Tfda julyaugust 2014 issuu

Legislative Session

Supported Candidates

Delinquent Accounts

Drug Monitoring

Health Care Reform

VOL. 26, NO. 5 • 2014 JULY/AUGUST

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July/August 2014 Today's FDA 1www.floridadental.org

contentsc o v e r s t o r y

42

Today’s FDA is a member publication

of the American Association of Dental

Editors and the Florida Magazine Association.

Read this issue on our website at: www.floridadental.org.

Locating the Denture Smile Line

n e w s 10 news@fda

17 Board of Dentistry Meets in Jacksonville

18 House of Delegates

20 2014 Legislative Session

23 Political Action Committee: Supported Candidates

25 Statewide Medicaid Managed-care Roll-out

f e a t u r e s32 Fill Out My Survey

34 Can “Nice People” Collect Delinquent Patient Accounts?

36 Odontogenic Infection Update: A Case

46 Prescription Drug Monitoring Program Aids Dentists in Managing Controlled Substances

54 Celebrating Member Milestones

58 Intentional Replantation of Mandibular First Molar with Separated Instrument in Periapex

62 FNDC Wrap-up

66 Dentistry and Amateur Radio Lead to Professional and Humanitarian Opportunities

69 Health Care Reform

l i t e r a r y29 Letters to the Editor

76 Book Reviews

c o l u m n s 3 Staff Roster

5 President’s Message

6 Legal Notes

9 Information Bytes

48 Diagnostic Discussion

80 Off the Cusp

c l a s s i f i e d s

72 Listings

2 Today's FDA July/August 2014 www.floridadental.org

FLORIDA DENTAL ASSOCIATIONJULY/AUGUST 2014 VOL. 26, no. 5

EDITORDr. John Paul, Lakeland, editor

STAFF Jill Runyan, director of communications • Jessica Lauria, publications coordinator

Lynne Knight, marketing coordinator

COUNCIL ON COMMUNICATIONSDr. Thomas Reinhart, Tampa, chairman

Dr. Roger Robinson Jr., Jacksonville, vice chairmanDr. Matt Henry, Vero Beach • Dr. Scott Jackson, Ocala

Dr. Marc Anthony Limosani, Miami • Dr. Bill Marchi, Pensacola Dr. Jeannette Hall, Miami, trustee liaison • Dr. John Paul, editor

BOARD OF TRUSTEESDr. Richard Stevenson, Jacksonville, president

Dr. Ralph Attanasi, Delray Beach, president-electDr. William D’Aiuto, Longwood, first vice president

Dr. Michael D. Eggnatz, Weston, second vice presidentDr. Jolene Paramore, Panama City, secretary

Dr. Terry Buckenheimer, Tampa, immediate past presidentDrew Eason, Tallahassee, executive director

Dr. David Boden, Port St. Lucie • Dr. Jorge Centurion, MiamiDr. Stephen Cochran, Jacksonville • Dr. Richard Huot, Vero Beach

Dr. Don Erbes, Gainesville • Dr. Don Ilkka, Leesburg • Dr. Jolene Paramore, Panama City Dr. Rudy Liddell, Brandon • Dr. Beatriz Terry, Miami Dr. Ethan Pansick, Delray Beach, speaker of the house

Dr. Tim Marshall, Weekiwachee, treasurer • Dr. John Paul, Lakeland, editor

PUBLISHING INFORMATIONToday’s FDA (ISSN 1048-5317/USPS 004-666) is published bimonthly, plus one special issue, by

the Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914. FDA membership dues include a $10 subscription to Today’s FDA. Non-member

subscriptions are $150 per year; foreign, $188. Periodical postage paid at Tallahassee, Fla. and additional entry offices. Copyright 2014 Florida Dental Association.

All rights reserved. Today’s FDA is a refereed publication. POSTMASTER: Please send form 3579 for returns and changes of address to

Today’s FDA, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.

EDITORIAL AND ADVERTISING POLICIESEditorial and advertising copy are carefully reviewed, but publication in this

journal does not necessarily imply that the Florida Dental Association endorses any products or services that are advertised, unless the advertisement specifically says so. Similarly, views and conclusions expressed in editorials, commentaries and/or news columns or articles that are published in the journal are those of

the authors and not necessarily those of the editors, staff, officials, Board of Trustees or members of the Florida Dental Association.

EDITORIAL CONTACT INFORMATIONAll Today’s FDA editorial correspondence should be sent to

Dr. John Paul, Today’s FDA Editor, Florida Dental Association, 1111 E. Tennessee St., Tallahassee, Fla. 32308-6914.

FDA office numbers: 800.877.9922, 850. 681.3629; fax 850.681.0116; email address, [email protected]; website address, www.floridadental.org.

ADVERTISING INFORMATIONFor display advertising information, contact: Jill Runyan at

[email protected] or 800.877.9922, Ext. 7113Advertising must be paid in advance.

For classified advertising information, contact: Jessica Lauria at [email protected] or 800.977.9922, Ext. 7115.

WCDDA 2014 SUMMER MEETINGAUG. 8-10, 2014 • RITZ-CARLTON NAPLES, FLNine hours of continuing education creditFeatured Programs: Meeting the Challenge of Change for Maximum Case Acceptance, Mark K. Setter, D.D.S., M.S.; HIV Awareness, Tom Robertsonwww.wcdental.org • 813.654.2500 • [email protected]

NEDDA FALL CE COURSEFRIDAY, NOV. 7, 2014SHERATON JACKSONVILLE HOTELSpeaker: Dr. Alfonso Pineryowww.nedda.org • 904.737.7545 • [email protected]

SFDDA WINTER MEETING FEB. 20, 2015 • Jungle Island, Miamiwww.sfdda.org • 305.667.3647 • [email protected]

NWDDA 2015 ANNUAL MEETINGFEB. 20-21, 2015 • The Grand Sandestinwww.nwdda.org • 850.391.9310 • [email protected]

ACDDA 5TH ANNUAL CRUISEAPRIL 22-26, 2015ROYAL CARIBBEAN – VISION OF THE SEASSpeakers: Dr. Brent Harris,Dr. Stuart Auerbach, Brian Calverley, Emerald Joneswww.acdda.org • 561.968.7714 • [email protected]

CFDDA ANNUAL MEETINGAPRIL 24-25, 2015www.cfdda.org • 407.898.3481 [email protected])sfdda

AccelerateYOUR PROFESSIONAL GROWTH

For a complete listing, go to www.trumba.com/calendars/fda-member.


The last four digits of the telephone number are the

extension for that staff member.

EXECUTIVE OFFICEDrew Eason, Executive Director

[email protected]

Rusty Payton, Chief Operating [email protected]

850.350.7117

Graham Nicol, Chief Legal [email protected]

850.350.7118

Judy Stone, Leadership Affairs [email protected]

850.350.7123

Brooke Mills, Assistant to the Executive Director

[email protected]

ACCOUNTINGJack Moore, Chief Financial Officer

[email protected]

Leona Boutwell, Finance Services Coordinator Accounts Receivable & Foundation

[email protected]

Deanne Foy, Finance Services Coordinator Dues, PAC & Special Projects

[email protected]

Tammy McGhin, Payroll & Property Coordinator

[email protected]

Mable Patterson, Accounts Payable Coordinator

[email protected]

COMMUNICATIONS AND MARKETING

Jill Runyan, Director of [email protected]

850.350.7113

Lynne Knight, Marketing [email protected]

850.350.7112

Jessica Lauria, Publications [email protected]

850.350.7115

CONTACT THE FDA OFFICE800.877.9922 or 850.681.36291111 E. Tennessee St. • Tallahassee, FL 32308

FLORIDA DENTAL ASSOCIATION

FOUNDATION (FDAF)

Stefanie Dedmon, Coordinator of Foundation Affairs

[email protected]

FLORIDA DENTAL CONVENTION

(FDC)

Crissy Tallman, Director of Conventions and Continuing Education

[email protected]

Elizabeth Bassett, FNDC Exhibits [email protected]

850.350.7108

Ashley Liveoak, FNDC Meeting [email protected]

850.350.7106

Mary Weldon, FNDC Program [email protected]

850.350.7103

GOVERNMENTAL AFFAIRS

Joe Anne Hart, Director of Governmental Affairs

[email protected]

Alexandra Abboud, Governmental Affairs Coordinator

[email protected]

Casey Stoutamire, [email protected]

850.350.7202

INFORMATION SYSTEMS

Larry Darnell, Director of Information Systems

[email protected]

Lisa Cox, Database Administrator [email protected]

850.350.7163

Ron Idol, Network Systems [email protected]

850.350.7153

Kerry Gómez-Ríos, Director of Member Relations

[email protected]

Ashley Merrill, Membership Relations Assistant

[email protected]

Kaitlin Alford, Member Relations [email protected]

850.350.7100

Christine Mortham, Membership Concierge

[email protected]

FDA SERVICES800.877.7597 or 850.681.29961113 E. Tennessee St., Ste. 200

Tallahassee, FL 32308

Scott Ruthstrom, Chief Operating [email protected]

850.350.7146

Carrie Millar, Agency [email protected]

850.350.7155

Carol Gaskins, Assistant Membership Services Manager

[email protected]

Debbie Lane, Assistant Membership Services Manager

[email protected]

Allen Johnson, Support Services [email protected]

850.350.7140

Angela Robinson, Customer Service Representative

[email protected]

Jamie Chason, Commissions [email protected]

850.350.7142

Kristen Gray, Membership Services Representative

[email protected]

Marcia Dutton, Administrative [email protected]

850.350.7145

Maria Brooks, Membership Services Representative

[email protected]

Nicole White, Membership Services Representative

[email protected]

Pamela Monahan, Commissions Coordinator

[email protected]

Porschie Biggins, Membership Services Representative

[email protected]

MEMBER RELATIONS

Group & Individual Health • Medicare Supplement • Life Insurance Disability Income • Long-term Care • Annuities • Professional Liability

Office Package • Workers’ Compensation • Auto • Boat

To contact an FDA Board member use the first letter of their first name, then their last name, followed by @bot.floridadental.org. For example, Dr. John Paul: [email protected].

JOSEPH PERRETTIDirector of Sales - South Florida

305.665.0455 Cell: 305.721.9196 [email protected]

DENNIS HEADDirector of Sales - Central Florida

877.843.0921 (toll free) Cell: 407.927.5472 [email protected]

DAN ZOTTOLIDirector of Sales - Atlantic Coast


RICK D’ANGELODirector of Sales - West Coast

813.475.6948Cell: [email protected]

RISK EXPERTS

JOE DUKESDirector of Sales - Northeast & Northwest 850.350.7154 Cell: 850.766.9303 [email protected]


PRESIDENT’S MESSAGE

RICK STEVENSON, DDS

”“ My journey continues, this time as

the president of the Florida Dental Association (FDA). Following Terry Buckenheimer through the chairs as a line officer has been a great honor and a rewarding experience.

Terry’s dedication to dentistry brought us our first — and very successful — Mis-sion of Mercy (MOM) event. He was able to balance his duties as the FDA president as well as the trustee to the 17th District of the American Dental Association (ADA). Rumor has it that he actually found time to see patients and have a personal life! Thanks, Terry, for the experience and legacy you left us, and we are looking forward to working with you for many years to come.

Now, Terry did not do this alone. Our new executive director, Drew Eason, and our wonderful FDA staff guided us in our efforts. They are always in the back-ground working on our behalf. The en-thusiasm they show is infectious and we are grateful for their dedication and hard work. Our governmental affairs staff has undergone some personnel changes, yet they were able to get three bills passed through the legislature and signed by Gov. Scott: the non-covered services bill that took four years to pass; keeping your sovereign immunity by allowing pay-

ment for lab fees by someone other than the dentist; and, keeping your private information you provide in surveys, just that, private.

I also would like to thank Dr. Bert Hughes, his Conventions and Continu-ing Education Committee (formerly the FNDC Committee) and the FDA staff who made this another successful year with increased attendance and revenue. He keeps setting the bar higher, and the enthusiasm and professional relation-ships they have made with the vendors and meeting attendees were noticed and commented on by everyone I talked with.

Even though we enjoyed much success this last year, we cannot sit back and rest — we must be vigilant. We face many new challenges in the workforce by out-side organizations that want to change how dentistry is done in the future and by whom. We are undertaking the job of making the FDA more efficient and meaningful. Your engaged volunteers on the Board of Trustees and the House of Delegates have already taken steps to keep us ahead of the challenges we will be facing by forming workgroups for strategic planning, workforce issues and bylaws reorganization, to name a few.

Remember, the mission of the FDA is “Helping members succeed.” The FDA and the ADA are dedicated to this mis-sion and they are there for you.

Dr. Stevenson is the FDA President. He can be reached at [email protected].

Even though we enjoyed much

success this last year, we cannot sit

back and rest — we must be vigilant.

A New Year, A New Journey


Legal Notes

of federally-funded health care program. The reason the federal government pro-hibits waiving co-pays is because it may be done in order to induce patients to obtain care that is not medically neces-sary. These laws prohibit any incentives (in cash or in-kind, overt or covert) that influence recipients of the discount to refer patients to the practice.

In the past, only federally-funded payers would prosecute doctors for waiving fees in exchange for patient referrals. When the doctor files a claim for services that were provided in ways that violate the federal regulations, the Conditions of Participation or the provider hand-book, then that claim also violates the False Claims Act (FCA). Violations of the FCA are punishable by a $5,000 per claim fine and imprisonment. The government plan also will refuse to pay the claim and may ban the dentist from participation in Medicaid.

In contrast, if the doctor was doing business with managed-care plans, then the plan would likewise refuse to pay the claim or deselect the doctor from their network, but, previously, it was unlikely to prosecute the dentist for fraud for false claims. But now, under HIPAA, it is a federal crime to defraud private insurance companies. So, regardless of whether you are billing a government plan or a private plan, if you waive fees

Usually, when dentists think of waiving or excusing pay-ment of co-pay amounts, it is in connection with extend-ing “profes-sional courtesy”

discounts to fellow health care profes-sionals or their families. With the poor economy, waiving co-pays also includes helping out patients who are experienc-ing “financial hardship.” Sometimes, the dentist will excuse the co-pay in order to provide a financially-challenged patient access to needed dental care; other times they will waive the co-pay amount to attract or retain patients.

Let’s look at professional courtesy discounts first. The U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) says: “It is unlawful to routinely waive co-payments, deductibles, coinsurances or other patient responsibility payments.” The HHS OIG has jurisdiction when the dentist accepts Medicaid, TRI-CARE/CHAMPUS or any other type

When is it OK for Dentists to Waive Co-pays?

Graham Nicol, Esq., HEALTH CARE RISK MANAGER, BOARD CERTIFIED SPECIALIST (HEALTH LAW)

in order to induce referrals (as may be the case when only health care profes-sionals get the discount) then you are at risk.

Arrangements for free or discounted care, especially if they are reciprocal be-tween two (or more) health care profes-sionals, are viewed as a type of fraud and abuse. If federal payers are involved, it can result in criminal prosecutions under the Federal False Claims Act and the Federal Anti-kickback Statute. Florida law also has similar exclusions that pro-hibit Medicaid fraud. Dentists should no longer extend professional discounts because it looks like the reduced fees are in exchange for patient referrals.

For example, an orthodontist who only extends professional courtesy to dentists and pediatricians who refer patients to him or her violates the law. Any type of incentive to refer patients is prohibited, even if it has other valid purposes. As another example, if a dentist is on staff at a hospital, it doesn’t mean that they can give all other doctors on staff and their families a discount. You may know them personally and they may be your friends or employees, but giving a dis-count could still influence them to refer patients to you; therefore, it is improper. Unless you are absolutely positive that the person who received the discount never has and never will refer to your practice, do not extend the discount.


Legal Notes

Now let’s look at giving regular patients (i.e., non-health care professionals) a discount or having an office policy that says you will accept as full and complete payment whatever the insurance or managed-care plan pays (i.e., a policy of waiving co-payment amounts across the board). What does the American Dental Association say about this practice?

The ADA Code of Ethics says:

A dentist who accepts a third-party payment under a co-payment plan as payment in full without disclosing to the third party that the patient’s payment portion will not be col-lected is engaged in overbilling. The essence of this ethical impropriety is deception and misrepresentation; an overbilling dentist makes it appear to the third party that the charge to the patient for services rendered is higher than it actually is.

Waiving a co-payment has been inter-preted as misrepresenting the dentist’s normal charges. For example, under traditional dental insurance, dentists are paid 80 percent of the “usual, customary and reasonable (UCR) amount” or the “actual charge,” whichever is less. If the plan allows $1,000 for a covered service, this means the plan will reimburse $800 and the patient’s co-payment amount is $200. But if the dentist accepts as payment in full only the amount paid by insurance, then the plan will argue the dentist’s actual charge is $800 (that is what the dentist actually collected in exchange for providing the service) and therefore, the resulting payment from the

plan should be only $640 — 80 percent of the collected amount.

Many patients, like many doctors, are suffering from a bad economy. But, ironically, doing a good deed for a pa-tient in financial need may get the doctor in trouble. Even though they are not themselves health care providers, patients refer other patients to the dental practice, so the same issues are present.

Only under narrow circumstances may co-payment amounts be waived lawfully. First, they cannot be waived across the board for all patients. Do not routinely waive co-payments regardless of whether they are deductibles, coinsurance amounts (e.g., 20 percent for insur-ance) or co-pays per visit (e.g., $15 per appointment for pre-paid dental plans or managed-care coverage).

Second, the dentist must document that the patient is indigent or experiencing financial hardship. In other words, docu-ment that your patient cannot afford to pay the deductible or co-pay before you waive it. This doesn’t mean you need to audit your patients before extending discounts, but at least have an applica-tion form that documents their monthly income, expenses and assets. If they are financially able to pay for the care but just experiencing a cash flow problem, suggest alternative methods of payment, such as credit cards, borrowing from family or installment payments.

In addition, carefully read your partici-pating provider agreement if you accept managed care. Sometimes, the plans have a “most favored nation” clause in their contracts with network dentists. This gives the plan the contractual right to pay the lowest charge that the dentist bills to any plan or any patient, even if they are covered under an entirely differ-ent plan. In other words, by agreeing to a most favored nation clause in the par-ticipating provider agreement, you have contractually obligated yourself to bill the plan no more than you bill anyone else. So, any pattern of discounts could result in a reduction in the dentist’s reim-bursement to the discounted amount.

This article is for informational purposes only and is not intended to be a substitute for professional legal advice. If you have a specific concern or need legal advice regard-ing your dental practice, you should contact a qualified attorney.

Graham Nicol is the FDA’s Chief Legal Counsel.

The Dos and Don’ts of Waiving Co-pays:

s Don’t provide professional courtesy discounts to anyone who refers or may refer patients to your practice.

s Don’t waive co-payments across the board for all patients in your practice.

s If you do waive co-pays, don’t hide it from the dental plan providing coverage.

s Before you waive co-pays for a par-ticular patient, do document that the patient has financial hardship and do make sure that you haven’t signed a participating provider agreement that includes a most favored nation clause.

LINK TO THE FORMS THROUGH THE BENEFITS & RESOURCE MENU.

FOR MORE INFORMATION

800.877.9922 • [email protected]

www.floridadental.org

benefit NUMBER

44

Helping Members SucceedOther HIPAA products cost more than $400 and don’t comply with Florida law!

Florida and HIPAA Compliant Forms for 2013 Omnibus Rule

Coming Soon! A free FDA webinar (in early September) on patient electronic communication and electronic HIPAA risk management.

As an FDA member, you now have access to forms that comply with both federal HIPAA and Florida confidentiality law. All of the documents are

available on the FDA website and are free of charge to members only. They are uploaded as Microsoft Word documents, so that you may add your

practice information to them.


Information Bytes

”“

Your Association’s Technology is Changing to Better Serve You

The three different levels of organized

dentistry are embarking upon an effort termed

the ‘Power of Three’ by the ADA,

and at its center is you.

By Larry Darnell

DIRECTOR OF INFORMATION SYSTEMS

You may have heard that the American Dental Association (ADA), Florida Dental Association (FDA) and its six compo-nents are moving to a new membership management system called Aptify. You might be wondering what this means for you, the member.

For far too long, the ADA, FDA and each component have been using their own member management systems. At times, this has led to member data discrepancies — one not having what the others did for member data. This was frus-

trating for both staff and members. As a result, the three different levels of organized dentistry are embarking upon an effort termed the “Power of Three” by the ADA, and at its center is you. Part of this effort means using the same member management sys-tem. The focus is to make sure we only maintain your information using one system — and that we get it right. We want to ensure you are provided the same consistent level of service whether you are interacting with your local component, the FDA or the ADA. Sharing the same member system will remove a great deal of duplication and eliminate a primary source of error.

Like any new technology, it may have its challenges in the beginning, but it is to your benefit we implement this. It is our hope that you will only notice that we are meeting your needs, solving any problems that arise for you and exceeding your expectations at every level. Partnered with this new member management system, which is slated to go live Aug. 1, will be a completely revamped FDA member website, coming in September 2014.

We will be busy, but never too busy to hear from you. If you have any questions or have suggestions on what you would like to see on our new website, please send me an email.

Mr. Darnell can be reached at [email protected] or 850.350.7102.


*Please note that FDA members have their names listed in bold.

2014 Legislative Session – A Good Year for Dentists!

The governor signed into law the follow-ing bills that will help Florida Dental Associatons (FDA) dentists:• Non-covered Services (SB 86): Insur-

ance companies can no longer dictate charges for non-covered services.

• Sovereign Immunity (HB 97): Allows patients to voluntarily contribute to-ward their dental lab costs without jeopardizing a dentist’s sovereign immunity.

• Dental Workforce Survey Public Re-cords Exemption (SB 520): Protects the personal identifying information of dentists and dental hygienists when completing the voluntary den-tal workforce survey.

For more information on specific appli-cation of the bills, contact the Govern-mental Affairs Office at 850.224.1089 or [email protected].

Governor Reappoints Dentist to the Board of Dentistry

On July 10, Dr. William Kochen-our, a Palm Harbor orthodontist, was reappointed by the governor to the Board of Dentistry (BOD). Dr. Koche-nour’s term ends on

Oct. 31, 2017 and is subject to confir-mation of the Senate during the upcom-ing 2015 Legislative Session. If you know Dr. Kochenour, please reach out and congratulate him on his reappoint-ment and continued commitment to organized dentistry!

Rusty Payton Receives MBA

The FDA’s Chief Operating Offi-cer, Rusty Payton, obtained his Master of Business Adminis-tration (MBA) at the University of North Alabama, conferred on May 10, 2014.

Mr. Payton has been with the FDA for 21 years. He began his career at the FDA in 1993 as a lobbyist, and held that posi-tion for 10 years before he was promoted to director of governmental affairs. Four years later, Mr. Payton became the FDA’s chief operating officer. The FDA is proud of Mr. Payton’s accomplishments and thanks him for all his contributions to the association!

FMA’s 2014 Charlie Awards

Recognizing achieve-ments by Florida magazines since 1957, the Florida Magazine Asso-ciation’s (FMA) an-nual Charlie Awards competition crowns publishers, writers,

editors, artists, photographers, printers, marketers and others as the best among

their peers in scores of categories. Juried by recognized out-of-state magazine and newspaper professionals, and college journalism professors, hundreds of en-tries vie for first, second and third place awards — Charlie, Silver and Bronze. This year, the Florida Dental Association (FDA) has been selected as a finalist for two separate entries in the category of “Best Editorial/Commentary/Opinion: Association” for Dr. John Paul’s well-loved column, “Off the Cusp.” Con-gratulations, Dr. Paul! We are proud of this achievement!

Dominican Republic Mission Trip

Dr. Payne with one of the patients in the Doominican Republic.

Dr. Tim Garvey, Department of Pedi-atric Dentistry, University of Florida College of Dentistry (UFCD), has been taking brigades of dental students to the Dominican Republic to do volunteer dental work since the mid-1980s. This summer, a large group of 30 students and five doctors volunteered: Drs. Tim Garvey, Ed Herod, Cliff Yanover, Rich Morales and Robert Payne. The volunteer group was incredibly diverse, including 18 dental students from other countries. Dr. Yanover had the added pleasure of having his son Josh, a UFCD student, on the trip.


The central compound was located in Las Matas de Farfan, near the Haitian border. At the central compound, there were three portable operatories run-ning on generators since electricity was infrequent. The students and doctors divided into five groups, and each group rotated to the central site as well as four remote sites for a total of five days. There were 19 established remote sites; some of them were two hours away. More than 900 people were provided with dental care — it was a wonderful opportunity to learn while providing care to those in need.

NSU Dental Professor Receives U.S. Patent for Developing New Bonding Technology

Over the past several years, dentists have shifted from metal to ceramic materials like zirconia for crowns, implants and other devices due to enhanced esthet-ics and biocompatibility. One downside of zirconia is that it does not bond well with other synthetic or natural sub-stances due to its chemically non-reactive nature, making it difficult to achieve long-term success in clinical applications.

Jeffrey Thompson, PhD, professor of prosthodontics and director of the Biosciences Research Center in Nova Southeastern University’s (NSU) Col-lege of Dental Medicine, and a team of researchers from RTI International in Durham, N.C., recently secured a U.S. patent for developing a surface modifica-tion technology to promote chemical bonding between high-performance ceramic materials like alumina and Please see NEWS, 13

zirconia; biological materials, like tooth structures; and, synthetic materials, like dentures and crowns.

The method uses a chlorosilane precur-sor to produce a very thin layer of silica on the inert ceramic surface. This allows traditional adhesive approaches and adhesives to be used in clinical bonding procedures with a high probability of a durable bond. The title of the patent is “Surface modification for enhanced si-lanation of ceramic materials” (U.S. pat-ent 8617704). The research was funded by a National Institutes of Health (NIH)/National Institute of Dental and Craniofacial Research (NIDCR) grant.

NSU ASDA Networking Weekend

Nova Southeastern University’s (NSU) American Student Dental Association (ASDA) is hosting a networking week-end for students, alumni and faculty to meet with Florida Dental Association (FDA) members that are looking to mentor students and find future as-sociates! A Flight Deck Mixer will take place at the NSU Flight Deck Pub on Friday, Sept. 19 from 5:30-8:30 p.m. and a golf tournament will be held the following day. For more information, go to nsuasda.com or email NSU ASDA President Casey Lynn at [email protected]. Please go to https://www.trumba.com/calendars/fda-member to see these events and search for others on the FDA’s master calendar.

ADA, Association of State and Territorial Dental Directors, CDC Honor Fluoridation Efforts of States, Communities

Marking 69 years of community water fluoridation, the American Dental As-sociation (ADA), the Association of State and Territorial Dental Directors and the U.S. Centers for Disease Control and Prevention (CDC) recently honored 130 states and communities with the 2013 Fluoridation Awards at the National Oral Health Conference at the Omni Fort Worth Hotel.

Some of the honorees are: qCalifornia earned the State Fluorida-

tion Initiative Award as the state hav-ing the greatest increase in population receiving fluoridated water in 2013.

qAnother 30 communities in 13 states earned Fluoridation Reaffirmation Awards for defeating initiatives to discontinue fluoridation or approving initiatives to maintain fluoridation.

qNine states earned State Fluoridation Quality Awards for maintaining the quality of fluoridation and optimal fluoride levels.

q85 water systems in 29 states earned Fifty Year Awards for achieving 50 years of continuous water fluoridation during the past calendar year.

In addition, the Tampa Bay Times and the Pinellas County Dental Association, Upper Pinellas County Dental Associa-tion and Pinellas County Oral Health Coalition received Fluoridation Merit Awards for their efforts to reinstate fluo-



news@fda

NEWS from 11

ridation in Pinellas County, Fla., after county commissioners voted to stop fluoridating in 2011. The Tampa Bay Times earned a Pulitzer Prize in 2013 for its pro-fluoridation editorials as well.

See the full list of winners on ADA.org.

Welcome New FDA MembersThese dentists recently joined the FDA. Their membership allows them to de-velop a strong network of fellow profes-sionals who understand the day-to-day triumphs and tribulations of practicing dentistry.

Atlantic Coast District Dental Association

Robert Bock, Fort LauderdaleZulima Munoz, Fort Lauderdale

Linda Niessen, DavieZeljka Vucetic, Fort Lauderdale

Central Florida District Dental Association

Andre Baptiste, OrlandoBruna DaSilva, Orlando

Christie Eastman, GainesvilleAvanthi Kopuri, Orlando

Jonathan McCabe, GainesvillePoonam Popat, WindermereMargarita Rivera, Orlando

Oscar Rosario Perez, ClermontMolly Smith, Gainesville

Northeast District Dental Association

Lily Gilchrist, JacksonvilleKelli Kanemaru-Takeuchi, Jacksonville

Stephanie Kinsey, Saint AugustineBrian Maples, Jacksonville

Amy McMahan, Jacksonville

Northwest District Dental Association

Peter Goltz, PensacolaChristopher Laing, Tallahassee

Lygia Nabors, Fort Walton BeachPamela Ottesen, Niceville

South Florida District Dental Association

Jossue Alfonso, MiamiErin Arroyo, Miami

Jenny Bello, HollywoodDorene Gerena, HollywoodMaria Lopez-Galan, MiamiJaime Marquez, Key West

Delia Reyes, MiamiEvan Rubensteen, HollywoodChristina Smith, HollywoodFernando Soltanik, Miami

West Coast District Dental Association

Devki Adi, Fort MyersMomodu Ali, Saint PetersburgAndrea Boucher, Cape Coral

Bobby Butler, Saint PetersburgDominick Catania, Tampa

Jerry Chery, BradentonShilpa Das, Tampa

Mariano De La Riva, Bradenton BeachDerek Espino, Spring Hill

Harrison Gollob, Bonita SpringsManuel Gutierrez, TampaJessica Irwin, Bradenton

Caroline Kott, New Port RicheyWayne Kuo, Fort MyersKrystina Lepore, Tampa

Jordan Martin, Fort MyersArnold Safirstein, Tampa

Flor Segovia, SarasotaAmanda Sharp, Saint Petersburg

Omari Sheehy, TampaAmy Vespa, Clearwater

Candace Whittington, BrandonMichael Witsil, Fort Myers

In Memoriam

The FDA honors the memory and passing of the following members:

Allan BerryKey Largo, FLDied: December 7, 2013Age: 77 Marion GreearWinter Park, FLDied: January 18, 2014Age: 73 Mary ButlerTallahassee, FLDied: February 12, 2014Age: 56

Russell VannIndialantic, FLDied: February 25, 2014Age: 78

John PayneOrlando, FLDied: February 26, 2014Age: 88

George L. WilliamsFort Lauderdale, FLDied: March 19, 2014Age: 73

Richard VollDeland, FLDied: March 29, 2014Age: 81

Thomas HolbrookTampaDied: May 6, 2014Age: 76

Don Tillery Sr.Winter Park, FLDied: May 25, 2014Age: 87

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By Casey Stoutamire, FDA Lobbyist

The Florida Board of Dentistry (BOD) met in Jacksonville on Friday, May 16. The Florida Dental Association (FDA) was repre-sented by BOD Liaison Dr. Don Ilkka, lobbyist Casey Stoutamire, President-elect Dr. Richard Stevenson, and Drs. Andy Brown, Jolene Paramore, Barry Setzer, Oscar Morejon, Mark Romer, Roger Robinson, Clive Rayner, Shreena Patel and others.

Ten board members were present: Dr. Joe Thomas, chairman; Dr. Robert Perdomo, vice-chairman; Drs. William Kochenour, T.J. Tejera, Dan Gesek, Wade Winker and Leonard Britten; hygienists, Ms. Catherine Cabazon and Ms. Angie Sissine; and consumer member, Mr. Anthony Martini. Consumer member, Mr. Tim Pyle, was absent. This was Dr. Tejara’s first meeting as a Board member; he suc-ceeds Dr. Carol Stevens, who has served on the BOD since March 10, 2010.

The BOD dealt with 15 disciplinary cases and two voluntary relinquishments at this meeting. Cases discussed included a patient’s death due to Mepivacaine overdose; several controlled substance violations; and the improper delegation of duties.

At the meeting, the BOD adopted draft rules for changes to Rule 64B5-17.002, Written Dental Records, Minimum Content, Retention. This is just a proposed rule and nothing is final; the current version of the rule is still in effect. At the June 2014 FNDC meeting, the House of Delegates (HOD) adopted a resolution stating the Florida Dental Association (FDA) opposes part of the proposed language added to the Records Rule and gave the FDA direction to take such steps as appropriate, up to and including, formally challenging the proposed rule.

The FDA’s Governmental Action Committee (GAC) has been working closely with the BOD regarding the many concerns expressed by the FDA membership. The GAC is researching the additions to the rule and working with BOD members and staff on this issue. The FDA expects to present a recommendation on the proposed rules to the BOD at its next meeting on August 22nd. After this meeting, the FDA will provide a full report on the outcome of the proposed rule.

Additionally, the BOD discussed a letter from a consumer regarding an individual’s right to refuse X-rays when requesting a teeth cleaning appointment. The BOD stressed the importance of communicating with patients on the importance of X-rays.

Board of Dentistry Meets in Jacksonville

Board of Dentistry

The next BOD meeting is scheduled

for Friday, Aug, 22, 2014, at 7:30 a.m. EST in Orlando, at the

Hyatt Regency Orlando. The last remaining BOD meeting date for 2014 is Nov. 21

in Weston.

The BOD urged practitioners to review and follow the ADA’s guidelines on Dental Radiographic Examinations — “Recommendations for Patient Selec-tion and Limiting Radiation Exposure,” which can be found at www.ada.org/en/member-center/oral-health-topics/x-rays. The BOD also discussed whether CPR courses must be done in person or online, and sent this issue to the Rules Committee to make changes to Rule 64B5-12.020 to clarify that CPR courses must be done in person and not online. Lastly, the BOD voted to support the use of local anesthesia by hygienists during the American Board of Dental Examin-ers (ADEX) exam as long as they follow the Florida statutory requirements and the North East Regional Board’s (NERB) rules (submit documentation of proper training).

Ms. Stoutamire can be reached at 850.350.7202 or [email protected].


By FDA Staff

On June 13-14, the Florida Dental Association (FDA) House of Delegates (HOD) met at the Gaylord Palms Resort and Convention Center in Orlando. The HOD discussed many issues, including the following business.

Dr. Terry Buckenheimer, 2013-2014 FDA president, reported that the next step for the FDA is to focus on improving mem-bership and in order to do so, the FDA will ensure relevance to members through infrastructure changes, political activity and membership services. Dr. Buckenheimer also announced that Gov. Rick Scott signed into law all four of the FDA’s priori-ties and congratulated the FDA Governmental Affairs Office (GAO) on a successful legislative session. He also reported that the FDA’s public relations firm, Moore Communications Group, is shaping public opinion, which includes all of the logo rebranding that already has taken place.

Dr. Rick Stevenson gave his address as the FDA’s incoming president. An excerpt of his remarks can be found in the Presi-dent’s Message on Page 5 of this issue of Today’s FDA.

Report of the Board of Dentistry Chair

Dr. Joe Thomas, Board of Dentistry (BOD) Chair, reported on recent changes to BOD rules, such as hygienists administer-ing local anesthesia, airway management for anesthesia permits

House of Delegates

June 13-14, 2014

House ofDelegates

and the rule allowing dentists to inject dermal fillers, which is not allowed in most other states. Dr. Thomas also covered in detail the records task force and the proposed rule. He stressed that while the proposed rule protects patients, it also is designed to protect dentists. The rule proposal is intended to clearly state what the records must include so that general dentists may guard against unintentional violations.

Report of the ADA President-elect

Dr. Maxine Feinberg, ADA president-elect, introduced herself as, first and foremost, a practicing dentist and acknowledged the sentiments of many dentists that practice is getting more difficult and dentistry is facing serious challenges as a profes-sion. Dr. Feinberg stressed that stronger membership involve-ment is the answer to these problems, and the way to achieve that is to have all levels of organized dentistry working to put the member first. To achieve this, the goal is to create an excep-tional experience for each member that is unique and emotion-al. Eliminating duplication of effort is key to this strategy and next year, the level of dentistry that does it best will be the sole provider of that service. She announced that the FDA was one of the first constituent societies to embrace Aptify. This cus-tomized software will give a one-step application to all levels.


FNDC Committee Name Change

The HOD adopted the following resolution that the Florida National Dental Convention committee will now be called “Conventions and Continuing Education” committee.

Waivers and Discounts

The FDA membership section of the bylaws was conformed to those of the ADA in regard to waivers and discounts.

FDA dues and assessments waivers and discounts due to ex-emption, disability, financial hardship, new dentist status and target market status, as well as proration, assessments, loss of membership and reinstatement, shall be determined, as closely as is possible, in accordance with the principles set forth in the ADA Bylaws. However, the FDA recognizes the following waiv-ers and discounts that are not recognized by the ADA:

1. Spousal Members. Dentists who are recognized under Flori-da law as husband and wife, who are dues-paying members in good standing of one of the component societies of the FDA, or are licensed as dentists in Florida, or are members of a federal dental service or agency on duty outside of this state, shall be classified as spousal members of the FDA. A spousal member shall be entitled to all of the rights and privileges of an active member except he/she shall receive only one copy of the official publications of the FDA per spousal pair. The dues for spousal member pairs shall be 150 percent of active member dues (both professionals) or 75 percent each of active member dues (for one profes-sional) and this new dues category shall be limited to 10 years and coincide with the ADA classification of the “new dentist” (the ADA classifies a new dentist as being one to ten years out of dental school).

2. Faculty Discount. Dentists who serve as full-time faculty at one or more accredited dental schools or dental hygiene schools and would otherwise be considered a “full dues” category member shall receive a 50 percent (50%) dues re-duction on FDA dues and assessments. For the purposes of this section, a dentist shall be considered “full-time faculty” only if the individual is considered by his/her employing institute of higher learning as “full-time faculty.”

Trustee Allocation

The HOD defeated having a single trustee per district and the bylaws will reflect that each district will have two trustees.

Board of Dentistry Records

The HOD adopted the following resolution where the BOD has recently voted on and passed new language imposing additional requirements for the Rule governing “written dental records, minimum content.” The FDA opposes the recent addition of language within this rule and will take such steps as appropriate, up to and including, to challenge the proposed rule.

Date of Next Meeting

Dr. Ethan Pansick, Speaker of the House, announced that the next meeting of the HOD will be held Jan. 23-24, 2015 at the Tampa Airport Marriott Hotel.

Election of OfficersThe following officers were elected and installed during the June HOD meeting.

• President: Dr. Rick Stevenson

• President-elect: Dr. Ralph Attanasi

• First Vice-president: Dr. Bill D’Aiuto

• Second Vice-president: Dr. Mike Eggnatz

• Secretary: Dr. Jolene Paramore

• Speaker of the House: Dr. Ethan Pansick

• Treasurer: Dr. Bryan “Tim” Marshall

• Editor: Dr. John Paul

House of Delegates

By Joe Anne HartDIRECTOR OF GOVERNMENTAL AFFAIRS

The governor signed SB 86, HB 97 and SB 520 into law — all supported by the FDA. So, what do these bills do?

Non-Covered Services (SB 86)

This legislation will prohibit insurance companies from dic-tating charges for non-covered services. Dentists will have the ability to agree with insurance companies to the dis-counts on services covered under the plan and then negoti-

ate with the plans for charges for non-covered services (if interested). The intent of this legislation is to provide the dentist with clear guidelines, resulting in the dentist not being forced to accept discounts in order to establish a contract with an insurance plan.

The legislation went into effect on July 1 and will impact contracts entered into or renewed on or after July 2014. THE LEGISLATION WILL NOT CHANGE THE TERMS OF YOUR CURRENT CONTRACT. If you are not sure when your current contract is up for renewal, contact the insur-ance plan you contract with today and have them clearly state in writing your contract renewal date. During renewal, you will need to evaluate your contract to make sure there are no provisions in your contract that set charges for non-covered services (without your agreement or knowledge).

Furthermore, as an FDA-member benefit, you can get your contract reviewed and analyzed through the ADA Contract Analysis Service program. This service is designed to provide you with clear information on what is included in the proposed contract, but will not provide direction on whether you should sign the contract or not. If you would like to get your contract analyzed by the ADA Contract Analysis Service program, please send it to [email protected].

Sovereign Immunity (HB 97)

Current law (ch. 766.1115, F.S.) grants health care providers who contract with a state government program sovereign immunity (which shields providers from

2014 Legislative Session

www.floridadental.org20 Today's FDA July/August 2014

civil suit or criminal prosecution) when providing free services (without compensation). The Department of Health (DOH) has a Volunteer Health Care Provider Program (VH-CPP) that allows health care providers to be covered under sovereign immunity as agents of the state. Eligible patients who receive services through the VHCPP are screened by the DOH and are referred to a participating health care provider in the program.

HB 97 extends the dentist’s sovereign immunity to allow patients to voluntarily contrib-ute toward their dental lab costs and not jeopardize the dentist’s sovereign immunity. The voluntary contribution toward dental lab costs would not be considered compensation to the dentist. This legislation became effective on July 1.

Dental Workforce Survey Public Records Exemption (SB 520)

During the biennial dental licensure renewal cycle, dentists and dental hygienists are able to complete a voluntary dental workforce survey. The dental workforce survey started in 2010 as a means to gather current dental workforce data for the state of Florida. Physicians started surveying their members in 2007 and passed legislation to have their personal identifying information exempted from the public record laws. SB 520 provides the same protection for dentists.

Information that is gathered through the dental workforce survey has been valuable for many policy decisions applied by the FDA. During the initial dental workforce survey, the data showed that Florida does not have a shortage of dentists, but a maldistribution of dentists, with more in urban areas around the state. The collection and consistency of this data is critical to assessing the needs of the public as many groups attempt to provide anecdotal solutions to access-to-care issues, such as opening more dental schools and add-ing additional licensed dental providers.

SB 520 became effective upon becoming law (June 13) and will be applied during the next dental licensure renewal cycle, which is February 2016.

Ms. Hart can be reached at 850.350.7205 or [email protected].

2014 Legislative Session

www.floridadental.org July/August 2014 Today's FDA 21


By Casey StoutamireFDA LOBBYIST

The Florida Medicaid program has begun implementing a new system. All Medicaid enrollees will receive services, including dental, through this system. This program is called the State-

wide Medicaid Managed Care Managed Medical Assistance program (MMA). There will be no more fee-for-service for Medicaid providers through the Agency for Health Care Administration (AHCA) and the Prepaid Dental Health Program (PDHP) no longer will exist. All dental services will be provided through the MMA. If a Medicaid-provider dentist wishes to treat patients in the MMA sys-tem, he/she will need to be credentialed with either the medical plan (if there is no dental subcontract) or through the dental plan if the medical plan subcon-tracts out its dental services. For a list of all medical plans by region and their corresponding dental plans, please see the following page.

In the MMA contracts between the state and the medical plans, there is a continuity of care provision. Plans must reimburse Medicaid dental providers for previously authorized services for

Statewide Medicaid Managed-care Roll-out

Medicaid

up to 60 days after the MMA starts in each region, and must pay providers at the rate previously received for up to 30 days. Dentists should not cancel appointments with current patients. Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network. It is important to note that providers need to contact the plan the patient is a member of and not the plan the provider may be credentialed with for payment. For example, the patient may be a member of United Healthcare, but the dentist is a provider for DentaQuest and MCNA and is not credentialed with United Healthcare. The dentist needs to contact United Healthcare for payment related to the patient, not DentaQuest or MCNA. Also, payment may take longer during this time because if the provider is not credentialed with the plan, then he/she is not set up in the pay-ment system. However, if you feel payment is taking too long, please contact the FDA and we will be able to assist you.

The FDA is working hard to ensure our members will succeed under this new program. If you have any issues with credentialing, payment or treatment authoriza-tions with any of the medical or dental plans, please contact Casey Stoutamire at 850.224.1089 or [email protected]. You also can file a complaint with AHCA at: https://apps.ahca.myflorida.com/smmc_cirts/. It is very important to log all complaints with AHCA in addition to contacting the FDA. If AHCA doesn’t know of a problem, then it can’t do anything to address it.

Your patients, who are Medicaid recipients, should receive a letter from Medicaid in the mail before the MMA starts in each region. The letter will have information about the MMA plans in their region. Please note, the information in the letter will be on the medical plans and not the dental plans the medical plans may have subcontracted with under the MMA. The dentist needs to be aware of what medical plans will be operating in their region and how those plans will handle dental. For a list of all medi-cal plans by region and their corresponding dental plans, please see following page. For example, if you are in Region 7, your patients could be a member of Amerigroup, Molina, Prestige, Sunshine State, United Healthcare or Wellcare. Each of these medi-cal plans handles dental differently. Amerigroup and Molina have subcontracted with DentaQuest; Prestige and Sunshine State have subcontracted with MCNA; United Healthcare is using its own in-house dental provider, Dental Benefits Provider Inc.;

Please see MEDICAID, 27

Coun

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Cove

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Region 1: Escambia, Okaloosa, Santa Rosa and Walton

Avai

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ans

Integral

Den

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ubco

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MCNA Humana DentaQuest

Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington

Prestige MCNA WellCare Liberty Dental Plan

Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee and Union

Prestige MCNA Sunshine State MCNA United Healthcare Dental Benefits Provider Inc WellCare Liberty Dental Plan

Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia First Coast Advantage MCNA Sunshine State MCNA United Healthcare Dental Benefits Provider Inc WellCare Liberty Dental Plan

Region 5: Pasco and Pinellas Amerigroup DentaQuest Prestige MCNA Sunshine State MCNA WellCare Liberty Dental Plan

Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk Amerigroup DentaQuest Better Health DentaQuest Humana DentaQuest Integral MCNA Prestige MCNA Sunshine State MCNA WellCare Liberty Dental Plan

Region 7: Brevard, Orange, Osceola, and Seminole Amerigroup DentaQuest Molina DentaQuest Prestige MCNA Sunshine State MCNA United Healthcare Dental Benefits Provider Inc WellCare Liberty Dental Plan

Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Integral MCNA Prestige MCNA Sunshine State MCNA WellCare Liberty Dental Plan

Region 9: Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Humana DentaQuest Molina DentaQuest Prestige MCNA Sunshine State MCNA

Region 10: Broward Better Health DentaQuest Humana DentaQuest SFCCN MCNA Sunshine State MCNA

Region 11: Miami: Dade and Monroe Amerigroup DentaQuest Coventry MCNA Humana DentaQuest Molina DentaQuest Preferred Florida Dental Benefits Inc. Prestige MCNA Simply DentaQuest Sunshine State MCNA United Healthcare Dental Benefits Provider Inc WellCare Liberty Dental Plan

Medicaid Medical and Dental Plans by Region


Medicaid

MEDICAID from 25

The FDA is working hard

to ensure our members will succeed

under this new program.

and Wellcare has subcontracted with Liberty. If a dentist wanted to provide dental care to patients regardless of what plan they are with, then he/she would need to be credentialed (become a network provider) with DentaQuest, MCNA, United Health-care and Liberty. It is important to ask your patients about their medical plan mem-bership so you can ensure you are properly credentialed with the appropriate dental plan and can continue as your patient’s dental home. After joining a plan, recipients (patients) will have 90 days to choose a different plan in their region. After 90 days, recipients (patients) will be locked-in and cannot change plans without a state ap-proved good-cause reason or until their annual open enrollment.

The timeline for the rollout of the MMA was as follows:May 1, 2014• Region 2: Bay, Gulf, Franklin, Washington, Jackson, Holmes, Leon, Wakulla,

Gadsden, Taylor, Madison, Jefferson, Liberty and Calhoun counties• Region 3: Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette,

Levy, Putnam, Suwannee, Union, Citrus, Hernando, Lake, Marion and Sumter counties

• Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia counties

June 1, 2014• Region 5: Pasco and Pinellas counties• Region 6: Hillsborough, Highlands, Hardee, Polk, and Manatee counties • Region 8: Sarasota, DeSoto, Charlotte, Lee, Hendry, Glades and Collier counties

July 1, 2014 • Region 10: Broward County• Region 11: Miami-Dade and Monroe counties

August 1, 2014• Region 1: Escambia, Santa Rosa, Okaloosa and Walton counties• Region 7: Brevard, Orange, Osceola, and Seminole counties• Region 9: Palm Beach, Martin, St. Lucie, Okeechobee and Indian River counties

During this time of transition, it is very important for Medicaid providers to stay updated with the latest information from AHCA.

To receive alerts from AHCA on the MMA, please visit: http://ahca.myflorida.com/Med-icaid/Statewide_mc/signup.shtml.

For more information on the MMA, please visit: http://ahca.myflorida.com/medicaid/statewide_mc/mmahome.shtml.

Ms. Stoutamire can be reached at 850.350.7202 or [email protected].


Letters to the Editor

Letters to the EditorBeing a Part of an Amazing Event

By Richard A. Mufson, DDS

I was truly inspired by Florida’s first Mission of Mercy (MOM) on March 28-29, which I felt was one of the most amazing events I have ever witnessed or been a part of.

Beyond the blitz of media coverage leading up to the event, long lines of cars stretching for several miles along Martin Luther King Boulevard into the Florida State Fairgrounds’ en-trance and helicopters hovering overhead shooting footage that would later appear on multiple local TV news stations in the Tampa area — I couldn’t help but feel awestruck upon stepping into the 40,000 square foot Special Events Pavilion.

Waiting inside, from as early as 5 a.m., were several hundred dental professionals (dentists, hygienists, assistants), students (dental, hygiene and assisting), dental office staff, lab techni-cians, physicians, EMTs and many other general volunteers from all over the state who joined forces to provide an unbeliev-able amount of needed dental care to more than 1,600 people.

As a volunteer within the oral surgery section for the better part of the two days, I was amazed by the amount of care delivered, which was both intensive and impressive. Numerous other sections — dental triage, medical triage, restorative, pediatric, endodontic, laboratory/prosthodontic, sterilization, volunteer registration, patient registration and patient “check out” areas — were humming at full capacity.

Patients were asked to submit comments and feedback regard-ing the care they received, and many contributed handwritten notes expressing their gratitude and other wonderful com-ments, which were then posted on a large bulletin board for all to read. Numerous blue-shirted “ambassadors” were busy performing many functions ranging from escorting patients in all directions, connecting assistants with treating doctors, translation and others.

I am certain that everyone on hand, volunteers and patients alike, could share their own stories on what this event personal-ly meant in their respective minds and hearts. Many hugs and, in many cases, tears were shared by not only those so grateful for having been on the receiving end of the generous outpour-ing of time and care given, but also by many on the giving end as well.

I would like also to share two personal “firsts” that I experi-enced as part of the MOM event. First, this marked the only time in my life I have ever administered local anesthetic and removed a tooth on someone as early as 6 a.m. (including my days while in residency training)! Second, but no less interest-ing for me, was the realization that I have worked alongside many FDA member colleagues year after year at House of Del-egates meetings, Specialty Forums, our annual convention and other venues. However, this was the first time I have worked alongside the same people in the same room while actually performing clinical dentistry!

Please see LETTERS, 31


The Peer Review Mediation Program settles disagreements between patients and dentists

more economically and efficiently than the legal system and is available only to FDA members.

This program is free of charge.

FOR MORE INFORMATION 800.877.9922 • [email protected]/peer-review

benefit NUMBER

10

Helping Members SucceedIt’s the best reason to join the FDA! PR is a very friendly, low-key, nonadversarial process that looks out for the best interests of the dentist and the patient. — Dr. Edward Daniel


The net result after the two days of this immense culmination of hard work was a thankful Tampa Bay community. Stories of the event abounded on TV and radio airwaves, featuring patient interviews – including one in which a father of six chil-dren shared a deep sense of gratitude for being able to receive care for himself and his entire family.

Tremendous gratitude and praise was expressed for the Florida Dental Association and the Mission of Mercy for having orga-nized and brought this event to the Tampa area. I would, with-out a doubt, participate in this wonderful event again if given the chance, and I encourage all of you reading this to consider doing the same. If you do, I know you also will feel inspired.

Dr. Richard A. Mufson is an oral surgeon with a practice in Miami and may be contacted at 305.935.7501 or [email protected].

LETTERS from 29 The True Crisis in Access to Dental Care

By Steven J. Ciaravino, DDS

Dear Editor,

For the millionth time, I’ve read, heard and been lectured to about the crisis in access to dental care. If advocates meant that there were too many dentists, too many corporate clinics, too many dental schools and that licensing has become too easy, then I would agree. So would the dentists who get paid based on how much work they do or what that work is worth.

Let’s skip the socialist rhetoric and face the truth. American dentists have huge gaps in their scheduling; they are booked days, not months, in advance; most only work about 200 days a year; staffs are smaller than they’ve ever been; dental schools are opening all over the country; licensing is opening more and more to foreign-trained dentists; yearly insurance payments have been stagnant for 40 years; and worst of all — dentists’ salaries have been stagnant the last six years!

Every suggestion, policy and idea, expressed by the FDA, ADA, etc. is supposed to improve dentists’ lives and increase our wealth, and not the opposite. This is the true crisis.

Dr. Steven J. Ciaravino is a general dentist in Haines City and can be reached at [email protected].

Editor’s note: Views and conclusions expressed in all editorials, commentaries, columns or articles are those of the authors and not necessarily those of the editors, staff, officials, Board of Trustees or members of the Florida Dental Association. For full editorial poli-cies, see page 2.

All editorials may be edited due to style and space limitations. Let-ters to the editor must be on topics and a maximum of 500 words. Submissions must not create a personal attack on any individual. All letters are subject to editorial control. The editorial board reserves the right to limit the number of submissions by an indi-vidual.

Letters to the Editor

SAVE THE DATEJ U N E 1 1 -1 3 , 2 0 1 5

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T H E O F F I C I A L M E E T I N G O F T H E F L O R I D A D E N T A L A S S O C I A T I O N

SAVE THE DATEJ U N E 1 1 -1 3 , 2 0 1 5


By Dr. John PaulTFDA EDITOR

Somehow, I managed to get a reputation as being hard to buy for; it seems to me like it should be practically effort-less. If it’s sharp, goes boom or makes sawdust — there’s

a great chance I will be interested in it. If I already have one, I certainly won’t be any less happy with two. Maybe it’s because I don’t want that much. Any-how, this label has stuck with me since I was young.

It makes my family’s life easier if I make a list for gift-giving events. I learned early on if there was something I really wanted, I should keep the list short and release the list with just enough time to get the gift wrapped. Instructions on where to find the item, all the specif-ics along with the price (to confirm it wasn’t a blue sky dream) seemed to be appreciated. This helped me end up with some fairly cool tools, two satisfied parents and great memories, like when Pa bought me that table saw to go with

Survey

my first house. It was nearly as old as the house, and still works as smooth and strong as the day it was made.

There is a moral to this story: To get what you want from someone else, you have to know what you want and you have to tell them. There is a survey post-card in this issue, on the following page, with pre-paid return postage, as well as online at https://www.surveymonkey.com/s/NFM5JGD; please fill it out. If there is something that interests you and it is not specifically addressed, there are some blank lines provided for adding your suggestions. We need your input to make the Florida Dental Association the organization you want it to be.

I look forward to hearing from you.

John H. Paul, DMD

FillOut MySurvey

Dr. Paul is the editor of Today’s FDA. He can be reached at [email protected].

To get what you want from someone else,

you have to know what you want and you have to tell them.

Survey


Analgesics

Local anes-thetics

By: Elizabeth ThillDENTAL COLLECTIONS SPECIALIST

Can “Nice People” Collect Delinquent Patient Accounts?

Patient Accounts

If you’re like most people, collecting past due accounts doesn’t rate that high on your “fun meter.” In fact, it’s probably just another one of the hats you have to wear that doesn’t fit well and probably makes you uncomfortable, right?

You’re not alone. That’s why we’ve com-piled some proven, easy-to-use collec-tion tips into this handy article. Keep it nearby, refer to it often and in no time, you will improve your cash flow and col-lect more of your past due accounts.

When invoices, statements and letters go unanswered, it’s time to pick up the phone. It’s the best collection tool in your arsenal because it offers convenient,

timely and cost-effective two-way com-munication. But to win on the tele-phone, it’s essential that you are prepared to handle patients who often have their own arsenal of stall tactics and excuses to avoid paying creditors.

Getting prepared

Pre-call planning starts with changing your attitude and then following four steps before each call.

Change Your Attitude

Your patient received a service and is better for it. Now, as the provider of that service, you deserve to be paid. Remem-ber, the first call is not your first contact. The patient has had many chances to pay: at the time of service, at the first invoice and at reminder notices.

Four Steps for Success

1. Gather facts. You must know ex-actly how much is owed, for what service(s) and for how long the debt has been owed. Knowing your facts establishes your credibility.

2. Review history. Has the patient owed you money before? What were their objections? Have precedents been set by previous deals? A thorough review helps you uncover potential problems or opportunities.

3. Decide in advance. Are you willing to accept less than full payment? How much less, and under what conditions? Experienced late paying patients try to make deals. Be pre-pared for their offers and know how you will respond.

4. Put time on your side. The best chance to catch a patient at home is between 4-8 p.m., Sunday through Friday. On Saturdays, try between 8-10 a.m.

Please see DELINQUENT, 35


Analgesics

Local anes-thetics

It’s essential that you are prepared to handle patients who often have their

own arsenal of stall tactics and excuses to avoid paying creditors.“

”Consumer Psychology 101

The following tips will help you under-stand what goes on in the minds of those who owe money and help you recover more from those who can and will pay, as well as identify those who will only pay following professional or extraordi-nary attention.

Know the Difference Between a Lie and a Fib!

When patients give you a tall tale along with a payment, it’s a fib, and fibs are good. People tell fibs to save face. Wise creditors accept such fibs as a way of preserving the payer’s self-esteem. But, when patients give you a tall tale instead of a payment — it’s a lie! And that’s bad, because effective two-way communica-tion cannot exist in the absence of truth. When you catch a patient in an out-right lie, you are dealing with a patient who needs to be confronted with real consequences. We’d suggest this type of account go to collection.

Don’t Get Mad — Get Paid!

When patients fail to respond to your statements and letters, or are “unavail-able” when you try to reach them by phone, remember, this is a common and deliberate tactic. And if it works (mean-ing you settle for it), they will give you more of it. Getting the silent treatment simply means the patient believes you’ll go away if they ignore you. More than likely, any time you put into collecting these accounts will be wasted. Turn these people over for collection.

Resolving Accounts is More Important than Collecting Money!

A collector’s most important job is to resolve as many accounts as possible — quickly. Resolving is the process of put-ting each debt into the right box.

1. Patients who clearly can and will pay with reasonable efforts stay in the office to be worked by internal staff.

2. Patients who clearly can’t pay are placed in a forgiven, or write-off status, for no further action.

3. Patients who clearly can pay, but just prefer not to, must be outsourced to professionals.

Isolating accounts into these three categories helps you focus your collec-tion energy for the greatest return. Nice people can collect delinquent patient accounts, but like any process, there are limits. If you’re looking for additional tips for your front office staff, check out our helpful webinars available at BrightTalk (www.brighttalk.com/chan-nel/10535).

When you run into accounts that require collection services, turn to the experts at I.C. System.

Ms. Thill is a dental collections special-ist at I.C. System. For more informa-tion, you can reach I.C. System toll-free at 800.279.3511 or go to dentistcollect.com. I.C. System is a member of the FDA Services' Crown Savings Program, an FDA member benefit.

Patient Accounts


By Matthew J. Dennis, DDS

You are a partner in a busy three-doctor practice. It is a full scope general dental practice, providing everything from complex restorative dentistry to rou-tine minor oral surgery. As you walk past your office’s sterilization area, you overhear the assistants: “You should see that guy out there. His face is really swollen!” You stop in your tracks, turn to the assistants and ask, “What are you talking about?” Mary, the most senior of the assistants, speaks up. “It’s Dr. Jones’ patient. He came in yesterday with a toothache and Dr. Jones put him on antibiotics. He’s back today and his face is all swollen!”

You ask Mary to get the patient’s chart. There a single entry from yesterday: “C/o TA No. 19. Gross caries, non-restorable. Perc ++. Swelling. Tx: Pen 500. Return 1 week for ext #19.” There is also a paper medical history form that the patient filled out on the chart, indicating “no” answered for all questions.

The patient has been seated in an opera-tory, and upon entering, you notice a significant swelling to the lower left face, causing the mid-body area of the mandible to protrude asymmetrically compared to the patient’s right side. The patient doesn’t look very happy. He is

Odontogenic Infection Update: A Case

wearing a blue work shirt with the logo “Acme Roofing Company” emblazoned in an ellipse above the left breast pocket, which is bulging with a pack of cigarettes. There is the unmistakable odor of tobacco present in the room. Further examination of the face reveals erythema surrounding the most prominent area of the swelling, but the face itself is rather pale, considering that the patient probably works outside and gets lots of sun. The lower lip is cracked and dry, with signs of solar keratosis. The patient looks tired. The skin is warm to the touch. “You gotta get this tooth out, Doc. It’s kill-ing me!” the patient says, distressed. “I can’t eat; I can’t sleep! I’d do it myself if I had a pair of pliers!”

Intraorally, No. 19 is grossly carious. There is a swelling in the left vestibule, such that the normal vestibular drape is obliterated by a convex elevation of the tissue, which is reddened and feels soft to the touch, having the characteristic feel of fluid beneath. The remainder of the oral exam reveals no other areas of redness or swelling, but gen-eralized severe caries and generalized gingival inflammation. There is no trismus. Oral temperature is 99 degrees F, as taken by the assistant; blood pressure is 140/92 and pulse is 110. Your assistant, Mary, looks up at you with a perplexed look on her face. “What would you like to do, doctor?”

Odontogenic infections arise from indigenous bacteria that gain access to deeper tis-sues as a result of dental disease, primarily dental caries. Dentists treat and/or prevent odontogenic infections every day; simple restorative procedures such as fillings prevent bacteria from accessing the dental pulp, which is the usual pathway for these infec-tions to gain access to deep tissues. There is a wide spectrum of severity for these in-fections, ranging from low-grade, well-localized and easily treated infections to rapidly spreading, life-threatening fascial space infections that may result in death.

The microbiology of these infections is characterized by multiple species1, involving both aerobic and anaerobic isolates. Tissue invasion usually starts with aerobes, which over time change the microenvironment to a more anaerobic one, looking for an-aerobic organisms to predominate. This illustrates how the bacterial composition will change over time in the same patient, depending on the redox potential of the tissue as well as other factors, such as sharing resistance genes and bacterial by-products altering the selective environment. The most common aerobic organisms isolated are Streptococcus species, with Streptococcus milleri (penicillin-sensitive) being charac-

Odontogenic


teristic of early odontogenic infections, and the Streptococcus viridans group being present in the more mature lesions. Staphylococcus is much less commonly encoun-tered and is likely to be a skin contaminant. Common anaerobic organisms include gram-positive anaerobic cocci (Peptostreptococcus), gram-negative anaerobic rods (Bacteroides including Prevotella and Porphyromonas) and fusobacteria. Determining the bacterial composition is dependent on culture techniques. Conventional culture procedures are limited and technique sensitive, especially anaerobic cultures. Nucleic acid detection techniques2,3 are faster and identify many more isolates per case; upwards of 20 isolates per case can be identified, although these techniques are not widely available at the present time. Many pathogens are not “culturable,” and recent studies have broadened the list of potentially important organisms in oral infections4. Bacterial taxonomy is classified according to the Human Oral Microbiome Database, which has identified that approximately 600 prokaryotic species are present in the human oral cavity.

The necrotic pulp of a tooth is a pathway for bacteria to gain access to the cancellous bone of the jaws. As the infection progresses, it may erode through the cortex of the jaw and enter the soft tissue. This “path of least resistance” is dependent upon the lo-cation of the perforation relative to the muscle attachments of the jaw. The buccinator muscle and the mylohyoid muscle attachments determine the pathway of mandibular infections. Perforation above the muscles results in vestibular space and sublingual space infections, respectively; perforations below the muscles result in buccal space and submandibular space infections, respectively. In the maxilla, the buccinators simi-larly partition infections into vestibular or buccal space infections, with the palatal mucosa and sinuses making up the medial and superior perforations, respectively. It is important for dentists to appreciate the anatomy of this area to correctly diagnose the location of an infection that has spread outside the boundaries of the cortex of the jawbone.

Infections may progress through various stages of development5. Bacterial spread through tissue, resulting in edematous swelling and erythema, but without a discreet accumulation of pus (dead white cells mixed with bacteria) has been described as a cellulitis. As white cells vigorously converge on the infected tissue, the palpation is that of induration or a firm, hard swelling. As anaerobic conditions increase in the tissue, the white cells necrose and liquefy, resulting in a localized collection of pus (abscess) that feels fluctuant or fluid-like. Most infections have regions of involvement with characteristics of both a cellulitis and an abscess. Decisions regarding drainage of infections will depend on a dentist’s ability to discern the presence of drainable pus. Some surgeons recommend draining a cellulitis even if there is no discernible pus, because they believe that drainage alters the microenvironment in favor of the host and disrupts synergistic patterns of cooperative pathogens.

Antibiotic resistance rates for odonto-genic infections are increasing1. Multiple studies show increasing therapeutic failure rate for the penicillins, especially for the more severe infections. Antibiotic inactivation with beta-lactamases, recep-tor site modification, membrane pore deletion, active transport, mutations, etc. all may occur. Cases that require hospitalization have a high probability of penicillin resistance. Highly resis-tant organisms continually challenge infectious disease experts. In contrast, however, early onset minor odontogenic infections respond well to the penicillins; they remain the drugs of choice for such infections.

Patients with odontogenic infections should be examined carefully6 and findings charted meticulously. Because the future behavior of infections is not known for certain, dentists are often criticized for failing to refer cases that worsen rapidly even after definitive treat-ment; therefore, baseline findings are essential to defend the dentist’s actions and justify the ultimate disposition of the patient.

After a past medical history is taken with emphasis on medical risk assessment and eliciting vulnerability factors for infec-tion (i.e., decreased host defenses such as immunosuppression, diabetes, renal failure, cancer, poor systemic health), initial history should gauge the severity of the infection by determining the time of onset and the rapidity of progression (gradual increase over days or weeks ver-sus a few hours). The classic symptoms of inflammation (dolor/pain, tumor/

Please see ODONTOGENIC 38

Odontogenic


swelling, calor/heat, rubor/erythema, and functio laesa/loss of function) should be elicited. A general physical exam should follow, including temperature (fever), vital signs (pulse increased with dehydration and fever), respiratory rate (increased with airway obstruction), abil-ity to swallow (impaired by swelling) and general appearance (is patient “sick” or “toxic”). The swelling should be palpated and the character (soft/edematous, hard/indurated, fluid-filled/fluctuant), precise location and dimensions (mild, moder-ate or large, or dimensions in cm), color, warmth and presence of any drainage noted. Next, the dental cause of the infection should be determined (car-ies, periodontal disease, fractured tooth, failed implant, untreated trauma, salivary pathology, infected cyst).

The primary principle in the treatment of odontogenic infections7 is drainage and removal of the cause of the infection as soon as possible. This may involve opening a tooth for endodontic treat-ment, a dental extraction, a simple inci-sion and drainage (I&D), or a multiple fascial space, wide soft tissue drainage for severe infections. Antibiotic usage is adjunctive and may be inappropriate without surgical treatment. Incision and drainage reduces tissue tension and pain, allows host defenses into the area and facilitates culturing. It is performed by making a less than 1 cm incision over a dependent area of purulence, inserting a closed hemostat that is opened upon removal, and placing a Penrose drain to keep the area open for continued drain-age over the next several days. Cultures

may be taken directly with a culturette swab, or taken prior to drainage by aspirating with an 18g needle into a closed syringe anaerobically. Culturing should be consid-ered with serious infection, chronic recalcitrant infection, previous use of multiple antibiotics, immunocompromised patients or hospitalized patients. Removal of the cause of the infection (extraction of the offending tooth) is necessary to ultimately cure the patient. Failure to remove the cause of the infection in a timely manner will introduce uncertainty into the case, including the possibility of developing resistance and spread of infection through vital fascial spaces, which could result in a threat to life.

Social issues, such as inability to pay for treatment, introduce ethical concerns when dentists encounter these patients. Turning patients away or simply sending them to the emergency room without a specific referral introduces inevitable delay in treat-ment that often results in worsening of the infection, requiring more invasive treat-ment (hospital admission versus outpatient treatment). Delay may even introduce the possibility that the infection becomes life-threatening to the patient, when they easily could have been treated as an outpatient at the time of initial presentation.

Treatment with local anesthesia can be challenging, because the acidity of infected tissue lowers the pH of the tissue, resulting in a shift of the dissociation constant (pKa) of the local anesthetic in the direction of the cationic form, which is absorbed less readily than the free base form across the nerve membrane. The result is a lower concentration of local anesthetic molecules available to bind membrane receptors in nerves and therefore block propagation of nerve impulses.

Antibiotics should be used for odontogenic infections when there is clear evidence of bacterial invasion into underlying tissues that is greater than the host’s defenses can ward off. Generally, antibiotics are considered when infection of pulpal origin pro-gresses outside the alveolar cortices and gets into adjacent fascial planes, which do not openly communicate with the extraction socket, or in any situation where drainage is not optimal. Rapidly progressing, diffuse swellings should be treated with antibiotics, as well as in situations where the host’s defenses are compromised or surgical treat-ment is not possible. Pericoronitis (infection and inflammation of the pericoronal operculum overlying mandibular third molars) is an exception to the immediate surgical treatment. In this case, the infection is superficial and performing immediate surgical extraction may open non-infected subperiosteal spaces to the superficial infec-tion. In this case, it is better to treat a significant pericoronitis first with irrigation/antibiotics and delay surgical removal of the mandibular third molar until after the pericoronitis resolves.

The choice of antibiotic8,9 depends on the likelihood of the presence of resistant organisms that dominate the infection. This depends on the timing of presentation, evidence of spread and aggression, history of previous antibiotic use and immune

Odontogenic

ODONTOGENIC from 37


status of the patient. No antibiotic has been shown to be clearly superior to all others for the treatment of odontogenic infection10. Antibiotics can then be chosen based on cost and safety. Empiric antibiotics of choice for minor outpatient infections include amoxicillin or penicillin, clindamycin and azithromycin. For penicillin-allergic pa-tients, clindamycin, azithromycin, metronidazole and moxifloxacin are used. For the more serious inpatient infections, ampicillin plus sulbactam, clindamycin, penicillin plus metronidazole or ceftriaxone are recommended. Choices for penicillin-allergic inpatients include clindamycin, moxifolxacin, and vancomycin plus metronidazole.

Infections require systemic management and it is the dentist’s responsibility to ad-dress the systemic manifestations of odontogenic infection. Dehydration is usually a prominent part of the systemic response to infection, with daily fluid requirements increasing as much as three-fold when fever is present. A history of decreased fluid intake should be determined and is supported by clinical signs such as dry lips, history of concentrated urine and compensatory tachycardia. Increased fluid intake, in-creased nutrition and caloric intake, rest, analgesics and antibiotics, as well as frequent monitoring of the infection, are necessary. Minor infections can become severe quite rapidly, and outpatient management requires frequent follow-up visits.

Treatment failure is usually due to inadequate surgical drainage, depressed host de-fenses, persistent foreign body or failure to remove the source of the infection. Antibi-otic failures include noncompliance, wrong dose or wrong antibiotic for the spectrum of organisms involved. Dentists should understand that the patient illustrated in this case may be at higher risk for other odontogenic infections, as he works outside in ex-treme heat and may hydrate himself with large quantities of sugared drinks. He also is a smoker, which may affect the risk of odontogenic infection due to chronic vascular compromise and tissue hypoxia. It is likely that his condition worsened in this case because the source of the infection was not removed in a timely manner, drainage was not established, and resistant organisms began to proliferate and dominate the infec-tion. Practitioners could consider switching antibiotics after definitive surgical care, as it is likely that the current prescription is ineffective. This decision is complicated by the fact that the records are poor as to the dosing prescribed. The patient should be encouraged to obtain preventive care before his other carious lesions gain access to deeper tissues.

Dentists should know the signs of increasing severity of infections that may become life-threatening. These include increasing trismus, airway obstruction, dysphagia, in-ability to take oral fluids or nutrition, multiple fascial space involvement, high fever, or signs of rapid and severe spread. Patients with severe infections should be referred to the oral and maxillofacial surgeon, and may require hospitalization, surgical drain-age in the operating room, and inpatient medical management. To treat or refer is sometimes a difficult decision for the general dentist and requires an honest assess-ment of the dentist’s anatomical knowledge, skills and experience, as well as skills in medical risk assessment.

Dr. Dennis is a clinical professor in the Department of Oral and Maxillofacial Surgery at the University of Florida College of Dentistry. He can be reached at [email protected].

References:1. Haug RH The changing microbiology of maxil-lofacial infections. Oral and Maxillofacial Clinics of North America Saunders 2003 Feb Vol 15 Issue 1. 2. Kim Y, Flynn TR, Donoff RB, Wong DT, Todd R. The gene: the polymerase chain reaction and its clinical application. J Oral Maxillofac Surg. 2002 Jul; 60(7):808-15. 3. Bruce J. Paster, Irena M. Bartoszyk and Floyd E. Dewhirst. Identification of oral streptococci using PCR-based, reverse-capture, checkerboard hybridization. Methods in Cell Science. Pub-lisher: Springer. Science+ Business Media B.V., Formerly Kluwer Academic Publishers B.V. ISSN: 1381-5741 (Paper) 1573-0603 (Online). DOI: 10.1023/A:1009715710555. Issue: Volume 20, Num-bers 1-4. Date: March 1998. Pages: 223-231.4. Flynn TR, Paster BJ, Stokes LN, Susarla SM, Shanti RM. Molecular methods for diagnosis of odontogenic infections. J Oral Maxillofac Surg. 2012 Aug; 70(8):1854-9. doi: 10.1016/j.joms.2011.09.009. Epub 2012 Feb 10.5. Topazian RG, Goldberg MH, Hupp JR, eds. Oral and maxillofacial infections. 4th ed. Philadelphia: W.B. Saunders Company, 2002:158-187.6. Dennis MJ. Treating odontogenic infections: an update for dental professionals. Today’s FDA. 2006 Mar; 18(3):20-3, 25. Review. No abstract available. PMID: 16639804 [PubMed - indexed for MED-LINE]7. Contemporary Oral and Maxillofacial Surgery. Hupp et al 4th edition, Mosby 2008. Principles of Management and Prevention of Odontogenic Infec-tions. Flynn TR. (291-315); Complex Odontogenic Infections, Flynn TR (317-336).8. Microbiology and Antibiotic Therapy of Oral and Maxillofacial Infections Surgical Minilecture. AAOMS 2004. Thomas R Flynn, D.M.D.9. Flynn TR, Halpern LR Antibiotic selection in head and neck infections. Oral and Maxillofacial Clinics of North America Saunders 2003 Feb Vol 15: 17-3810. Oral and Maxillofacial Surgery Clinics of North America. Oral and Maxillofacial Infections: 15 unan-swered questions. FlynnTR, Haug RH, eds. Vol 23 (4) Nov 2011(491-612).

Odontogenic

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Incisal Edge PositionOnce you know where you want the edge of the upper relaxed lip, you can start determining where you want the central incisors. The occlusion rim must be adjusted so there are minimal or no teeth showing when the muscles and lips are at rest. As a general rule, the incisal edges will be 1-2 mm below the relaxed lip for women; for men, it is usually even with the lip.

I find the Alma Gauge (Dentsply) to be a very useful instrument for locating the incisal edge position. It will pinpoint in millimeters the vertical and horizontal position of the central incisor edges rela-tive to the incisive papilla. At the impres-sion appointment, I place their old den-ture on the Alma Gauge, depress the pin into the denture’s incisive papilla groove, and record the vertical and horizontal

Locating the Denture Smile Line

By Mark Williams, DMD

Your denture patients want to have a great smile and you should be able to provide that for them. Follow these steps and help them get that smile they have always wanted.

Lip SupportWhen you put the wax rim in the mouth, the first thing you should exam-ine is the lip support. Does the upper lip need more support or less? The reason for adjusting the lip first is because, as you remove lip support, the upper lip will drop slightly and become longer and can change the amount of tooth displayed when smiling or talking. Shape the upper rim using hot water and/or a heated rim former until you achieve the desired lip support and the rim follows the contour of the upper ridge.

Denture

readings. If I want the teeth on their new denture to be positioned out more, then I will add to the horizontal measure-ment. If I want them down more, I will add to the vertical. Using these measure-ments, the lab can construct an occlusion rim that greatly minimizes the time I have to spend making adjustments to the wax. Of course, the lab also must have an Alma Gauge to use.

Lip LengthLip length is determined by measuring the distance from the crest of the ridge to the bottom edge of the relaxed lip. Nor-mal lip length is 4-5 mm. Using a papil-lameter (Ivoclar or Blue Dolphin) will give you the lip length. Major problems arise with a short lip because teeth and the denture base will show even when the lip is relaxed. The patient needs to be made aware of this before treatment


Denture

starts. Some dentists use the papillameter to determine incisal edge position, but the measurement lacks a horizontal com-ponent, so I prefer the Alma Gauge.

Occlusal PlaneNow that you have determined the position of the edges of the centrals, you want to create a level and pleasing plane of occlusion for the remaining upper teeth. We don’t want the posterior teeth to look like they are going downhill or leaning to one side or the other.

Place the wax rim in hot water (135-140 degrees) until it becomes pliable, then remove it from the water and press the back of the rim down on your counter-top. Put it back in the mouth and repeat the process until the rim is parallel to the interpupillary line. You can use a heated rim former, but with a little practice you will save time by using the hot water.

In order to better visualize the cant of the rim, I find it helpful to have my as-sistant retract the upper lip from the left with a mouth mirror while I retract from the right, and line up the rim with the patient’s eyes.

MidlineMany times, I’ve had to send everything back because I did not have the midline correctly positioned and the patient noticed it right away. If the patient has a distinct philtrum, I will mark it there, but with crooked noses, flabby chins and thin lips, do the best you can by tightly holding vertical floss until it is in harmony with the middle of the face. The midline may or may not match the position of the labial frenum but it will get you very close.

Do not even attempt to put the lower rim in the mouth until you have com-pleted forming the upper rim.

If you follow this sequence, I believe your frustration level with occlusion rims will go down and the number of smiles on your patients’ faces will go up.

Reprinted with permission by The Profit-able Dentist.

Dr. Williams has a practice in Altamonte Springs and can be reached at [email protected].

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Your denture patients want to have a great

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By Bob Macdonald, MS EXECUTIVE DIRECTOR OF FLORIDA'S PRESCRIPTION DRUG MONITORING PROGRAM FOUNDATION

In 2009, following passage of Chap-ter 893.005, F.S., Florida-licensed dentists, along with other health care practitioners, became part of the state’s Prescription Drug

Monitoring Program (PDMP). This statewide database was established to encourage safer prescribing of controlled substances and to reduce drug abuse and diversion.

Prior to the law’s passage, many of Florida’s city governments, especially in Fort Lauderdale, Orlando, Lakeland, Daytona Beach and Tampa, had an epi-demic on their hands. The Centers for Disease Control and Prevention (CDC) labeled Florida the epicenter of prescrip-tion drug diversion because it had weak regulatory oversight of pain management practices, limited regulation of practitio-ner dispensing habits and, most impor-tantly, no prescription drug monitoring program. Florida became known as the “pill mill” capital of the country.

Forty-nine of the top 50 clinics in the U.S. that prescribed oxycodone, the na-tion’s number one painkilling drug, were

Prescription Drug Monitoring Program Aids Dentists in Managing Controlled Substances

located in the Sunshine State. Forty-five of the pill mills were in Broward County, and were selling more than one million oxycodone pills per month. Before new regula-tions were enacted by the Florida Legislature, it was projected from state medical examiners’ records that about 10 people each day died of prescription drug overdose, primarily due to oxycodone abuse.

In 2010, the Drug Enforcement Agency’s (DEA) statistics showed that the Sunshine State had more than 900 unregulated pain management clinics. However, with the passage of the law, new regulations for the establishment and operation of pain man-agement clinics, standards of care for practitioners in dealing with patient pain man-agement and mandatory registration of clinics were adopted, reducing the number to about 500 clinics. In addition, the legislation authorized the establishment of the PDMP, making Florida the thirty-ninth state to have this critically important data-base. A statewide task force appointed by the governor also was established to close illegally operating pain management clinics and take legal action against criminal violations.

Two years after the law was passed, Florida’s PDMP, known as E-FORCSE (Electron-ic-Florida Online Reporting of Controlled Substance Evaluation Program), became active. Operating under the Department of Health, the database collects controlled substance prescription information from dispensers within seven days of provision. All other licensed health care practitioners who prescribe controlled substances are encouraged to register and access the program’s patient information. This can help guide the practitioner’s decision in prescribing and dispensing highly abused prescrip-tion drugs. It also can help the practitioner identify patients who may be doctor shop-ping or trying to obtain multiple prescriptions of the same controlled substance from several health care offices. In addition, the law provides law enforcement organizations access to the database to seek information on active investigations of a criminal action.

Because use of the database is voluntary for practitioners who are not dispensers of controlled substances, registration has varied between the health care professions. E-FORCSE statistics for 2012 showed that pharmacists were the highest percentage of program participants (40.5 percent) since they are the major dispensers. The next highest percentage was osteopathic physicians at 24.3 percent of licensees participat-ing. Physician assistants were third at 14.2 percent, followed by medical doctors at 11 percent, advanced registered nurse practitioners (ARNPs) at 5 percent, podiatrists at 4.8 percent, dentists at 4.3 percent and optometrists at less than 1 percent.

Drug Monitoring


The PDMP has had great success in its two and a half years of operation. As of May 1, 2014, it has collected more than 100 million controlled substance prescription records from 6,100 registered dispensers. More than 25,000 practitioners are using the data-base; of that total, there are 594 dentists registered, and 331 have queried the database approximately 8,700 times for information.

Use of the PDMP has helped reduce the rate of inappropriate use of Scheduled II-IV prescription drugs, which in turn has led to a 41 percent reduction in the number of deaths from oxycodone. The program also has reduced the quantity of controlled sub-stances obtained by individuals attempting to engage in fraud or deceit, thus deterring doctor shopping, potential addiction and improper drug sales.

According to a July 14, 2011 Time Magazine article, dentists prescribe 12 percent of all immediate-release opioids, second only to general practicing medical doctors and osteopathic physicians. Therefore, dentists who participate in the program will gain the ability to check the database for their patient’s prescription history. The practitio-ner can then better evaluate a patient’s treatment plan, which may result in the avoid-ance of detrimental interactions with existing prescriptions. It also will help prevent over-prescribing of controlled substances.

Because the legislature wanted the program’s operations supported by non-state revenue, E-FORCSE’s nearly $500,000 yearly budget is funded by federal, state and private grants and contributions from individuals, corporations and law enforcement agencies. A private charitable foundation established by the legislature as a Direct Support Organization to the Department of Health raises the funds for the PDMP. The foundation’s nine-member board is appointed by the State Surgeon General. After a one-year state-funded allocation to jump-start the program, the PDMP Foundation turned to other sources for funding assistance. It has raised more than $2.2 million through the 2013-2014 fiscal year, thanks to a major gift of $2 million from Attorney General Pam Bondi from funds received in a settlement with CVS/Caremark and contributions from individuals, corporations and state, county and municipal law enforcement organizations.

Dentists interested in registering for E-FORCSE can do so by going to its website at [email protected], or by calling 850.245.4797. For information about supporting the program through a tax-deductible contribution to the PDMP Foundation, please contact the executive director at [email protected].

Bob Macdonald is the executive director of Florida’s Prescription Drug Monitoring Program Foundation. He can be reached at: [email protected].

“

”

Drug Monitoring

Because use of the database

is voluntary for practitioners who are not dispensers

of controlled substances,

registration has varied between the health care

professions.


Diagnostic Discussion


By Dr. Don Cohen

A 78-year-old Caucasian male was seen in March 2014 for an emergency visit by Craig M. Misch DDS, MD, a specialist in oral and maxillofacial surgery and prosthodontics in Sarasota, Fla. He complained of pain and swelling of the gingiva under his implant prosthesis. The patient had no facial swelling. His neck was supple with no lymphadenopathy. There were no le-sions on the floor of the mouth, palate, buccal mucosa, tongue or posterior oropharynx. There was swelling of the mandibular right gingiva under the right side of the prosthesis (Fig. 1). The lower prosthesis was removed to allow evaluation of the im-plant post. Periodontal probing found deep pocketing around the mandibular right anterior implant post with bleeding but no exudate. The implant was not loose despite the bone loss. His oral hygiene was fairly good. A periapical radiograph (Fig. 2) revealed marginal bone loss around the mandibular right anterior transosseous post. He was diagnosed with peri-implan-titis. Dr. Misch recommended a surgical repair/deep cleaning of the implant post. Prescriptions were written for amoxicillin and Chlorhexidine rinse. Dr. Misch had seen the patient for follow-up exams and maintenance almost yearly since 2002 and most recently in June 2013.His original tranosseous im-plant was placed in 1994 by a clinician in the Northeast, where the patient originally resided.

His past medical history was significant for stomach ulcers, glaucoma, alcohol use (three times per week) and cigarette smoking (a half of a pack per day for more than 40 years). His medication included azopt. He had no known drug allergies. The patient returned in nine days for his surgery and was experiencing less discomfort since his last visit. Written consent

was obtained. A mucoperiosteal flap was reflected to expose the right anterior post. The implant post had severe marginal bone loss with a crater bone defect. An excisional biopsy was taken from the surrounding tissue with a scalpel. The defect was filled with bovine hydroxylapatite and covered with a collagen membrane. The flap was approximated with 4-0 chromic gut interrupted sutures. The patient tolerated the procedure well and was given post-op instructions. Dr. Misch submitted the excised tissue to the University of Florida College of Dentistry Oral and Maxillofacial Biopsy Service in Gainesville, Fla.

Microscopic examination revealed numerous islands of squa-mous epithelium scattered throughout the underlying con-nective tissue (Fig. 3a). There did not appear to be an origin for the lesion from the overlying surface epithelium. At higher magnification, the epithelial islands were composed of both squamous cells and cells with abundant clear cytoplasm (Fig. 3b).

Question:

Based on the clinical, radiographic and microscopic features pic-tured and described above, and the brief medical history, what is the most likely diagnosis?

A. Bisphosphonate-related Osteonecrosis of the Jaws (BRONJ)B. Metastatic Carcinoma (MC)C. Peri-implantitis (PI)D. Osteomyelitis (OM)E. Squamous Cell Carcinoma (SCC)

Please see DIAGNOSTIC, 50



Fig. 1 – Clinical photo demonstrates a large destructive lesion of the right side of the anterior mandible. In addition to the hyper-plastic soft tissue, close examination shows the blade of the implant prosthesis and exposed bone.

Fig. 2 – Occlusal X-ray reveals an ill-defined marginal area of extensive bone loss involving the implant post on the patient’s right side.

Fig. 3a – Photomicrograph showing islands of epithelial cells (E) scattered throughout the underlying dense fibrous connective tissue. These islands extend to the surface but no origin of the lesion from the surface epithelium is noted (H&E stain original magnification 10x).

Fig. 3b – Higher power photomicrograph shows islands of epithelium infiltrating throughout the underlying dense fibrous connective tissue. There are two types of cells making up these islands: cells with abundant eosinophilic cytoplasm (epithelioid cells) and those with clear cytoplasm. (H&E stain original magni-fication 20x).



DIAGNOSTIC from 48


A. Bisphosphonate-related Osteonecrosis of the Jaws (BRONJ)Incorrect — but a good guess. Bisphosphonate-related osteonecrosis of the jaws is now called medication-related os-teonecrosis of the jaws, or osteochemonecrosis, to differentiate it from osteonecrosis caused by radiation (osteoradionecrosis).It is defined as an area of exposed bone present for at least six to eight weeks that is unresponsive to therapy. The patient must be on a high-potency bisphosphonate and there must be no history of radiation. The reason this is such a good guess is that this patient has some obvious long-standing areas of exposed bone and is having some discomfort in the area. He also is showing significant bone loss that is quite irregular and ill-defined on the X-ray–features that would be compatible with an infection or an osteomyelitis secondary to the bisphos-phonate necrosis. However, this patient is not and has never been on a bisphosphonate, and reference to the medical history would confirm that. The histologic features also are not those seen with osteochemonecrosis.

B. Metastatic Carcinoma (MC)Correct. Now the rest of the story! The patient was unaware of any existing malignan-cies, but a further in-depth work-up ordered after his gingival biopsy was very revealing. The patient had paralysis of his vo-cal cords and liver mets in addition to his oral cavity neoplasm. In addi-

tion, he had lymphadenopathy and a definite lung mass. Our histologic diagnosis of the gingival biopsy was a high-grade,

possibly squamous cell carcinoma. We commented that due to the unusual histology (lack of keratinization, presence of clear cells and lack of tumor origin from the overlying surface epithelium), the patient needed to be evaluated for a possible metastasis. The final diagnosis: metastatic adenocarcinoma of the lung with areas of squamous differentiation.

Metastatic carcinoma is the most common form of malignancy found within bone, far surpassing the incidence of primary bone cancers such as osteogenic and chondroblastic sarcomas. Metastatic carcinoma is primarily a disease of the elderly, which makes this patient a prime candidate. The mandible (usually posterior) is the most common site for metastasis to the jaws making up more than 80 percent of jaw mets.

The take-home message is: Beware of lesions that look like peri-implantitis but fail to respond to conservative therapy. Kaplan et al.1 found seven new cases of malignancy adjacent to dental implants. She commented that clinicians must increase their awareness of the diagnostic trap due to clinical similar-ity of gingival malignancies to peri-implantitis. Of all the oral malignancies, gingival carcinoma and metastases to the gingiva are the ones that most mimic inflammatory disease and are often diagnosed late in the course of the disease when the teeth become very loose. Importantly, in her case series, only one patient had a history of smoking. Of the 41 cases found in the literature of perimplant malignancy, 93 percent were found in the mandibular gingiva. So concern and suspicion should be highest for recalcitrant peri-implantitis in the mandible even in the absence of risk factors, such as smoking and drinking.

Interestingly, in Dr. Kaplan’s series of seven cases, she found four primary squamous cell carcinomas, one lymphoma, a skin basal cell carcinoma and — just as in our case — a metastatic lung cancer. In the literature as a whole, almost all (39/41) of the cases of peri-implant malignancy were primary squamous cell carcinoma of the gingiva. Therefore, squamous cell carci-noma is the most common diagnosis by far for peri-implant malignancy. However, keep in mind that breast cancer and lung cancer, the two most common malignancies that metasta-size to the jaws and spread to bones 66 percent and 33 percent of the time, prospectively. Also, approximately 15 percent of patients dying of metastatic carcinoma will have jaw mets.

Fig. 4 – Clinical photo of innocuous-look-ing red patch on the posterior mandibular gingiva that turned out to be a squamous cell carcinoma.



Therefore, metastases, though much less common, must still be considered in the differential diagnosis of a peri-implant malignancy, especially in the presence of unusual histology, as in this case.

Looking at the clinician’s diagnostic impression on submitting a biopsy specimen of these malignant lesions, peri-implantitis was suspected in 26.8 percent, and a non-specific swelling or mass in 53.6 percent. Therefore, in more than 80 percent of the cases, malignancy was not considered. As implants surge in popularity, we will be seeing a lot more peri-implantitis. Since the vast majority are placed in an elderly cohort of patients — those most susceptible to cancer — we need to increase aware-ness that peri-implant cancer closely mimics peri-implantitis. Again, failure to respond to conventional treatment should immediately raise suspicion of possible malignancy, even in the absence of traditional risk factors such as smoking and drink-ing. Excessive bone loss, especially in the presence of good oral hygiene, is another red flag. Biopsy is essential for diagnosis, though sadly not yet a routine procedure in treatment of peri-implantitis. Many clinicians discard the suspected inflamma-tory tissue only to see the lesion recur and quickly grow. This could lead to fatal delays in treatment. If tissue is removed it should be sent for microscopic examination to ensure the safety of the patient.

C. Peri-implantitis (PI)Incorrect, but by far the most likely diagnosis a clinician would make when presented with this case scenario (minus the biopsy of course!). Peri-implantitis is a condition that resembles periodontal disease in the natural dentition. In peri-implantitis, there is inflammation and often destruction of the bone sur-rounding the implant. Peri-implantitis is most often caused by dental plaque and/or occlusal trauma. It starts as gingivitis and then, just as with natural teeth, progresses to periodontitis with loss of surrounding bone and deep pocketing. Since implants lack a periodontal ligament attachment, they may be thought to be even more susceptible to gingivitis and periodontitis than natural teeth.

With the marked increase in the number of implants being placed, we can expect to see a large increase in the number of cases of peri-implantitis. Peri-implantitis should respond to oral hygiene procedures, plaque control and antibiotic therapy. Surgical debridement may be necessary. If peri-implantitis does not respond to local therapy, a biopsy should be done to confirm the benign nature of the lesion. Although malignancy is rarely associated with implants, lesions that fail to heal should be biopsied.

D. Osteomyelitis (OM)Incorrect — but an answer with some merit! In this case, the patient has exposed bone and signs that mimic inflammation of the bone just as in osteomyelitis. Also, there is a ragged, ill-defined radiolucency and possible sequestrum present just as we would see with chronic osteomyelitis. Obviously, the histologic findings in this case would preclude a diagnosis of osteomyeli-tis.

Osteomyelitis is an acute or chronic inflammatory process of bone marrow or cortex. A wide age range of patients is affected, but there is a strong male predominance. Most cases involve the mandible. Symptoms include fever, tenderness, soft tissue swell-ing and lymphadenopathy. Radiographic changes range from unremarkable in acute forms to ill-defined radiolucencies with the chronic form. Pain, sinus tracts with purulence and boney sequestrum are common. Due to the radiographic features and frequent presence of paresthesia or anesthesia, the differential diagnosis for chronic osteomyelitis would include a metastatic lesion as well.

E. Squamous Cell Carcinoma (SCC)Incorrect, but a good guess! Almost all (39/41) of the cases of peri-implant malignancy were primary squamous cell carcinoma of the gingiva. Therefore, squamous cell carcinoma is the most common diagnosis by far for these peri-implant malignancies. Even the histologic features in this case resembled a squamous carcinoma, although not a primary squamous cell carcinoma. Furthermore, of the 41 cases found in the litera-

Please see DIAGNOSTIC, 53

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Diagnostic Discussion is contributed by UFCD professors, Drs. Don Cohen, Indraneel Bhattacharyya and Nadim Islam, and provides insight and feedback on common, important, new and challenging oral diseases.

The dental professors operate a large, multi-state biopsy service. The column’s case studies originate from the more than 10,000 speci-mens the service receives every year from all over the United States.

Clinicians are invited to submit cases from their own practices. Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter.

Continuing Education Opportunity You can now earn continuing education credit for reading Diagnostic Discussion articles! Visit the FDA website

at www.floridadental.org and click “Online Education” under the “Benefits and Resources” tab for this free, members-only benefit. You will be given the opportunity to review this column and its accompanying photos,

and will be asked to answer five additional questions. If you have questions about this opportunity, email FDC Meeting Assitant, Ashley Liveoak at [email protected] or call 800.877.9922.

Be sure you are logged in to the members-only side of www.floridadental.org to access the online CE.

Dr. IslamDr. BhattacharyyaDr. Cohen

ture of perimplant malignancy, 93 percent were found in the mandibular gingiva. Most importantly, recalcitrant mandibular peri-implantitis should be of particular concern. Therefore, the take-home message is to beware of lesions that look like peri-implantitis but fail to respond to conservative therapy.

Gingival squamous cell carcinoma makes up between 10-30 percent of all oral cancers, depending on the study population. It is a disease of the elderly with an average age of 72 at the time of diagnosis. The mandible is the most common location, being the site of origin 72 percent of the time. Unlike this case, it does, however, favor the posterior mandible. Dr. Sarah Fitz-patrick and the rest of our group at UF College of Dentistry reported on 519 cases of gingival carcinoma7 and noted the dif-ficulty in diagnosing these lesions due to their frequent benign clinical appearance (Fig. 4). Gingival carcinomas often mimic benign conditions, such as pyogenic granulomas, granulation tissue, gingivitis and periodontal disease. These lesions most of-ten appear red in color just as most inflammatory lesions (Fig. 4). Because of this deceptive appearance, on average, there is more than a two-month delay before these patients are treated and more than one-third present with nodal involvement sig-nificantly worsening their prognosis.

As the number of patients receiving implants continues to increase, the prevalence of peri-implantitis also is likely to increase. Therefore, clinicians must increase their awareness of the diagnostic trap due to clinical similarity of gingival malig-nancies and peri-implantitis. Any lesion that does not respond to conservative therapy should be biopsied and the tissue submitted for microscopic examination to ensure arriving at the correct diagnosis.

DIAGNOSTIC from 51 Some useful references:1. Kaplan I, Zeevi I, Raiser V, Tal H, Rosenfeld E, Chaushu G. Abstract #2 American Academy of Oral and Maxillofacial Pathology meeting April 2014 St. Augustine, Fla.2. Czerninski R, Kaplan I, Almoznino G, Maly A, and Regev E. Oral Squamous cell carcinoma around dental implants Quintessence Int 2006 Oct; 37(9): 707-11.3. Gulati A, Pythussery FJ, Downie IP and Flood TR. Squamous cell carcinoma presenting as perimplantitis: A case report. Ann R Coll Surg Engl 2009; (9)1-3.4. Block MS and Scheufler E., Squamous cell carcinoma appearing as peri-implant bone loss: a case report. J Oral Maxillofac Surg 2001; 59: 1349-1352.5. Pfammatter C, Lindenmuller IH, Lugli A, FiliPPI A and Kuhl S. Metastases and primary tumors around dental implants: A literature review and case report of peri-implant pulmonary metastasis Quintessence Int. 2012 Jul-Aug 43(7): 563-70. 6. Sorsa T, Tjaderhane L and Salo T. Matrix metalloproteinases in oral diseases. Oral Diseases (2004) 10; 311-318 7. Fitzpatrick SG, Neuman AN, Cohen DM, Bhattacharyya I. The clinical and histologic presentation of gingival squamous cell carcinoma: a study of 519 cases.




Life MembersDr. Rodger Stuart AidmanDr. Joel T. AlfordDr. Nolan W. AllenDr. Stephen F. AndersonDr. Michael J. BasistaDr. Albert J. BauknechtDr. Jon Howard BaxterDr. Charles A. Beck Jr.Dr. John C. BelcherDr. Joel S. BergerDr. Richard W. BlakeDr. Charles M. BravermanDr. David A. BrownDr. Mark Joseph BrunswickDr. Donald I. Cadle Jr.Dr. Frank A. CatalanottoDr. Richard J. ChichettiDr. Victor D. ChristophDr. Peter B. ClaussenDr. Daniel C. CohenDr. Robert Martin CohenDr. Jack CohnDr. Frank Anthony ColaizziDr. Richard B. ConfortiDr. Albert S. CowieDr. Joseph R. CraigDr. Phillip C. CrawfordDr. Donald CurlDr. Thomas J. Dahlan

Milestones!

CelebratingMember

Member Milestones

The Florida Dental Association (FDA) would like to rec-ognize its life members and those who have belonged to the association for 60, 50, 35 and 25 years. Each member listed below has been mailed a special membership pin. The FDA congratulates these members and thanks them for outstanding personal commitment to the association and the dental profession.

Dr. Diana DavissonDr. Barry DeGraffDr. Joseph W. DeluciaDr. Gregory T. DickinsonDr. Elsa M.C. DominguezDr. Albert J. EndruschatDr. Louis J. FazioDr. Thomas A. FellnerDr. Jonathan FelthamDr. Robert Thomas FerrisDr. Howard FinnkDr. James Patrick FlatleyDr. C. Robert FortDr. Kurt E. FriedmanDr. Craig A. GlaesnerDr. Jack W. GoldeyDr. E. William GoldnerDr. Burton M. GolubDr. William T. GrantDr. Robert A. GrumetDr. Fredric Donald HaerichDr. Ronald M. HagenDr. John Hamman Jr.Dr. Dan B. HenryDr. John H. Hinman IIIDr. James B. Hodge IIIDr. Alan L. HoffmanDr. Howard J. HoffmanDr. William B. HolbrookDr. Thomas P. HughesDr. Robert D. Iver

Dr. John Robert Jordan Jr.Dr. Theodore W. KadukDr. Bruce Arthur KanehlDr. Richard I. KarpayDr. George J. KarrDr. John Gary KemenyDr. William Carl KingDr. Alan B. KingstonDr. Gerald M. KluftDr. Richard KornDr. Gregg R. KroenDr. Dennis A. KuackDr. Steven J. KusnickDr. Gus LaroccaDr. Jeffrey R. LashDr. Eric J. LebowitzDr. James L. LeeDr. Richard S. LeidermanDr. Hal R. LippmanDr. Jeffrey B.LissauerDr. John L. LoschiavoDr. Glen A. LoudermilkDr. Ray A. MaiwurmDr. William MarcheseDr. Steven B. MargolinDr. Joseph P. McCainDr. Daniel J. MelkerDr. Sandra Louise MercierDr. Gary S. MillerDr. Thomas Michael MillmanDr. William A. MoonDr. Jack W. MorrisonDr. Wayne P. NewmanDr. William B. Nipper Jr.Dr. Michael Doyle OdlandDr. Steven OppenheimerDr. Jose A. Ortega Jr.Dr. Rodney Duncan OwensDr. Edmund Ira ParnesDr. Marcus E. PaulDr. George Thomas Peak IIIDr. John R. Pell II

Dr. Bruce M. PerlmanDr. Leroy R. PoliteDr. William PorcellDr. Ronald M. ProssDr. Edmund E. RahalDr. Enna A. RomeuDr. Richard L. RushDr. Edward J. SarrineDr. Leslie Thomas SchwarzDr. Stephen Charles SemescoDr. Sanford ShapiroDr. David G. SheltonDr. Alan Michael SilvermanDr. Maxine SindledeckerDr. Richard A. SkripakDr. Edward Joseph SmithDr. Jerry B. Smith Jr.Dr. Richard SteinDr. Paul H. TannenbaumDr. Stephen R. TeitelbaumDr. Robert A. UchinDr. Thomas G. Van BuskirkDr. Seymour WeinerDr. George L. WilliamsDr. Larry C. WilliamsonDr. William Arthur WrockDr. Neal B. ZieglerDr. Nury E. Zurbano

60-year Members

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Milestones!

Dr. Henry Giddens KingDr. Alvin L.KrasneDr. Ralph J. LeidnerDr. Norman Mark MillerDr. Roger V. MummDr. Hugh Delbert NortonDr. James Everett PaulkDr. Neil Garrett PowellDr. Sidney George RachlinDr. Neal Martin RothDr. Donald Woodley SittersonDr. James Seymour SledgeDr. John Charles StantonDr. Thomas Darius Williams

50-year Members

Dr. Norton H. AgronDr. Stanton BassDr. Allan BerryDr. Frank Vincent BervaldiDr. Edward BrennerDr. Robert D. BurgDr. Seldon T. ChildersDr. Stanley CohenDr. Richard George CooperDr. Everett Cornish Crouch Jr.Dr. Henry De StefanoDr. Henry Anthony FischerDr. Richard ThomasGainesDr. Ralph Garcia Jr.Dr. Bertram F. GoodhartDr. Arnold George GreeneDr. Harold G. GreggDr. Gerald William HaltrichDr. Ronald W. HigelDr. Andrew Clements HintonDr. Albert Payton Hodges Jr.Dr. Joseph A. HusztyDr. K. Denis InouyeDr. Donald L. KaneDr. Niles Henry Kinnunen Jr.Dr. Phil Jay LevineDr. Walter Edgar Mac DonellDr. Richard C. MarianiDr. Robert Earl MarlinDr. Alan J. MartinDr. William Jones McCallieDr. James E. MongovenDr. Daniel Gordon NolandDr. William Richard PaladinoDr. Harvey S. PallenDr. David B. PereDr. Michael R. PetersDr. Charles John Pinkerton

Dr. William E. RichardsonDr. Austin G. RiddleDr. John Catlett RumbleDr. Don Trawick SearsDr. Augustus Norman SharpDr. Donald SiegendorfDr. Charles John SimonDr. James M. SteigDr. Sidney L. SwindleDr. James Atwood Taylor Jr.Dr. Frank Benedict TriznaDr. Donald Herbert WadsworthDr. Frederic J. WassermanDr. William Paul WeberDr. Isadore R. WeinsteinDr. Billy Rupert WestgardDr. Robert Wayne WilliamsDr. Stanley L. Zakarin

35-year Members

Dr. Rafael B. AbislaimanDr. Sudhir K. AgarwalDr. Joel T. AlfordDr. Paul E. AndersonDr. Stephen F. AndersonDr. Sol AnkerDr. Jacob L. ArmaniousDr. Michael J. AxelrodDr. Harvey J. BarbagDr. Mark BeharDr. Eric BensonDr. Joel S. BergerDr. Hector BethartDr. Eugene BlackDr. Leonard BrittenDr. David A. BrownDr. Randall C. BrownDr. Larry B. ButlerDr. Nicholas D. CatsosDr. Francis C. ChaneyDr. Robert M. ChristDr. Peter B. ClaussenDr. Richard B. ConfortiDr. Albert S. CowieDr. Joseph R. CraigDr. Dennis W. DaltonDr. Frank Delgado IIIDr. Stuart DropkinDr. Glenn E. DuPontDr. James E. EdwardsDr. John B. EllisDr. Peter M. FallonDr. Edward A. FellowsDr. Nora S. Fornaris

Dr. C. Robert FortDr. Robert D. GearDr. Jack W. GoldeyDr. Fredric Donald HaerichDr. Charles Richard HambrookDr. Gary E. HerbeckDr. Elena F. HernandezDr. James B. Hodge IIIDr. William B. HolbrookDr. William Judson HolthDr. Teri-Ross IcydaDr. John Robert Jordan Jr.Dr. Gary L. JoynerDr. Harvey Lee KansolDr. John Gary KemenyDr. Bernard E. KeoughDr. Frederic G. KirschDr. Scott H. KlareichDr. Lawrence M. KleinDr. Stephen Michael KristDr. Dennis A. KuackDr. Jeffrey N. LangDr. Julian C. LeichterDr. Patrick J. LepeakDr. Robert J. LevDr. Jeffrey B. LissauerDr. Yohama LorenzoDr. John L. LoschiavoDr. Larry Louis MaggioreDr. William Barry MartinDr. Joseph P. McCainDr. E. Lynn McLartyDr. Michael K. McRoyanDr. Sandra Louise MercierDr. Bernard E. MetrickDr. Douglas E. MilsapDr. Shawn A. MitchellDr. Charles Moses IIIDr. Esteban MulkayDr. James E. Nabors IIDr. Gary F. OzgaDr. Marcus E. PaulDr. Stephen J. PeirceDr. Dale R. PellotDr. Robert PerezDr. Leroy R. PoliteDr. Edmund E. RahalDr. Paul Stanford SaariDr. Jack SabanDr. Ramsey B. SalemDr. Thomas A. SchoplerDr. Selden D. SchwartzbergDr. Sanford ShapiroDr. Markus SherryDr. Michael S. SilverDr. Richard A. StevensonDr. James M. Tinsley

Dr. Joseph Campbell WalshDr. D. Michael WatkinsDr. Seymour WeinerDr. George Michael WombleDr. Clark J. Wright

25-year Members

Dr. Gregory AldrichDr. Rodney L. AnthonyDr. Victor C. ApelDr. Stanley H. Asensio IIDr. Edward F. AugustyniakDr. Wayne M. BakerDr. Steven Bateh Dr. William Thomas BellDr. Don Black IIIDr. Carolyn R. BottomleyDr. Linda BranhamDr. Alexander L. BretosDr. Robert BrockettDr. Gilbert BrodachDr. Barbara A. BucyDr. Tommie L. BurchfieldDr. Richard D. CarlsonDr. Louis P. CerilloDr. Jerry H. CheesmanDr. Heather L. ChildersDr. Robert ChuongDr. Gerald A. CioffiDr. David A. CohenDr. Donald Wood Cooper Dr. Thomas A. CopulosDr. Tracey Bach DavidDr. Richard N. DevitaDr. Brian Curtis DeweyDr. Tadeusz B. DomanskiDr. Lawrence DuffyDr. Rita EchevarriaDr. Michael D. EggnatzDr. Stephen David EingornDr. Robert Erdman Dr. Donovan EssenDr. John FerulloDr. William K. FravelDr. Ira S. FreedmanDr. Fernando A. GassetDr. Douglas G. GenningerDr. Christopher D. GoldenDr. David L. GoldsteinDr. Howard T. GoodpasterDr. Nathan GraddyDr. Laurence Allen GrayhillsDr. Jeffrey M. Greenhill

Member Milestones

Please see MILESTONS, 57


Member Milestones

MILESTONES from 55

Dr. Daniel GreensteinDr. Jerald W. GrimesDr. Maria C. GundianDr. Jeffrey A. Hameroff Dr. Wayne HarperDr. William Harriett Dr. Dave W. HeatonDr. Philip Neal HeineckeDr. Loren K. Hofer Dr. Susan Jane HoganDr. Carol A. HorkowitzDr. Rodney F. HorvatDr. Barry JacobsDr. A. Helena JimenezDr. Felix Jimenez Jr.Dr. Dwight Jones Jr.Dr. David A. KailingDr. Frederick E. KaneDr. Ronald KertesDr. David A. KimmelDr. Samuel L. KleinDr. Anthony J. KopczykDr. Michael A. LampDr. Michael J. LanganDr. Mitchell R. LevineDr. Sandra Jean LiloDr. Kenneth S. LiszewskiDr. Philip LoGrippoDr. John J. MarchettoDr. Valerie A. MarinoDr. Ricky MarsDr. Celia S. MartinDr. Elliot MausnerDr. Terry G. MaxDr. Michael G. McCorkleDr. William H. McElveenDr. Andrew Peter McKevenyDr. Hugh J. MillerDr. Nick J. MindenDr. Raul G. Molina Jr.Dr. James Edward MontgomeryDr. Keith Erickson MooreDr. Blake MooresDr. Marco J. MoralesDr. Jill M. MorrisDr. Dianne MorseDr. Timothy MuscaroDr. Marcia M. NemecekDr. Maureen L. O’FlanaganDr. Mark S. OffenbackDr. Cara Lane OverbeckDr. Yolanda ParayuelosDr. Robert W. PayneDr. Kevin L. PaytonDr. Richard A. Perallon

Dr. Gary D. PerlmanDr. James Calvin Pettigrew Jr.Dr. Rose F. PiazzaDr. Edgar J. PorrasDr. Mary PorterDr. Subhash G. RegeDr. Steven C. RhodesDr. Jose E. RibasDr. Helmut A. RichardtDr. Ernest A. RillmanDr. Ramon A. RodriguezDr. Vicki Rodriguez Dr. Kenneth B. RogersDr. Clayton L. RothDr. Enrique R. Rovira-SabaterDr. Thomas G. RubinoDr. Randy J. RuscinDr. Linda Kulma RussowDr. Jose L. SalgueiroDr. Hans R. SalheiserDr. Richard SalkoDr. Miguel J. SantamarinaDr. W. Jack SaxonhouseDr. Nigel A. SchultzDr. Paul J. SkomskyDr. Maria Victoria SmithDr. Douglas L. StarkeyDr. Kenneth L. Staudt Jr.Dr. Carol W. StevensDr. Nicholas VincenzoDr. Phuong-Chau VuDr. Frederick H. WaggenerDr. Steve WarnerDr. Alfred B. WarrenDr. Kurt WeberDr. Douglas Alan WebsterDr. Gary R. WeiderDr. John A. WhitsittDr. Carl Clint WilkinsonDr. David E. WilleyDr. Robert M. WilliamsDr. Andrew Lawrence Witten Dr. Rolf B. WolfromDr. David WollenschlaegerDr. Anthony I. WongDr. Walter R.L. WoodDr. Emilio S. Zapata III


By Drs. Ramakant M. Tiwari, Pradnya P. Nikhade and Manoj G. Chandak

Abstract

Intentional replantation of teeth may be indicated when routine endodontic treatment is impractical or impossible. However, the success rate for replanta-tion is far below that for either nonsurgi-cal or surgical endodontics. Replantation is preferable when extraction is the only remaining alternative.

This report is on a case of intentional replantation. Replantation was required because root canal treatment had failed and the tooth, which had been open to the oral environment, could not be reclosed with comfort. The patient chose not to have apical surgery because of the potential complications and, as an alternative to extraction, replantation was recommended.

Introduction

Intentional replantation is defined by Grossman as the removal of a tooth and its almost immediate replacement, with the object of obturating the canals apically while the tooth is out of the socket1. It is considered by many as a procedure of last resort.

An indication for intentional replanta-tion includes previously failed nonsur-gical endodontics or an apicoectomy procedure is unfavorable because of anatomical factors (e.g., buccal plate thickness; proximity to anatomical struc-

tures, such as the mandibular nerve, or inoperable sites, such as lingual surfaces of mandibular molars; and, a separated instrument in root canal in apical third that cannot be retrieved with nonsurgi-cal methods). Buccal plate thickness may preclude surgical endodontic treatment in mandibular molars and the palatal root of maxillary molars2. Although post removal is frequently possible in the hands of a skilled clinician, occasionally posts or separated instrument removal may pose risks greater than the potential benefits, as compared with other options including extraction3.

Contraindications to intentional replantation include: a more favorable prognosis with either conventional apical surgery or implant placement; active periodontal disease; a non-restorable tooth, extraction requiring hemi-section or osseous recontouring; a tooth that is part of a multiple-tooth prosthesis; or roots that are divergent. In cases involv-ing individual teeth (non-splinted) with divergent roots, a single tooth oste-otomy may be considered4. Advantages of intentional replantation are that it’s potentially more cost-effective and less time-consuming than the alternatives. Disadvantages include a risk of root fracture or root resorption. Bender and Rossman reported a success rate of 81 percent of 31 teeth followed for up to 22 years5. Kingsbury and Weisenbaugh reported a success rate of 95 percent for 151 teeth followed for three years6.

Case Report

A 43-year-old female reported to the Department of Conservative Den-tistry and Endodontics at Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences in Wardha, India in December 2013 with a chief complaint of continuous dull pain in the lower left back region of the jaw for one week. The patient’s past dental history revealed that an incomplete root canal treatment with tooth No. 19 was performed by a private practitioner 10 days prior. On examina-tion, tooth No. 19 was tender to percus-sion. Radiographic examination revealed a separated instrument in perapical area with tooth No. 19 in the mesial canal. The presence of periapical radiolucency also was noticed (Fig. 1).

Intentional Replantation of Mandibular First Molar with Separated Instrument in Periapex:

Case Report

Fig. 1

The separated instrument was in the apical third of the root canal and had crossed the apex. Since the patient was in pain during the initial visit, complete isolation was done using a rubber dam. Working length was determined with tooth No. 19 (Fig. 2).

Intentional Replantation


Fig. 2

Soon after the extraction, the tooth was grabbed by artery forceps from the coro-nal aspect. The radicular portion was left untouched by any instrument during the whole procedure. The separated instru-ment was grabbed by tweezers and was pulled out of the apex (Fig. 5 and 6).

Fig. 7. Intraoral periapical radiographs (IOPA) were taken after the splinting.


Removal of the separated instrument with Masseran technique or other instru-ment retrieval kit was quite difficult due to apical location of the separated instrument. Two H-files were intro-duced into the mesio-buccal canals and instrument retrieval was attempted, but was unsuccessful. Hence, apical surgery replantation or extraction were the only other treatment options. In view of the importance of this tooth, treatment by replantation was suggested.

Fig. 3. Atraumatic extraction was carried out under local anesthesia with tooth No. 19 with mandibular cowhorn forceps and elevators.

Fig. 5

Fig. 6

Please see REPLANTATION, 61

Fig. 4. Intraoral view after the extraction.

Biomechanical preparation was carried out by hand using ProTaper in a sequen-tial manner. Irrigation was carried out by 5.25 percent sodium hypochlorite and normal saline. Obturation of the prepared canals was carried out by lateral condensation technique using AH-Plus sealer. Temporary dressing was placed and the tooth was repositioned into the socket. Provisional flexible splinting was given to the patient for a two-week period.

Fig. 8. The patient was kept on analge-sics and antibiotics for five days. IOPAs taken after the removal of the splint.

Fig. 9. Two months postoperative IOPA.

Discussion

Intentional replantation is indicated when the apex of the involved tooth is in close proximity to the inferior alveolar nerve, mental nerve or the maxillary sinus. Provisional splinting is used to secure the reimplanted tooth because rigid splinting may harbor bacteria, delay healing and promote replacement


resorption by not allowing physiological mobility.

Extraoral time in this treatment was less than five minutes. The success of inten-tional replantation is likely dependent upon a minimally traumatic extraction, short extraoral time with copious irriga-tion and meticulous instrumentation, as well as carefully controlled postoperative patient compliance. Successful comple-tion, according to Kratchman, of ex-traoral manipulation should not exceed 10 minutes7. Clinical signs of success of replantation are the absence of pain and tenderness in the sinus tract or periodon-tal pocket. Radiological signs are the absence of root resorption, regeneration of lamina dura within two to four years and marked reduction in size of original periapical rarefaction within six months.

Conclusion

The patient will be frequently called in for checkup and radiographic evaluation, and its success will be determined. This case serves as a reminder that replanta-tion can provide additional years of function for teeth that otherwise would be considered hopeless.

Drs. Ramakant M. Tiwari is a post gradu-ate student, Pradnya P. Nikhade is a profes-sor and guide and Manoj G. Chandak is a professor and HOD at the Department of Conservative Dentistry and End-odontics, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences, Wardha, India. They can be reached at [email protected], [email protected] and [email protected], respectively.

REPLANTATION from 59


References:1. Grossman LI. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc1982; 104:633–9.2. Jin GC, Kim KD, Roh BD, Lee CY, Lee SJ. Buccal bone plate thickness of the Asianpeople. J Endod 2005; 31:430–4.3. Ruddle CJ. Nonsurgical retreatment. J En-dod 2004; 30:827– 45.4. Kany FM. Single-tooth osteotomy for inten-tion replantation. J Endod2002; 28:408 –10.5. Bender IB, Rossman LE. Intentional replan-tation of endodontically treated teeth. OralSurg Oral Med Oral Pathol 1993; 76:623–30.6. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular pre-molars and molars. J Am Dent Assoc 1971; 83:1053–7.7. Kratchman S. Intentional replantation. Dent Clin North Am 1997; 41:603–17.

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By Crissy TallmanDIRECTOR OF CONVENTIONS AND CONTINUING EDUCATION

The 2014 Florida National Dental Convention (FNDC) was a complete success! This event was signified by a rededicated commitment to “recharging” the Florida Dental Association (FDA), our members and attendees during the Thursday keynote session. Based on your feed-back, we did just that! More than 6,300 attendees from around the world gathered in Orlando for this significant event. In-depth educational sessions, training courses and networking events provided attendees the opportunity to exchange ideas with industry experts and colleagues.

Highlights of the convention included:D new logo reveal, rebranding and new mission state-

ment.D keynote sessions each morning from industry experts.

FNDC Wrap-up: Networking, Peer Recognition

and CE Headlined FNDC2014 EventD more than 120 courses/workshops, including live

dentistry in the Exhibit Hall.D 295 exhibiting companies showcasing the latest in

products and innovations.D nightly entertainment.D inaugural Awards Luncheon that honored the Leon

Schwartz Lifetime Service Award, Dentist of the Year and other award recipients.

Part of the FDA’s rebranding included renaming our convention to keep a cohesive brand: the Florida Dental Convention (FDC). Next year’s FDC will take place June 11-13, 2015 and does NOT conflict with Father’s Day weekend. Make plans now to attend!

Go to http://bit.ly/1taes5T to see all of the photos from FNDC2014!

Ms. Tallman can be reached at 850.350.7105 or [email protected].

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By Dr. Jay Garlitz

Dentists enjoy many hobbies; our hob-bies and community involvement can support practice growth, as newly made friends find their way into our practices with a respectful and personal connec-tion to you as the choice for their happy dental home. Amateur radio (also called ham radio) is a non-commercial hobby of operating communications equipment in the quest of making new friends with similar interests locally and all over the world.

You may have seen many examples of ham radio themes in popular culture: in movies, such as “Phenomenon,” “Con-tact” and “Frequency;” TV shows, such as Tim Allen in “Last Man Standing;” and even a few famous musician-partic-ipants, such as Joe Walsh and Ronnie Milsap. It is a great time to get interested in amateur radio and easy to do so.

Dentistry and Amateur Radio Lead to Professional and

Humanitarian OpportunitiesMorse code is no longer required for licensure, and license exams are given locally by volunteers who process the results and submit them to the Federal Communications Commission (FCC).

Amateur radio is not your “father’s hobby” any longer. It is a vibrant endeavor of voice, code, satellite and computer-interfaced communications supporting many ac-tivities. Radio “hams” use their home stations to operate contests and earn awards, go mobile with car and backpack equipment, operate expeditions in rarely visited locales, assist in time of disasters and much more.

Ham radio has a home at the University of Florida (UF) College of Dentistry. UF’s campus-wide club station, W4DFU, has been in existence since 1934, and located on the 11th floor of the dental tower since 1981. The antennas on three radio tow-ers are a dominant feature on the roof. High frequency shortwave equipment is the central theme for speaking around the world. Many a UF friend has been made from the station, with radio-licensed students, faculty and staff serving as everyday ambas-sadors of UF, a worldwide voice. Special operating events are held with other schools in the Securities and Exchanges Commission (SEC). The Gator Nation Earth Station, launched in November 2013, is one of two amateur radio control stations on campus for UF’s SwampSat CubeSat (a satellite).

Dentists also have a home in amateur radio. MARCO, the Medical Amateur Radio Council (www.marco-ltd.org), is a group of health professionals with ham radio interests. Their charitable arm, MediShare International (www.medishare.org), funds


Amateur radio is not your ‘father’s

hobby’ any longer.

ham radio-related medical projects, such as radios for ambulances in Sri Lanka. Their members meet on the air every week and cover medical topics for continuing educa-tion (CE). The “Grand Rounds on the Air” is a shortwave radio-based discussion with a moderator and questions/answers. I am a member of the group and enjoy attend-ing meetings on the air, in person and working with health professionals all over the country and the world.

I have been fortunate to serve as FCC trustee for UF’s W4DFU station and as a faculty advisor for the Gator Amateur Radio Club since 2005. This has afforded me many opportunities and has included great dental satisfaction. In 2012, I was con-tacted through MARCO by a group of “hams” who wanted to make an expedition to a rarely visited island in the Central Pacific. They had a request from the Island Tribal Council for one of the radio operators to be a dentist and to provide dental surgery. I normally would not take a month off from my office for a trip, but after research-ing Banaba Island in the Republic of Kiribati, this situation was so attractive that I decided to join the team and become one of the 19 radio operators – and to be the sole dentist on the trip. (See www.t33a.com for more information.)

I left the U.S. on Oct. 29, 2013 and made my way to our departure point of Tarawa in the Republic of Kiribati, by way of Fiji. I was licensed by credentials after a year of planning and picked up my license and work permit upon arrival Nov. 1. Humanitar-ian outreach during this radio “expedition” was aided by shipping a 40-ft. container loaded with 17,000 lbs. of radio gear and supplies by sea from LA. There was room for my supplies and equipment to take a free ride, and for reading curricula for the local school, donated shoes, soccer balls, etc. We also picked up fresh provisions and chartered a boat, as there is no commercial transportation to Banaba. We departed on Nov. 5 and 40 hours later we arrived, staying for 13 days.

My plan was targeted at providing preventive and surgical care, and upon arrival, it was evident I had planned wisely. I did find a small medical clinic built by the European Union (EU) to set up shop and a family planning aide to train as my dental assistant. Normally, a medical assistant is present on the island, but there wasn’t one during my stay. Chronic dental infections were the norm with a share of more acute ones. There was no electricity or running water on this island of 325 residents. Sleep-ing arrangements were a half of a star! Sixty-five patients were seen and 165 extrac-tions provided. One unexpected and humbling experience took place on our arrival back in Tarawa — it was the seventieth anniversary of the World War II Battle of Tarawa — and being present was a Forrest Gump-type of experience.

Thank you to MARCO for donating supplies, John Taggart of Benco Dental for as-sisting me in getting supplies for the trip, the University of Tennessee Orthopedics for donating emergency medical supplies and to many more who made online donations toward supporting the expedition.

For more information on amateur radio, go to www.gatorradio.org/dentalhams.htm. The site has many links to photos, videos and background information. If you are interested in presentations that would be appropriate for affiliate staff appreciation meetings, please contact me.

Dr. Garlitz is the president of Gator Dental Associates, PA and Connected World Inter-net Ventures Inc. of Hawthorne, Fla. He is a former chairman of the FDA Council on Communications and was named the FDA’s Dentist of the Year in 2001. He can be reached at [email protected].

“”

Amateur Radio


FDA Services (FDAS) is the wholly owned, for-profit insurance agency of the Florida Dental Association. FDAS is a full-service insurance agency and takes pride in manag-ing the insurance portfolios of each and every client. Last year alone, FDAS contributed more than $1,000,000 to the FDA to help reduce membership dues.

About FDA Services Inc.

By Carrie Millar, MBA, CAEFDA SERVICES AGENCY MANAGER

This is a general overview of the health care reform law as it relates to the small business dental practice. It does NOT attempt to cover the law’s provisions and should not be used as legal advice for implementation activities.

At the 2014 Flor-ida Dental Na-tional Convention (FNDC), I presented the course, “Under-standing the Afford-able Care Act.” More than 80 dentists and team members

attended the course; here are their most frequently asked questions.

Health Care Reform: More Frequently Asked Questions

Individual Mandate

Starting in 2014, if you do not have health insurance, you can be fined 1 percent of your household income? Yes. If you go more than three months without coverage in 2014, you can be fined the GREATER of 1 percent of your household inco me or $95 (with a maximum amount capped at a yet to be determined amount that will be about equal to the premium of a Bronze Plan).

Open Enrollment

Is it true everyone is required to have insur-ance, but you can only purchase individual insurance during open enrollment which ended March 31 of this year? Correct. You must have a special situa-tion that would create a special election period (SEP), which includes loss of essential coverage, change in geographic area, birth, divorce, change in income, etc. The open enrollment period for 2015 will be Nov. 15, 2014 through Feb. 15, 2015, with the earliest effective date of Jan. 1, 2015.

When is the best time to compare health insurance options? It’s best to compare twice a year: 60 days prior to your health insurance renewal and during open enrollment. This will al-low you to compare you current plan to the Affordable Care Act (ACA) options.

Small Group

One of our employees can’t afford the employee portion of the group plan. If they get a plan on the exchange, will it hurt participation for our group? With most carriers, the answer is no. Starting in 2014, most small group health insurance carriers will consider in-dividual health insurance a valid waiver, which would not hurt the group partici-pation.

If an employer has fewer than 50 em-ployees, will they be fined for not offering coverage? A small employer of fewer than 50 will NOT be fined for not offering coverage. Additionally, they will NOT be fined for offering coverage that is not consid-ered affordable (defined as more than 9.5 percent of the employee’s household income).

If I have coverage with my spouse, will it prevent my employer from getting group coverage? In most situations, no. Group coverage would be considered a valid waiver, but if the employer only has one other employ-ee (themself ), then it might be needed to meet the basic definition of a group.

Health Care Reform

Please see HEALTH, 70

Individual Insurance

If an employer offers group health insurance to employees, can an employee still qualify for a subsidy on healthcare.gov? Based on the current rules, the answer is no. One of the first questions asked on the exchange is if group health insurance is available. However, the employee can purchase the plan without a subsidy dur-ing open enrollment.

Pediatric Dental

Patients have been coming in convinced that they have dental coverage but were surprised that their deductible was so high. Why is this? ACA-compatible plans are required to cover 10 Essential Health Benefits (EHBs), which include pediatric dental and vision. However, some insurers are

offering the pediatric dental with an integrated deductible with the medical. This means that the deductible for medi-cal and dental are the same and must be met before services are covered. This deductible can be as high as $6,350 for an individual.

If you have any questions, give us a call. FDA Services’ experienced staff is ready to get to work for you. If you need a review of your current insurance policies, call FDA Services at 800.877.7597 or email [email protected].

Ms. Millar can be reached at 850.350.7155 or [email protected].

Health Care Reform

HEALTH from 69

JOSEPH PERRETTIDirector of Sales - South Florida


DENNIS HEADDirector of Sales - Central Florida

877.843.0921 (toll free) Cell: 407.927.5472 [email protected]

DAN ZOTTOLIDirector of Sales - Atlantic Coast


RICK D’ANGELODirector of Sales - West Coast

813.475.6948Cell: [email protected]

RISK EXPERTS

JOE DUKESDirector of Sales - Northeast & Northwest 850.350.7154 Cell: 850.766.9303 [email protected]

[email protected]

www.fdaservices.com

JOSEPH PERRETTI

DIRECTOR OF SALES SOUTH FLORIDA

305.665.0455

Cell: [email protected]

GET TO KNOW JOE PERRETTIJoe graduated from Florida State University with a degree in Finance in 2005. While in school, he interned at FDA Services and he knew he wanted to work in insurance. When the position opened up in his area, he could not pass up the opportunity.

Joe has been assisting members of the Florida Dental Association in the South Florida District for more than seven years. He is well versed in all lines of insurance. He enjoys helping his clients understand the products, as well as finding them the best coverage available while reducing their annual premiums.

Joe is married and lives in the South Florida area. He enjoys spending his spare time with friends and family, playing sports and being active in his community.

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The FDA’s online classified system allows you

to place, modify and pay for your ads online,

24-hours a day. Our intent is to provide our ad-

vertisers with increased flexibility and enhanced

options to personalize and draw attention to

your online classified ads!

The FDA online classified ad model is for “paid

online advertising.” Effectively, the advertising

rate you pay will entitle you to online classified

ads with increased exposure. As an added

benefit, we will continue to publish the “basic

text” format of paid, online classified ads in our

bimonthly printed journal, Today’s FDA, at no

additional cost to you. All ads posted to the

online classified system will be published during

the contracted time frame for which you have

posted your online classified advertisement.

Our magazine is published bimonthly, and

therefore, all ads currently online will be

extracted from the system on roughly the

following dates of each year: Jan. 15, March 15,

May 15, July 15, Sept. 15, Nov. 15. The ads ex-

tracted at this time will then be published in the

following month’s issue of Today’s FDA.

Please view the classified advertising portion

of our website at http://www.floridadental.biz/.


OppOrtunities

ANNOUNCING: Hands On Extraction Classes. Remove Teeth on Live Patients, including impacted wisdom teeth, and receive 40 hours of AGD PACE accepted CE Credit. Learn how to remove teeth and handle complications. Learn how to elevate flaps and suture properly. Classes July 27-31, Sept. 26/27, Oct. 24-30, and January 17-22, 2015. For more information contact Dr. Tommy Murph: 843.488.4357, [email protected].

FLORIDA – DENTIST. Fine opportunity. General Dentist who enjoys treating children for group practice with offices in north Clearwater, New Port Richey and Spring Hill; $160,000-$200,000 plus bonuses, three weeks’ paid vacation, eight paid holidays and health insurance. CE expense. Fax resume to: 727.785.8485 or call: 727.446.3259.

FLORIDA – DENTIST. Tampa Bay. General Dentist desired by group practice with offices in Clearwater, New Port Richey and Spring Hill. Base salary $160,000-$200,000 plus bonuses. Three weeks’ paid vacation, 8 paid holidays and health insurance. CE expense. No Capitation. Fax resume to: 727.446.3359 or call: 727.446.3259.

ORTHODONTIST SEEKING Position FT/PT or Locum tenens. Certified specialist. AAO, ADA member. Mature judgment. Communicative and organizational skills. Personable, Hardworking team player. Great liking for people. Like responsibility. Experienced working with diverse cultures and various professional groups. Totally dependable. Willing to travel. Available immediately. Contact: [email protected], Tel: 305.801.7537.

A blockbuster opportunity. Full or part time for General Dentists, Endodontists, Orthodontists, Pedodontists, Periodontists, and Oral Surgeons. Generous compensation with unlimited potential. Guaranteed referrals. Join our group specialty care practice with a significant general dental component. Established in 1975 in Aventura, Coral Springs, Delray Beach, Boynton Beach, Stuart, Ft. Pierce and Melbourne. Call: Kelly Oliver: 954.461.0172. Fax resume to: 954.678.9539. Email: [email protected].

Need an Associate? Need a job? There’s no fee for finding you a job! Call Doctors Choice Companies. Sandy Harris: 561.744.2783, [email protected].

Part time Dentist. Private practice in Sun City Center needs licensed part time general dentist with strength in endodontic and restorative dentistry. Must have excellent communication skills with comprehensive approach to dentistry. Please send us your resume via fax to 813.655.9945.


Please see CLASSIFIEDS, 74

Dentist Opportunities. Dental Partners is one of the fastest growing family dental practice groups in the Southeast. We give you the ability to focus on patient care while earning a base of $125K-$200K and the opportunity to earn more based on production. Benefits package of medical/vision/life/FSA, 401K, professional liability and yearly CE allowance. Relocation and student loan repayment assistance program may be available. Email resume to [email protected] or call Ashley Reimiller, Director of People Development 321.574.8003.

General Dentist Needed, Boca Raton. If you love dentistry, have excellent chair-side and communication skills, and want to surround yourself with talented staff, we invite you to join our busy, state-of-the-art, paperless, practice. Part time or full time. Compensation: $600/day minimum, depending on qualifications, plus high percentage of collections. Call 954.703.9309 or email [email protected].

Florida – Orlando/Daytona/Jacksonville/Tampa/S. Fla. General Dentist and Specialists. http://www.greenbergdental.com. [email protected].

3-4 Days FFS office. 3-Day week, same comp. as 5 days! South Central FL practice, 45 min from Wellington, 1 hr. from Plantation. Amazing staff and patients. Great opportunity for Good Doc. Must do: Molar RCT, Dentures and extractions. Well above average take home. [email protected].

ASSOCIATE LEADING TO PARTNERSHIP – BRADENTON, FLORIDA. Well established high quality, fee for service, restorative/prosthodontic and esthetic practice looking for a highly skilled and motivated associate. Excellent opportunity for the right person. [email protected].

Pedo/Ortho OFFICE wants General or Specialist dentist. PEDO/ORTHO office looking for some great help. Possibility for General Dentist, Pediatric Dentist, or maybe even Orthodontist. Pay, hours, and arrangement TBD. [email protected].

We are an exceptional multi-specialty group practice composing like-minded dentist, orthodontist, oral surgeons, denturist and ceramist. We offer a phenomenal opportunity both financially and professionally! For recent and new graduates, we will remove all financial pressure. We are willing invest the time, effort and resources to mentor and train you which will fast track your career goals and financial compensation. Many offices promote the possibility of making significant compensation, we GUARANTEE it in writing! Doctors right now are making $1,000+ a day. [email protected], 850.450.8935.

General Dentist. Dynamic Dental Health Associates, a new private fee-for service group, is growing and expanding statewide in particular Jacksonville, Orlando, St. Petersburg, Sarasota, Port Charlotte and Fort Myers. Top Compensation, daily guarantee, health insurance, modern facilities with latest technology, great patient flow, no administrative headaches and professional mgmt. We also buy dental practices and create exit/transition strategies for solo and group practices. If interested in selling your practice, please email Dr. Alex Giannini at [email protected]. If interested in an Associate Dentist position please email your CV to Jeff Hokamp: [email protected] or call 941.312.7838. Current openings in Sarasota, Bradenton, Port Charlotte, North Port, Tampa/Clearwater, Jacksonville and Gainesville. However, please don’t hesitate to send your CV if interested in other areas.

General Dentist. Smile Design Dentistry is seeking experienced general dentists working 4-5 days per week at our offices in Spring Hill and in the Villages. Our dentists have the clinical freedom and autonomy enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. SDD offers a daily guaranty, stable and growing patient base, PPO and FFS based patients, and we offer medical and other benefits. Email [email protected] or call 813.765.0879 for more information.

A traditional fee for service general practice seeking full or part time associates. Seven locations on Florida’s West Coast including Tampa, Clearwater, St. Petersburg, Port Richey and Bradenton. Immediate income, paid vacation, health insurance, 401k, flexible days. Established in 1981. NO CAPITATION. Please contact Carolyn Mallory: 727.461.9149, Fax 727.446.8382 or www.FloridaDentalCenters.com.

Seeking a motivated associate. Ad updated JULY 11, 2014 — High-end multidisciplinary team seeking a motivated associate. The center is located in an upscale area near Gulf Stream Plaza. Approximately one mile from the ocean. The practice recently underwent a modern and technological renovation. Please visit us online at www.ThePremierSmile.com. Our team coordinates and provides continuing education courses i.e. Invisalign, dental implants, cosmetics, sedation, and prosth. We employ a wonderful and highly trained staff that focuses on providing high quality care in a state of the art environment. We will provide the practice support needed for your success. Partnership opportunities are available. Please email CV to Howard Corbeau: [email protected] or fax to 888.800.4955.

Part-Time Associate General Dentist Position in Southwest Florida. Our practice is a long established private practice in Osprey, FL. If you are a DMD looking for a part -time associate position (2-3 days a week) in a well-established private practice, we encourage you to apply. Please submit your CV to [email protected] or fax to 941.497.5650.

Experienced General Dentist Needed for fast growing practice in New Port Richey, Florida. Guaranteed salary plus percentage. Medical and mal-practice paid for you. High-tech office with experienced staff. No nights or week-ends. Excellent opportunity for experienced clinician. Please email resume ([email protected]) or fax (727.945.9661). Immediate opening.

Full Time Associate Dentist needed. Full time dentist required for general dental practice near Orlando. You will be paid 40% of collections minus lab fees. Email [email protected] for more info.

Cocoa Beach, FL – Full Time Dentist. We are currently seeking a full time General Dentist that appreciates the professional, financial and administrative benefits of group practice to join our team. Our doctors are offered a generous compensation and benefit package. Future ownership is available and encouraged. Email C.V. to [email protected].

Associate Dentist wanted for Private Practice located in Clermont Florida. This position is for 2-4 days per week and is flexible. Position seeking motivated dentist who is looking to build a patient following on a permanent basis and become a part of our dental family. [email protected].

Associate Full time or Part time Pensacola, FL. Located on the beautiful gulf coast! Busy practice with newly renovated office looking for an energetic and compassionate associate. Comprehensive care including pediatrics, endo, pros, and surgery. Great working environment with excellent staff. Send resume to [email protected].

ASSOCIATE OPPORTUNITY – NEED HELP. Associateship opportunity for caring, competent, experienced General Dentist in well established, high quality private practice in beachside community near Melbourne, FL. Part-time (2-3 days/week) with potential for up to 4 days. 7 operatories, computerized, digital X-ray, flat screen TVs ... Email CV and contact info to [email protected] or call 321.431.2711.


CLASSIFIEDS from 73

Your Classified Ad Reaches 7,000 Readers!

CLINICAL COORDINATOR. The University of FL College of Dentistry has an opening in their Hialeah Dental Center for a Clinical Coordinator. Responsibilities include: day to day management of the financial, business, customer service, and clinical operations of the dental clinic. For more information and/or to apply, please see our posting at http://jobs.ufl.edu/postings/53804. Deadline for applications is August 4, 2014.

Associate Dentist FT/PT Wanted. Associate Dentist needed for busy Dental office in West Palm Beach who is comfortable treating Children and their Parents (3-4 days/week). We are a family-oriented practice with experienced staff and friendly office environment. We offer competitive compensation. Please send resume to [email protected].

Great Opportunity for General Dentist. Come join our growing team at Dental Associates of Florida! Our dentists have the clinical freedom enjoyed in a traditional private practice without the additional financial or administrative burdens associated with practice management. Our administrative team handles staffing, human resources, purchasing, financials and marketing so you can focus on patient care. Dentists can expect generous production based earnings and a stable patient base with long term career growth potential! We currently have openings at the following locations Lakeland, Tampa, and Clearwater. [email protected].

fOr sale/lease For sale ... Iluma vision 3D cone beam CT scanner. Link to brochure is http://bit.ly/1lRDwIT. State of the art scanner renders fantastic high resolution images, sure to impress. Included computer and dual monitors flawlessly match providing end user with all control necessary for diagnosis and treatment planning. My loss, your gain! Expanding practice, new practitioner needs operatory that scanner is occupying. [email protected].

40,000 cars/day visibility at future stoplight, Sarasota. Sarasota, University Health Park “one stop shop” health care campus, universityhealthpark.net, massive signage directly on corner of future stoplight, 40,000 cars/day visibility, 3,000 patients/week presently flow through campus, fully built out suite, affluent area, perfect for dentist, orthodontist, endodontist, prosthodontist, etc., 15 minutes from #1 ranked beach in USA, Sarasota #1 mid-sized city in U.S. for arts and culture. Call Don Harvey, MD at 941.724.3259.

Beautiful Lakefront Property. Brandon, FL. Beautiful 2000 sf lakefront office space available for custom build out. Adjacent to Endodontist. Ideal for Oral Surgeon or Periodontist. Contact Julie: 813.654.3636 or [email protected].

Immokalee Rd., 2 mi W to US41 and 2 mi E to I-75. Main access to (5) major, N-S routes. The site is enclosed by (16) major hi-residential sub-divisions. Yr. 2014, (2) major developers permitting new projects. “Great partnership facility/Major residential area.” Email [email protected] for listing package.

ORLANDO: DENTAL BUILDING FOR SALE including all equipment and supplies. 7 operatories with 5 equipped. 2500+ sq. FT. stand-alone building. Dentrix networked in all operatories. Start treating patients tomorrow. Call Dr. Zoch at 407.365.9037 or email: [email protected].

Fort Myers, FL - 6 Ops-1,600 Square Foot Office-Well-Established Practice. The local community is family friendly and filled with activities and amenities. The nearby white sandy beaches offer swimming, boating, fishing and much more! Please contact: Henry Schein Professional Practice Transitions, Heather Brown-Licensed Sales Associate. Cell: 727.844.8588. Email: [email protected].

BRAND NEW MEDICAL RETAIL FRONTING W. HILLSBOROUGH AVE. Under Construction – Brand new 2 Story Office/Medical Retail Building. Downstairs – 3,300 sq. ft. total that can be divided into two units. Upstairs – (3) Three 1,100 sq. ft. Executive Office Suites. Frontage on W. Hillsborough Ave. Average traffic counts 55,000+/day. Largest LED display sign on W. Hillsborough Ave. Built with SIPS panels to save you 50% on electric. Pavilion, Future Nature Trails. [email protected].

2 Ops Ready to occupy by SPECIALIST. 4 ops, equipped, new dental office in best part of New Tampa/Wesley Chapel is used 2 days a week by GP and has this up and running dental office to share with a SPECIALIST 3 days a week and weekends. Dental equipment, phone, fax, internet, etc. are included. [email protected].

Sarasota, FL – The #1 Beach Destination in the USA! Established 30 year old practice with $302,000 Gross and 95% collection rate. Solid 3 day hygiene program with 1200 active patients — 25% PPO. 1100 sq. ft. business condo unit also for sale. Owner retiring. Contact Dr. Rotole at: [email protected] or 941.256.6903.

Buyers and Sellers. We have over 100 Florida dental practice opportunities; and the perfect buyer for your practice. Call Doctor’s Choice Companies today! Kenny Jones at 561.746.2102, or [email protected]. Website: doctorschoice1.net.

FOR LEASE: Plumbed Space. [email protected]. http://www.doctorschoice1.net.

Private practice for sale in sunny South Florida! Owner moving out of state. 4 ops with potential for fifth ... PPO/FFS in busy shopping plaza. Email [email protected] with inquiries. Price under negotiations. Sale confidential to staff.

Beautiful Clearwater. General practice, FFS, well established. Owner retiring for health reasons. All equipment new 2007. Must see to appreciate. Extraordinary. Telephone 727.488.0215 for additional information. www.dentistrytampabay.com.

**PEDODONTIST PRACTICE SALE!!!! ** 3,000 sq/ft space. 6 Ops incl 2 Quiet rooms. Equipment includes intra oral Cameras, Digital X-rays, Panographic X-ray unit, Digital Panoramic unit, Lasers, Nitrous and I.V. Sedation System. Family friendly community within minutes of Raymond James Stadium and Busch Gardens. #FL104. Please contact: Henry Schein Professional Practice Transitions, Heather Brown-Licensed Sales Associate. Cell: 727.844.8588. Email: [email protected].


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Book ReviewsBook Reviews

Defense from Within: A Guide to Success as a Dental Defense ExpertAuthor: Jeffrey A. Krompier, Esq.Published by Quintessence

Reviewed by: Mark J. Szarejko, DDS

Please see REVIEWS, 78

The professional interrelationship be-tween members of the dental profession and the legal profession usually occurs when dentists seek legal advice for pro-fessional and business-related matters, or when attorneys instruct dentists about the principles of risk management as they relate to the practice of dentistry. The use of an attorney for the defense of a professional liability case or for the defense of issues before the Board of Dentistry is an association that all within the dental profession would prefer to avoid, but will be a necessity for some practicing clinicians.

Jeffrey A. Krompier, Esq, author of “De-fense from Within: A Guide to Success as a Dental Malpractice Defense Expert,” offers a potential relationship between both professions that is not often consid-ered. His text provides guidelines about

the development of a general dentist or dental specialist as a retained expert who is used in the defense of a professional liability case against another general dentist or dental specialist. The key word here is “development,” as this 11-chapter book provides an outline of the skills which practicing clinicians must acquire if they are to be of a maximum benefit for the defense team. It’s not enough to be a skilled practitioner or one with professional and academic accolades, as the components of the legal system — especially the courtroom and cross-examination by adverse counsel — are usually unfamiliar to dental clinicians.

Krompier introduces us to the legal con-siderations of the defense of professional liability cases that must be confronted and mastered if the dental clinician is to be an effective retained expert. Clinicians who desire to be experts retained by defense counsel must consider how they are viewed from the perspective of the adverse counsel and the jury. The com-mitment of time required of the retained dental expert to adequately prepare for initial reports, depositions and the trial is emphasized. Legal cases can span months or years, so clinicians must be prepared to be available for case review, depositions and trials, which will require their absence from their practice at in-tervals of time that cannot be adequately discerned at the initiation of the litiga-tion proceedings. The case’s defense will be compromised if the availability of the retained expert for the duration of the legal process is interrupted or terminat-ed, and the search for another retained defense expert is required. Clinicians

who want to serve in this capacity have an ethical obligation to the defendant and the defense team that requires them to make an honest self-assessment of their knowledge and clinical skills, which are used to formulate written reports and oral testimony that will be subject to review by the plaintiff’s expert witness and by rigorous cross-examination by adverse counsel.

This book is certainly recommended for clinicians who are interested in serv-ing as retained experts for the defense. They will find this book an excellent initial resource. It will introduce them to topics and subject matter that those who aspire to serve in this capacity must consider before becoming involved in the legal defense process. It also has an appeal to those clinicians who want to become more familiar with the defense proceedings involved in dental profes-sional liability cases. Mr. Krompier notes that since the plaintiffs and adverse counsel have their retained experts, it is essential that the defense team has theirs. Clinicians who can develop the skills that make them an effective retained expert are beneficial to the defendant, the defense team, the legal system and ultimately to the profession of dentistry.

Dr. Szarejko has a general practice in Tampa. He can be reached at [email protected].


Successful Local Anesthesia for Restorative Dentistry and EndodonticsAuthors: Al Reader, DDS, MS; John Nusstein, DDS, MS; and Melissa Drum, DDS, MS

Published by Quintessence

Reviewed by: J. Tim Russin, DDS

A patient’s resistance to new or recur-rent dental procedures rests primarily on the fear of pain during treatment. It is the dentist’s responsibility to provide profound pulpal anesthesia during treat-ment so the patient feels no pain during the procedure. They become relaxed, and feel confident that what is happening in their mouth will not hurt them through the entire appointment. Once anesthe-tized, the patient remains physiologically and emotionally calm, feels secure and returns again for future care. The dentist feels no distress in providing the needed treatment. Sounds simple … but what does the dentist do when the patient will not get numb?

The authors of this book, using more than 25 years of residents’ theses at the Ohio State University’s (OSU) Depart-ment of Graduate Endodontics, have compiled a research-based rationale for the advantages and limitations of

REVIEWS from 76

Book Reviews

conscious sedation or general anesthesia, but is limited to local anesthesia issues only presented in extensive, but concise detail.

I liked the book, for it is a good “read as you go” publication. It becomes a chairside reference manual and definitely will improve your local anesthetic suc-cess due to its scientific, research-based background. My only complaint lies in the fold-over flapped front and back cov-ers, which act like a page bookmark, but got in the way; at times I felt like cutting them off with a pair a scissors or taping them closed.

As a full-time practicing endodontist/CS permit/part-time University of Florida (UF) faculty member, I reviewed this book not only for improving my own lo-cal anesthesia skills, general interest and training the UF endo residents, but also for recognizing the outstanding faculty and graduate students at OSU. Their world-class local anesthetic research for more than a quarter of a century is the backbone for this publication’s highly recommended content. The three authors have a combined peer-reviewed publication count of 225 articles and are all well-known in endodontic literature. The senior author (Al Reader, DDS) was consistently active over the years in the American Association of Endodontists (AAE) Annual Sessions as a presenter, was a past Board examiner for the AAE and director/chairman of the OSU End-odontic Program. All royalties from the book sales are equally divided between the AAE Research Foundation and the OSU Graduate Student Research Fund to support further research on anesthesia and pain control.

Dr. Russin has an endodontic practice in Brandon. He can be reached at [email protected].

various anesthetic agents, and routes of administration to promote profound local anesthesia. The compact 168-page book is broken down to seven chapters, including topics such as: the clinical fac-tors related to local anesthesia; mandibu-lar, maxillary, supplemental, endodontic anesthesia; clinical tips and a detailed index. Definitions and measurements of success/failure; evaluations of the numer-ous study’s outcomes, alternate solutions, various techniques; etc. are all presented.

The publication has clear, color photo-graphs and tables, but most importantly the consistent use of colored X-Y axis graphs of the studied anesthetic variable versus duration of anesthesia (time) of the research study are used throughout the book, making the understanding of the specific information easy and obvious to the reader. At the end of each discussed topic, there is a blue colored “In Conclusion” text summary that reinforces the subject matter clearly and distinctly.

The book is not a basic technique manual of local anesthetic delivery for the dental professional, but emphasizes the drugs, equipment, technology and techniques to establish profound pulpal anesthesia for extensive restorative or endodontic procedures. It helps trouble-shoot local anesthetic failures, describes scientifically what really works and why, and provides the practitioner with a sound understanding of “what to do next.” Many techniques that had an historical or empirical promise of local anesthetic success may not have survived the double-blind, statistical definition of pulpal anesthesia. The ideas presented often will surprise you in their outcome, and will change your own bias to your own learned techniques. The book does not enter into any discussion of oral-IV

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www.fdaservices.comAny projected balance amounts or other projections shown herein are for illustrative purposes only.

“Qualified members” refers to members who have met the five-year continuous coverage requirement.

The FDAS Professional Liability program, with The Doctors Company,

has almost 4,000 policyholders.


GUEST EDITORIALOFF THE CUSP

I recently called a colleague of mine; I had heard he retired and I wanted to congratulate him — or to at least deter-mine if it was on his terms. I was a bit curious because I suspected he was a bit younger than me. How much younger? He has five digits in his license number … I only have three. Turns out, he was happy about it and in good health. Envy may have crept in at this point. He also shared that a lot of his happiness was getting away from the “daily grind” of patients and staff — being under-appre-ciated for what we do, etc. We promised to exchange beers at some point, but I could tell in his voice that his mind was already wrapped around a mai tai in the Bahamas.

His words sort of bothered me. How can we elevate the appreciation of our profes-sion? What profession is one of the most appreciated? After an elaborate three-minute Internet search, it turns out to be: professional athlete. And what’s the most popular sport in the world? Fútbol/soccer. This month, billions of people worldwide are watching the FIFA World Cup. Hmm ... maybe we can combine the two.

First, we need better “u-neez.” I don’t think OSHA would have a problem with

The World Cup of Dentistryus working in soccer shorts. Mmm ... comfy. I know my team members would like it. How many annual photo calen-dars of dentists in scrubs with loupes have you seen? Zippo. We need to move the operatory to the reception area so relatives and friends can waive banners, chant and jump around in flag-colored body paint. Let’s turn that prep into a peppy party. And the best thing ever? We get to wear goalie gloves. Have you ever seen these? Mickey Mouse would be proud. Not sure how they would help, but they must be extra grippy. Mickey never sent a patient for a chest X-ray for a fumbled K-flex file or implant wrench. Donald, yes. Mickey, no. However, if your crown doesn’t fit, I don’t think we could flop to the floor like cooked broccoli, grab our shin, roll around and grimace like we had a bone sticking out. This is standard behavior in soccer. I hate that part.

Don’t get me wrong, I am thrilled for my friend. Who doesn’t want to one day retire, or at least retire to doing only the precise procedures that please you? All professions have stress, but dentistry is unique. Therefore, the tensions are unique. We should do a better job com-municating to patients the precision required for the job. Any patient that I

ever sent to the dental lab always came back saying, “Wow, I had no idea what is involved in that!” We are humble people by nature. And if you were to roll a tooth right out with little effort — take a bow for not having to make it a big surgical event. Give yourself some credit. Be hon-est with your patients and the expected outcomes. Make sure they understand the limitations of the materials with which we work. My father was a dentist, and we always had a common bond and friendship because we both knew what it took to be a good dentist. I don’t have my father anymore, but I do have a family of colleagues that I can consult and counsel with on a daily basis if I need to. I love what I do, but frustration can creep in. Better communication is the key — to your family, friends and patients. It’s that or the Mickey Mouse gloves.

Dr. Wunderlich is a general dentist in Palm Harbor. He can be reached at 727.789.1212.

HUGH WUNDERLICH, DDS, CDE

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Dr. Paul Palo, FDAS treasurer (left) and Scott Ruthstrom, FDAS Chief Operating Officer (right) present Dr. Terry Buckenheimer, FDA president, with a check for $1,014,770 at the annual convention in June. Revenue generated from FDAS insurance sales goes directly toward helping fund FDA programs and

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