the best-run practice that you can. Keeping the practice systemized, efficient, and simplified is critical to success. Advancing technology will make daily dental practice easier and more efficient and allow for increased production. The concept of technology workflow in practices is continuing to emerge, and technologies are becoming excellent in advancing comprehensive clinical treatment. In addition, the practice should be designed as an extremely well-run business with documented, proven, and step-by-step systems that allow the team to become highly trained and manage day-to-day operations effectively.

Staff burnout

Trend and challenge

Stress, anxiety, fatigue, and burnout in dentistry are at higher levels than ever before. It is similar in many fields due to the complexity of moving through the pandemic and managing a business.

Keep in mind that burnout is not a short-term effect; it is recognized as an occupational phenomenon by the World Health Organization (WHO), and it should be addressed preventively if possible. A team that suffers from burnout, fatigue, anxiety, or stress is a less effective team and could result in individuals leaving the practice permanently.

Recommended solutions

There are numerous ways to prevent burnout-related fallout. Here are some that you might consider:

1. Take care of yourself. As always, sleep, nutrition, and exercise are part of the solution. It simply makes sense that if you get enough rest, eat well, and exercise, your stress level and pathway to burnout will be reduced.

2. Take time off. Make sure you have adequate downtime. Taking vacations and days off, enjoying weekends, and spending time with people you love all contribute to less burnout.

3. Take care of your team. If you take care of your team, they take care of you. Having monthly surprises such as lunches, stocking the refrigerator with food, and giving out gift cards all demonstrate caring. It is also essential for team members to have vacations so that they get downtime and rest. Finally, periodically meeting with team members for 10 or 15 minutes just to check in on them goes a long way toward avoiding burnout and showing them that you genuinely care.

At the time I am drafting this article, what will happen with the economy, gas prices, global conflicts, and interest rates is unknown. There will always be good economic cycles and not-so-good ones. The key to success in any business is to be proactive and resilient. Great leaders think ahead. Systemizing the practice, training the team, taking care of the team, building a culture of excellent customer service for patients, and having excellent financial management all go toward the heart of building and maintaining an extraordinarily successful practice.

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