The National Association of Dental Laboratories (NADL) has released the results of its 2015 Costs of Doing Business Survey, which polled the group’s members, certified dental technicians, recognized graduates, certified dental laboratories, and subscribers of the group’s publication, JDT Unbound.
“We’ve created this survey to give dentists a better sense of what kind of labs are out there,” said NADL president Dena Lanier. “There are many lab owners who invest in making sure their staff is highly skilled, educated, and trained, and we praise those laboratories. However, we want to make dentists aware that not all labs are following quality standards.”
The survey questioned respondents in 9 areas: demographics and laboratory characteristics, payroll and salaries, benefits, fees by product line, sales, remakes, clients and profit, outlook/layoffs, and outsourcing. According to the data, lab owners and managers are concerned about pricing, computer-aided design and manufacturing technology, certification, regulation, and offshore outsourcing.
“Since outsourcing labs often don’t register as laboratories, more outsourcing is done than reported,” said one of the respondents. The most cited reasons for outsourcing include price, requests from dental clients, labor savings, overabundance of work, and outside expertise. Also, 80.2% said their labs weren’t inspected by government agencies.
“It is crucial that dentists are informed about where they are getting their dental restorations from to ensure the health of the patient,” said Lanier. The NADL’s “What’s in Your Mouth?” campaign aims to raise awareness among dentists and the public alike of regulations, standards, transparency, safety issues, and the role that the lab and the technician play in oral healthcare.
“The dental industry needs to be less focused on the price aspect,” said a lab owner who participated in the survey. “Expertise, quality, and artistry are more important in the creation of dental restorations.”
The NADL urges dentists to find out if their state requires minimum dental laboratory standards, stay up to date with legislation, and find out if the laboratory they work with is certified to ensure that their patients are getting the quality restorations they deserve.
About 702,000 children were substantiated victims of child abuse or neglect in 2014, according to the Centers for Disease Control and Prevention (CDC). Additional data indicates that more than one in 10 children experienced abuse or neglect in the past year.
“Child abuse occurs at every socioeconomic level, across all ethnic and cultural lines, all religions, and within all levels of education,” said Camille Kostelac-Cherry, chief executive officer of the Pennsylvania Dental Association.
With these significant totals, the odds are strong that one of your pediatric patients may be a victim of child abuse. Also, state laws require dentists as well as other personnel in the office in many cases to report suspected abuse to the appropriate authorities.
Concerned groups are providing dentists with the tools they need to better identify these victims and get them help that could save their lives, as more than 1,500 children died in the United States from abuse and neglect in 2014.
Know the Physical Signs
The CDC defines physical abuse as the use of physical force against a child. Sexual abuse involves engaging a child in sexual acts. Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. And, neglect is the failure to meet a child’s basic physical and emotional needs.
“Most states have a child protective services law, and each of those laws will define child abuse very specifically,” said Kostelac-Cherry. “Most of those definitions will also define the age of a child. Generally, it’s from newborns up to 18 years of age.”
Dentists may begin to suspect neglect, for example, when pediatric patients have significant tooth decay that seems to have accumulated over a prolonged period of time. These cavities do more than cause substantial pain. They also may affect the child’s overall health.
“It will hurt to bite down. It will hurt to drink,” said Kostelac-Cherry. “That will affect their ability to thrive. It could lead to malnutrition, if the child is not able to get enough nutrients because of rampant caries. They are also more prone to infection.”
Dental neglect, then, is the willful failure of the parent or caregiver to follow through with any kind of dental treatment that is necessary to give the child a level of oral health essential to function adequately, free of pain and infection while eating enough to grow.
“Children who have rampant caries and more infection in their system tend to miss a lot more days of school,” Kostelac-Cherry added. “So dental neglect very much has an impact even on their educational progress.”
Additionally, dentists should look for indicators of physical abuse. According to Kostelac-Cherry, 75% of the injuries suffered by abused children occur to the face, head, neck, and mouth—all areas that dentists are trained to examine.
“There are very clinical indications of slap marks. You can see the handprint and you can see where a lot of the blood pools in between the spaces of fingers. You should look for the pattern of petechiae that form between the fingers of a slap mark,” said Kostelac-Cherry.
Dentists are advised also to look for ligature marks or handprints around the neck that could indicate choking. Pattern bruising may reveal impressions left behind by objects such as belt buckles and electrical cords. Plus, there are differences between accidental and intentional burns from cigarettes, curling irons, stovetops, and boiling liquids. Even bitemarks are suspect.
“The parent may say a bite was caused by the neighbor’s dog,” Kostelac-Cherry said. “But because of your experience, education, and expertise, you know the interarch distance shows that it was not an animal bite and that it likely is a human bite.”
Kids can be clumsy, and accidents are inevitable. But there are other important differences between accidental and intentional injuries. Children who fall on the playground or off of a skateboard, for instance, will see scrapes and bruises on bony protuberances such as their knees and chins. Injuries caused by abuse, though, happen elsewhere.
“As children get older, they tend to be bruised on the back and buttocks because they are more able to defend themselves, so they have defensive wounds as they are running away and their abuser catches them from behind,” Kostelac-Cherry said.
Dentists also may see signs of sexual abuse, which often involves oral contact. There may be symptoms of syphilis such as oral lesions. Genital warts in the oral cavity are another indicator. Dentists are advised to look for soft or hard palate bruising or torn frenums caused by repeated penetration as well.
Know the Behavioral Signs
Even when dentists can’t see the physical injuries, they may be able to infer abuse from the way the child is moving. For example, children who have trouble walking or who are uncomfortable sitting in the dental chair may have been injured in their legs, back, or buttocks. Attitude is another potential indicator.
“Look for a child who is either very compliant or overly compliant for their age, who appears to be fearful of upsetting their parents or making them angry,” Kostelac-Cherry said. “They want to please their parents so they don’t get hurt when they get home. Before they answer any question, they will look at the parent to see if it is okay to answer.”
Conversely, abused children may be overly aggressive since they tend to model the behavior that they have learned. Many times, their behavior is a product of a whole house that suffers from abuse and they are accustomed to violence and aggressive behavior.
While many kids feel anxiety in the dentist’s office, children who are abused also may display significant levels of fear by cringing when the dentist approaches them, for example. They may avoid eye contact and say very little as well, speaking briefly only when prompted.
“Children who have been sexually abused are very, very fearful of oral exams because of the horrible things that have happened to them,” said Kostelac-Cherry. “Look for kids who are socially withdrawn, melancholy, and shying away from physical contact.”
Parental behavior can be very revealing as well. While the dentist is in the operatory or office, personnel at the front desk have a good eye on the waiting room and can observe how parents treat their children there.
“We find that parents who are on absolutely their best behavior in the operatory while the dentist is there show a very much different side of themselves while they’re in the waiting room,” said Kostelac-Cherry.
Office personnel can look for parents who are verbally aggressive toward their children, including yelling at them, threatening them, trying to embarrass them, or using otherwise inappropriate discipline including hair and ear pulling. Or, abusive and neglectful parents may show a complete lack of interest in their child as they wait.
The Next Step
Dentists who see physical injuries should try to determine how they happened. Kostelac-Cherry suggests separating the child from the parent before asking the child about them, though. Otherwise, there is little likelihood of an honest answer. If parents are unwilling to leave the child alone, however, there are ways around it.
“You can separate the child from the parent by taking the child back for radiographs. ‘Sorry, Mom, you can’t come back here. We’re taking x-rays,’” Kostelac-Cherry said. “Then compare their stories to see if there is a difference.”
Kostelac-Cherry also says that dentists should try to have a witness present when they are asking children about their medical history, including the origins of suspicious injuries. Next, dental personnel should make an effort to document those injuries, including photographs.
“In Pennsylvania, we have a special provision under the law that allows mandated reporters of child abuse such as dentists to take pictures or radiographs without the parents’ permission,” said Kostelac-Cherry. “I would suspect that most states have a similar exception.”
Dentists who suspect abuse based on these observations are required to file a report with their appropriate authorities, such as local or state youth services agencies. Typically, dentists do not need physical evidence or any kind of confirmation from the child or parent to make these reports.
“In Pennsylvania, there are protections built into the law so that any mandated reporter who makes a report in good faith is immune from any civil and criminal liability,” said Kostelac-Cherry. “There’s also confidentiality, so their names will not be disclosed to the parents, to the guardian, to the media, and so on.”
In fact, many states have stiff consequences for mandated reporters who fail to act on their suspicions. In Pennsylvania, these penalties range from misdemeanors to felonies. They also are tied to the same penalty that the perpetrator gets for inflicting the abuse.
“If there’s substantial evidence to indicate the abuse has occurred and it’s a misdemeanor 3, a dentist who sees that and fails to report the suspicion could also be punished with a misdemeanor 3,” Kostelac-Cherry said. “And the penalties are increased if a pattern of failing to report emerges.”
Whether or not the dentist should confront the parent with these suspicions, though, is a trickier question. Kostelac-Cherry says that it depends on each individual case, and dentists should trust their own judgment based on how well they know their patients and their parents.
Questions about abuse could lead to a simple denial or to an angry or violent confrontation there in the office. Or, now knowing that they are under suspicion, parents may coach the child to lie in later interactions with protective services. Even worse, abusers may punish their children for telling the dentist about the abuse.
“Never question the parent if you believe that the parent may further retaliate against the child or harm the child for explaining how things happened, especially if in good faith you believe there’s a concern about the immediate safety of the child,” Kostelac-Cherry said.
Yet some good may come out of questioning the parent. Sometimes the child may be with the mother, and she is a victim of abuse at the hands of the child’s father too. Approaching these women may give them the opportunity they need to come forward.
“Sometimes, those caregivers are just waiting for somebody to ask,” Kostelac-Cherry said. “If this is a parent who seems to be a little bit meek and mild herself, she may actually welcome the opportunity to open up about any other domestic abuse that may be occurring.”
Additionally, dental neglect might not be the result of any kind of malice or indifference toward the child. Kostelac-Cherry notes that 30% of children who are abused or neglected nationwide come from families on public assistance, and another 14% come from families who lack the financial resources to meet the family’s daily needs.
“By questioning the parents, you are really opening up the door to allow them access to other social services that are available to them. You don’t need to do it in an adversarial style,” Kostelac-Cherry said. “You can find out that here’s a family that doesn’t even know that there are Head Start programs, parenting classes, transportation available to them so that they don’t need to neglect their children’s dental needs.”
To Learn More
Kostelac-Cherry encourages dentists and other professionals to investigate a program called Preventing Abuse and Neglect through Dental Awareness (PANDA). The regional organizations in this national coalition offer training programs and other resources about recognizing signs of neglect and abuse and intervening in those cases.
For example, the Delta Dental of Kansas PANDA Program notes that 24,000 reports of suspected child abuse and neglect were made in the state last year. Its website includes links to the Kansas Code for Care of Children and the Guide to Reporting Child Abuse and Neglect in Kansas as well as other downloadable materials.
Statewide dental associations offer training as well. The Pennsylvania Dental Association has a series of workshops and seminars scheduled throughout 2016 across the state. These courses will explore how the law defines abuse and neglect, indicators of abuse, clinical and intraoral pathologies, legal responsibilities, reporting procedures, and protections and penalties for reporters.
“These programs are critical, not only for dentists and dental professionals who are required to make these reports, but really for any citizen of the United States who suspects abuse against a child,” Kostelac-Cherry said. “It is a national epidemic.”
The dental profession faces a number of emerging financial changes and challenges. Combined, they make achieving and sustaining a stable cash flow a difficult yet still essential part of any management plan.
U.S. government spending on dental care has increased, as 4 in 10 children in the United States now have public dental coverage. Also, new dentists entering the market are well trained, but they carry an average debt load of $200,000. These changes have prompted a shift from solo dental practices to group or corporate practices.
Additional changes in the profession have been brought about by the shift in population from northern states to the Sunbelt. Also, consumers are more sophisticated and well informed about their medical and dental care. They seek high-quality care without a premium.
These transformations require different patient care, insurance acceptance, and technologies. Personnel need expertise to deal with healthcare reform including insurance billing, setup, and claims processing. So now, there is a trend towards corporate-supported dental practices, with outsourced management or dental billing services.
The Need for Expertise
With these changes in dentistry, there is a need for efficiency, decreased expenses, technology investment, and expert assistance by outsourcing services for productivity and cost effectiveness. The underlying factor necessary in operating a dental office is cash flow.
Offices that have skilled, motivated, and sharp team members working on accounts have no more than $3,000 to $5,000 in over 30 days aging (total insurance and patient balances) for every $80,000 of monthly production.
Today’s typical dental office structure on average has one dentist, a hygienist or 2, and an assistant or 2. There also may be an office manager who covers the front desk or individual front desk and management personnel.
There is formal training for the dentist, assistant, and hygienist as well. But clerical personnel learn on the job and through weekend coding classes. Errors and limited education are passed on.
The dental industry has changed from fee-for-service to insurance dependence, so the demand for dental billing expertise has increased. So has the demand for uninterrupted time for dental billing.
Yet the typical dental office cannot afford to have a dedicated team member chasing insurance claims and patient balances. It also does not have the expertise in insurance plans or their billing or coding, nor does it have systems or managerial skills in place for working accounts receivable, especially with the continuous interruptions of patients and phone calls.
As the medical industry has become more dependent upon insurance, many practices have outsourced medical billing, realizing that it is the most efficient and productive way to get paid.
How It Works
Insurance balances are different. With skilled billing, you should get paid in 3 weeks by dental insurance if your team is sending “clean claims.” Otherwise, you wait for claims to be resolved, and your cash flow is affected.
Sending “clean claims” takes expertise, time, persistence, clinical knowledge, and hours of follow-up. If your billing over 30 days is not within the efficient range, then there is an internal problem. The top problems among dental clerical staff when it comes to dental billing include:
- A lack of time;
- Interruptions by phones and patients;
- A lack of expertise in insurance billing, coding, and claims processing; • A lack of motivation.
As a result, you acquire unresolved claims that hold up your cash flow due to several common errors:
- Incorrect patient, practice, provider, or employer information such as demographics (35% of errors);
- The front office forgets something and supporting documentation has not been submitted with the initial claim (25%);
- The insurance company delays payment by asking for more information (20%);
- The insurance is set up incorrectly in the patient’s account (10%);
- The front office does not know how to set up the account, especially in dual insurance, blended families, or plans that are administered by major dental insurances (5%);
- The insurance company did not receive the claim so there is a need to follow up with phone calls (5%).
In addition, as the insurance benefits decrease, the patient’s copay is increasing. As a result, the treatment-plan acceptance to proceed with treatment has decreased, and patient balances accounts receivable has increased. If patients’ balances are not collected at time of service, the aging patient balances get out of control and the team will need time to work the collections. Recovery of patient balances decreases significantly with time, and so does the dentist’s cash flow.
Is your current dental billing effective? Hiring a skilled and dedicated person will cost you at least $15 an hour plus benefits and taxes. This person is usually unsupervised and very busy, while lacking direction and accountability.
For $2,000 flat fee per month ($12/hour full time), services like Dental Claims Cleanup LLC handle your accounts receivable for you. These companies never call in sick or take personal leave. Now your team can focus on patients in the office, treatment-plan acceptance, and booking your schedule. (That’s what your team does best.)
Dental Claims Cleanup systematically works accounts from week to week with weekly spreadsheet reporting of its progress. It also cleans up unresolved claims, patient balances and increases cash flow. And, it meets weekly with clients with a 30-minute conference call informing them of its progress and providing advice on future error correction.
Dentaid is looking for volunteers to provide emergency dentistry at Red Cross refugee camps in Cherso and Nea Kavala in northern Greece. These camps, which each house 4,000 people who have fled the conflict in Syria, offer some basic healthcare, but there is no dental provision.
The charity, which provides dental care and education to vulnerable populations around the world, is assembling a team of dentists, dental nurses, and dental therapists who will fly to northern Greece. Working from a tent and using portable equipment, these professionals will provide pain-relieving dental treatment for the refugees.
“Dentistry is an area where there is a real gap in provision and none of the agencies are providing it,” said Gwen Wilson, a nurse and emergency overseas health delegate with the British Red Cross. “There is a desperate need, and we are keen to get volunteers out there as soon as possible, although they will need to work in the most basic conditions.”
While the Red Cross has been working to improve sanitation in the camps, access to personal hygiene items like soap and toothpaste has been very limited. Many of the refugees have been suffering from dental pain for a long time and have developed complications affecting their health.
“The images we have seen of people in the refugee camps in Greece are deeply upsetting and worrying,” said Andrew Evans, strategic director of Dentaid. “We know there is a huge dental need, and we are pleased that the Red Cross has approached Dentaid so that we can help.”
With the support of 8 dental specialties and 3 international oral and maxillofacial surgical associations, the American Association of Oral and Maxillofacial Surgeons (AAOMS) has released a white paper advocating evidence-based guidelines in managing third molar teeth.
“For many years, the discussion surrounding the care and management of third molars, or wisdom teeth, has been obscured by unsupported statements and misinterpretation of the data,” said Dr. Louis K. Rafetto, president of AAOMS. “This white paper reflects the latest evidence-based research and offers clear, clinical guidelines for managing these teeth.”
According to the paper, the best evidence-based data indicates that third molar teeth associated with disease or at high risk of developing disease should be surgically managed. When there is no disease or significant risk of disease, active clinical and radiologic surveillance would be indicated. The supporting organizations include:
- The American Academy of Oral and Maxillofacial Pathology
- The American Academy of Oral and Maxillofacial Radiology
- The American Academy of Pediatric Dentistry
- The American Academy of Periodontology
- The American Association of Endodontists
- The American Association of Orthodontists
- The American College of Oral and Maxillofacial Surgeons
- The American College of Prosthodontists
- The British Association of Oral and Maxillofacial Surgeons
- The Canadian Association of Oral and Maxillofacial Surgeons
- The International Association of Oral and Maxillofacial Surgeons
Authorities in the United Kingdom have arrested and convicted Dilbar Dishad for the illegal sale and supply of counterfeit dental drills. He was selling these fakes, which were identical to a reputable brand that costs about £335 (about $490), for only £75 (about $110) on eBay. He had purchased them for about £10 (about $15) from a Chinese company and using stickers to make them appear legitimate.
“Remember, if a deal sounds too good to be true, it probably is,” said Alastair Jeffrey, head of enforcement with the Medicine and Healthcare Products Regulatory Agency (MHRA).
Dishad was caught when a potential customer tipped off the authentic manufacturer. He was sentenced to 9 months imprisonment, suspended for 2 years, and 200 hours of unpaid work to be completed within 12 months. Also, he has been disqualified from being a company director for 5 years and must pay £2,000 (about $2,900) to the MHRA.
“Along with medicines, there is a growing and disturbing trend in counterfeit medical devices. From the counterfeit devices that have been identified, many are poorly manufactured and do not meet strict European requirements for the European Conformity (CE) marking of medical devices,” said Danny Lee-Frost, head of operations at MHRA.
“In relation to counterfeit dental products, there is a risk that their poor quality will result in failure in use; for example, disintegrating in the patient’s mouth,” said Lee-Frost. “The risk to patients’ health and safety from a device operating at high speed in close proximity to your teeth and gums is obvious.”
The MHRA works closely with the British Dental Industry Association (BDIA) and the General Dental Council to monitor the use of substandard, counterfeit, and illegal medical equipment and to promote awareness of the dangers it presents to patients and operators.
“MHRA is responsible for protecting public health, and we will continue to seek out and prosecute those who recklessly endanger the public by counterfeiting medical devices,” said Jeffrey.
During the past 4 years, MHRA has seized more than 700 counterfeit drills, though many more may be in use, it warns. In January, MHRA seized more than 100 counterfeit and noncompliant items including handpieces from a single chain of 14 practices. Other agency seizures of noncompliant and counterfeit equipment have included a nonapproved portable dental x-ray unit that could emit harmful radiation.
MHRA notes that there are no specifics about spotting counterfeits, as they often are externally similar to the goods they are replicating. Differences may be minor, but they aren’t easily spotted. Counterfeiters, MHRA says, are skilled in manufacturing the devices as well as the documentation related to authenticity, compliance, and guarantee.
The BDIA offers tips on spotting fake equipment and encourages dentists who think they may have counterfeits to report them online at http://www.bdia.org.uk/device-reporting.html through its Counterfeit and Substandard Instruments and Devices Initiative. It also urges dentists to avoid fakes by only purchasing equipment from its directory of BDIA members.
“It is vital that dentists and dental staff buy equipment from bona fide suppliers in order to avoid substandard, unapproved, or counterfeit devices,” said Jeffrey. “I urge all dental professionals to be cautious of seemingly cheap devices that may be unfit for purpose and potentially dangerous to patients and the staff that use them.”
ACTEON North America will partner with TeamSmile to provide equipment such as its NEWTRON scalers and PSPIX2 cordless digital imagers to the nonprofit organization, which provides free dental care to underserved children across the United States.
TeamSmile connects children’s service groups, dental professionals, and professional sports organizations and their athletes to give children a life-changing dental experience that combines the excitement of sports with the importance of lifelong dental healthcare.
“We are thrilled to be working with TeamSmile and honored to support a program that will allow us to reach children across the country,” said Tim Long, vice president and chief operating officer of ACTEON North America. “Our minimally invasive products like the PSPIX2 make digital imaging more comfortable, particularly for pediatric patients with small mouths.”
“TeamSmile is grateful to have ACTEON as a partner that shares our values and makes our mission all the more achievable through its generosity,” said Lezlie Doyle, executive director of TeamSmile.
There is only one dentist for every 42,000 people in Kenya, which is far below the World Health Organization’s recommendation of one for every 7,000. Also, most dentists in Kenya practice in the country’s urban areas, leaving most rural residents without access to oral care. Poor oral health in these populations has been linked to diabetes, cardiovascular disease, and strokes, as well as absenteeism from work and school.
Researchers from the Columbia University Medical Center (CUMC) are now teaming up with the University of Nairobi, Unilever East Africa, and the Columbia Global Centers | Africa to improve oral health care and disease prevention in Kenya and other resource-poor countries in East Africa. The project is part of the Children’s Global Oral Health Initiative at Columbia.
“The time has come for a radical change in our thinking about the importance of teeth and the mouth in terms of overall health,” said Christian Stogler, DMD, dean of the Columbia University College of Dental Medicine. “Left untreated, certain oral health-related diseases, such as oral cancer, can be fatal.”
Partners also include the ministries of health in Kenya, Uganda, and Tanzania and the Kenya Dental Association. Together, the groups will aim to improve oral health and related illnesses by integrating oral health care into these countries’ health prevention and education initiatives. They hope to inform policy that these ministries of health can implement to meet local needs.
“We have chosen to initially engage stakeholders from Kenya, Uganda, and Tanzania because these 3 countries share a common history, ethnicity, and language and cooperate both politically and economically,” said Kavita P. Ahluwalia, DDS, director of Global Oral Health Initiatives for Africa and South Asia at the College of Dental Medicine.
The project also will include a research component. In June, students from CUMC will begin research in Kenya under the mentorship of Ahluwalia and professor Regina Mutawe of the University of Nairobi. The results of their research are expected to be applicable to other resource-poor countries in the region.
In March, members of the partner groups met at Columbia Global Centers | Africa in Nairobi. Participants included more than 100 leaders in oral health as well as high-ranking government and dental officials. Together, they identified regional priorities and began defining next steps to address oral health needs. Sustainable models of oral care delivery were presented as well.
“The summit was a great success,” said Stephen W. Nicholas, MD, principal director of the Children’s Global Oral Health Initiative and professor of pediatrics and population and family health at CUMC. “It far exceeded our expectations at every level, including in participation, attendance, and enthusiasm.”