Q: During the pandemic, there was a spike in teledentistry adoption. How did teledentistry perform during this trial by fire? 

A: Although teledentistry has been around for 25 years, there was a tremendous spike in its adoption during the pandemic-related closure of dental offices. As dentists scrambled for ways to stay in touch with their patients and keep them out of hospital emergency rooms, the technology proved itself to be a highly effective and reliable communications and triage tool. Of course, the results varied based on the sophistication of the teledentistry platform used. Although a pandemic emergency was not the way we intended to introduce dentists and DSOs to the benefits of our TeleDent platform (MouthWatch), we could not have imagined a better proof of concept. 

Q: Post pandemic, are private practices and DSOs refocusing on the everyday benefits of teledentistry? 

A: Yes, because the “peacetime” benefits that teledentistry was initially designed for can be demonstrated every day. Many practice owners are now discovering that teledentistry can serve as the “Swiss Army knife” of dental workflows. It can enhance a broad range of practice operations, including patient introduction and triage, diagnosis, case presentations, referrals, homecare education, post-procedure monitoring, and more.   

Q: Are patients selecting dentists based on whether or not they offer teledentistry services? 

A: Today’s healthcare consumers want to be part of a healthcare ecosystem where most of their providers offer telehealth services. 

Part of the disparity between telemedicine and teledentistry is the fact that medical appointments are 90% diagnostic compared to dentistry, which is more hands-on and only 5% diagnostic. However, the adoption gap is closing as more dental providers incorporate diagnostic services such as salivary diagnostics and diabetes testing into their practices. More current and prospective patients, especially younger ones, expect a virtual encounter option from all of their healthcare providers. Moreover, according to a recent survey conducted by CareQuest Institute, 86% of patients were satisfied with their teledental experiences and would recommend teledentistry. 

Q: Is there a strong business case that can be made for teledentistry?

A: First, teledentistry is very affordable compared to other components of digital dentistry. In fact, the average teledentistry software license is generally less than the average monthly cable/internet package, which has been estimated to be $217.42 per month by allconnect.com, a website that compares cable rates. In contrast, the monthly fee for TeleDent software starts at $149.00 for 3 users. 

Teledentistry will also improve the patient dental experience, which, in turn, helps attract and retain patients and minimize no-shows. It must also be noted that the reduced cost for virtual visits and the ability to reserve chair time for billable treatment significantly boosts the bottom line. For example, Advantage Dental+, a DSO comprised of more than 70 locations, more than 200 providers, and more than 600 support employees throughout 5 states, reported to us that transitioning just 7% of their in-office appointments to virtual encounters with TeleDent reduced the DSO’s annual cost of treating patients by 70%. What’s more, the use of teledentistry in your practice is a billable and reimbursable CDT code when used correctly. 

Q: What is “value-based” oral care? How is MouthWatch bringing it to the forefront? 

A: Value-based care is designed to achieve better oral health and overall health outcomes at lower costs by emphasizing a minimally invasive and risk-based approach to ensure an equitable distribution of resources. Earlier this year, we launched a new MouthWatch subsidiary named Dentistry.One, which helps patients to get the care they need, when they need it, and provides the ability for organizations supporting patient health to drive improved outcomes, lower costs, and an enhanced patient experience. 

Dentistry.One includes a network of highly trained dentists to deliver the best dental telehealth experience possible, meeting patient needs such as emergencies, oral-systemic conditions, prescriptions, second opinions, cosmetic consultations, and overall preventive care. We also have an in-house team of Care Advisors—dental hygiene experts who will provide patients with a complete care experience, including coordination of in-person dental visits, benefits navigation to help patients better understand their insurance coverages, guidance for improving home care, and recommendations for oral healthcare products and services. 

Q: What is the future of teledentistry? 

A: Teledentistry stands ready to help dentists and physicians communicate with each other and share records in order to co-manage the health of their patients effectively—especially those with chronic systemic diseases. We predict that more medical providers, including hospital systems, will begin incorporating intraoral cameras as part of routine exams to help them obtain more complete patient histories and baseline documentation. Digital imaging, combined with teledentistry, can play a major role in reconnecting the mouth and the body within our healthcare system.   

Dentistry.One will serve as a digital pathway to bridge a patient’s oral health with their overall well-being. We will achieve this in the near future by integrating with leading electronic health record platforms so that when a patient is diagnosed with an oral-systemic disease or condition, Dentistry.One can simultaneously help the patient begin a better oral health and overall care journey.  

ABOUT BRANT HERMAN

Mr. Herman is the founder and CEO of MouthWatch, LLC, and Dentistry One, LLC. He most recently led the development of Dentistry.One.

He can be reached at brant@mouthwatch.com.

FEATURED IMAGE CREDIT: SergioVas/Shutterstock.com

Q: When was your first inkling something required further examination?

A: My tumor was discovered during a routine dental exam, as is often the case with serious head and neck conditions. 

In an idle moment during a laid-back ski vacation one January, I offhandedly asked my partner Evie to help me confirm a funny protrusion in the gumline over my back teeth. Hardly noticeable—who knows how long it had been there? It didn’t hurt. Probably nothing. We agreed I should have my dentist take a look at it in my February appointment, and we headed for the slopes. It was nothing.

So I introduced the bump to my dentist. He paused, vaguely suggested some endodontic ailment, and straightaway sent me to his colleague, an endodontist, to be evaluated for, perhaps, a root canal. After a conspicuously brief exploration, the endodontist concurred with my dentist and proposed a tentative treatment plan—but first, he wanted corroboration from his surgical associate. Two weeks later, the oral surgeon took a look, summarily pulled the tooth, and immediately ordered a biopsy. By March, I had my diagnosis: “well-differentiated sarcoma…unusual….possible extension of a neoplasm into the gingival tissue….” I was in surgery by April. As I remember it, I’d been a hair’s breadth from skipping that dentist appointment altogether.

Q: Was it customary in your previous dental experience to have head and neck examinations and an oral cancer screening as part of your regular care?

A: In retrospect, I think pre-emptive oral cancer screening must have been part of my dentist’s regular process because his response to my anomaly was immediate and complete with follow-through. However, I would not have recognized it as such at the time because nothing like this had ever happened to me or anyone I knew. Interestingly, I was approached years later by that endodontist for permission to reference my case in a paper underlining the importance of teaching dental students to expect the unexpected, inasmuch as many catastrophic illnesses present initially in the mouth.

Q: How did the diagnosis impact you personally and professionally?

A: As an opera singer, the distinction between the professional and the personal is exceedingly fine, because the body itself is the instrument of the profession. The diagnosis of craniofacial OS was cataclysmic for me, as it put my career plans and my very instrument at risk, never mind my life. It changed the trajectory of my life forever, though we could not know that at the time. It was existential for me because I was unable to contemplate not existing, whereas others were forced to contemplate existence without me, so I was determined to recover, to believe in recovery, and to focus on it. But with so many crucial medical concerns, reasonable apprehensions, and our preparations for surgery and recovery, a generalized anxiety engulfed everyone I knew and terrified my partner. 

Still, I am reluctant to remember the experience as a “catastrophe” because it was unexpectedly rich in so many ways. And it was life. It was my life.

Q: What was the most challenging part of your treatment and recovery?

A: The surgeries certainly presented challenges, though more for my loved ones than for me. The contemplation of the surgery coming up was more difficult for me in its otherworldly audacity. A weeklong induced coma produced its own array of unimagined consequences. Three-and-a-half months of chemotherapy was grueling and all-consuming. The intersection of chemo mucositis and an intraoral appliance of acrylic and titanium was a special kind of torture.

In the emergent crisis, the greatest challenge was just to accept that it was actually happening and that every necessary thing was also going to happen. It required a concentrated effort to relinquish the illusion that it could be controlled, hurried, or avoided. Then, because my facial reconstruction stretched over months and then years, hobbled by resistant infections, complications, and setbacks, we were overcome by a stultifying limbo. The limbo was destructive. It corroded the very buttresses—psychological and emotional—that had helped us bear more active crises, which we had come to rely on. That’s when things really began to fall apart.

Q: If you were standing in front of a dental audience, what would you like them to know?

A: From a patient’s point of view, I admit I appreciate that light patter dental professionals seem to wield so well when they’re up to their elbows in your mouth. But nowadays, I’m hyper-aware of, and grateful for, everything else going on behind the patter. 

For less experienced professionals, I would echo my endodontist’s admonition: Expect the unexpected. Because with head and neck disease, the stakes are high, and time is of the essence. It does no harm to anticipate the worst, but speculating, hoping, and waiting can be deadly. And if you aren’t sure, pass your patient off to someone senior. There’s nobility in that, too.

Q: Is there something, such as a quote or statement, that repeatedly brought you strength and/or comfort throughout your journey?   

A: I know something biblical or otherwise inspirational would be good here. And many such things did come to mind. But mostly, I remember thinking, “Just hang on. It’s not gonna kill ya.”

ABOUT KATHLEEN WATT

Ms. Watt attended the Rhode Island School of Design, Brown University, and Brigham Young University (earning a double BFA in art and music), along with postgraduate studies in opera performance at Boston University. She is the author of Rearranged: An Opera Singer’s Facial Cancer and Life Transposed. Learn more at kathleenwatt.com. 

FEATURED IMAGE CREDIT: PDPics from Pixabay.

Q: Can I be sued more than once for the same information getting out?

A: Yes, cyber regulation and healthcare regulation have merged in many ways for dental offices, making compliance more necessary, more expensive, and more complicated than ever before.

During treatment with patients, many types of sensitive data will be exchanged, but sensitive data is defined differently by both HIPAA and by different state laws. This may include names, social security numbers, and personal health information (PHI), among other things. The variation in state laws is immense for what is considered protected data. A dental office can be sued multiple times by different parties for the same data breach. If the breach occurs through your website, then even more penalties and suits can be added. Offices are required to protect all data, and not just electronic personal health information (ePHI).

Q: Doesn’t my IT guy protect me from these little fines?

A: No, the Office of Civil Rights (OCR) investigates HIPAA violation cases that result in settlements with the Department of Health and Human Services. Many data breach investigations start with complaints submitted by patients or healthcare employees. You are responsible for any breach unless you have a protective agreement with someone else. As of October 2023, minimum fines for HIPAA penalties in some cases can be as high as $68,928 for a single violation if it is willful and not corrected within 30 days and a maximum penalty of 1.5 million for one year.

Q: What is an example of a compliance violation? 

A: The OCR and the Attorney General for each state may each take action, and in some states, there is a private cause of action for data security breaches that also allow the owner of the breached information to take action. A California dentist was recently fined $23,000, agreed to adopt a corrective action plan to address non-compliance, and accepted monitoring for 2 years for posted responses to several reviews by patients on Yelp. The onsite investigation found that the practice did not have the required content in its Notice of Privacy Practices and had not implemented appropriate policies and procedures concerning protected health information, including the release of protected health information on social media platforms and in public places. This was the 21st financial penalty to be imposed by OCR in 2022 to resolve HIPAA violations—more than in any other year since OCR was given the authority to enforce HIPAA compliance.

Q: What happens if my website isn’t ADA-compliant?

A: People with disabilities have filed lawsuits against businesses when the websites were not coded properly to work with the assistive technology they use. Legal obligation under Title III of the Americans with Disabilities Act (ADA) and Section 504/508 of the Rehabilitation Act of 1973 allows damages under Section 508 Non-Compliance Penalties to be up to $55,000 for the first violation and $110,000 for each subsequent violation. 

Q: What is the Supremacy Clause? 

A: It allows HIPAA (federal) laws regarding patient records to supersede any state provisions regarding patient records. However, state laws can exceed the minimum regulations. According to OCR director Melanie Fontes Rainer, “patients have a fundamental right under HIPAA to receive their requested medical records, in most cases, within 30 days. I hope that these actions send the message of compliance so that patients do not have to file a complaint with OCR to have their medical records requests fulfilled.” In 2020, a Georgia orthodontic provider was fined $80,000 for $170 being too high a fee to copy records and excessive delay in providing a patient with his or her records. The same year, a Las Vegas provider was fined $25,000 for an 8-month delay from the initial request to final records being provided. State laws may also provide for additional damages (see the addendum below).

Q: What can you do to mitigate your risk?

A: Train your employees and continue to retrain your employees. Under Federal HIPAA regulations, healthcare providers are required to train their workforce who handle PHI regarding compliance with the HIPAA Privacy Rule and Security Rule. The Privacy Rule requires training for each new member of the workforce within a reasonable period of time after the person takes the role handling PHI and when his or her functions are affected by a material change in policies or procedures. The Security Rule calls for periodic training. 

Once you make your written plan, follow it. Annual training is recommended by your compliance officer. Know that the risk is real, and it is rising. In 2009, there were 14 reported data breaches, and in 2023, there were 328. My final advice is to know your state laws or hire someone who does. Have updated manuals and follow them, train annually, use encryption when needed, hire a website company that updates its cyber regulation monthly, and don’t respond to online reviews without expert advice. 

ADDENDUM

You can be in violation of a data breach without knowing it and still be liable. Each state defines its data privacy law differently. Here are some examples:

1. Laws that define a breach

California: Unauthorized acquisition of computerized data that compromises the security, confidentiality, or integrity of personal information maintained by the person, business, or agency. Cal. Civ. Code §1798.82(g) (as applicable to non-governmental entities); Cal. Civ. Code §1798.29(f) (as applicable to governmental entities).

2. The definition of personal information that triggers a breach

New York: Personal information is defined as any information concerning a natural person which can be used to identify the person. Private information is either: (i) personal information consisting of any information in combination with any one or more of the following data elements, when either the data element or the combination of personal information plus the data element is not encrypted, or is encrypted with an encryption key that has also been accessed or acquired: (1) SSN; (2) driver’s license number or non-driver ID card number; or (3) account number, credit or debit card number, in combination with any required security code, access code, password, or other information that would permit access to the individual’s financial account; (4) account number, credit or debit card number, if circumstances exist where the number could be used to access an individual’s financial account without additional identifying information, security code, access code, or password; (5) biometric information, meaning data generated by electronic measurements of an individual’s unique physical characteristics, such as a fingerprint, voice print, retina or iris image, or other unique physical representation or digital representation of biometric data which are used to authenticate or ascertain the individual’s identity; or (ii) a user name or e-mail address in combination with a password or security question and answer that would permit access to an online account.N.Y. Gen. Bus. Law § 899-aa(1)(b), as amended by 2019 N.Y. Laws ch. 117 (as applicable to non-governmental entities); N.Y. State Tech. § 208(1)(a) (as applicable to governmental entities).

3. The variation on whom must be notified

Texas: Any individual whose personal information was, or is reasonably believed to have been, acquired by an unauthorized person, provided that such individual is a resident of TX or another state that does not require a person to notify the individual of a breach of system security. Tex. Bus. & Com. Code § 521.053(b), Tex. Bus. & Com. Code § 521.053(b-1). Must also notify national consumer reporting agencies if notifying more than 10,000 persons at once. Tex. Bus. & Com. Code § 521.053(h). In addition, a domestic insurer or HMO should contact its assigned financial analyst at the Texas Department of Insurance if the insurer or HMO experiences or discovers an unauthorized acquisition, release, or use of personal information or sensitive company information. See Commissioner’s Bulletin # B-0022-16.

4. The time you have to notify the data owner

Florida: As expeditiously as practicable and without unreasonable delay, but no later than 30 days after the determination of a breach. A covered entity may receive 15 additional days to provide notice to individuals, if good cause for delay is provided in writing to the Department of Legal Affairs within 30 days after determination of the breach or reason to believe a breach occurred. Fla. Stat. § 501.171(4)(a).

Third-party agent must notify covered entity of breach of security as expeditiously as practicable, but no later than 10 days following the determination of the breach of security or reason to believe the breach occurred; covered entity must then provide required notices. Fla. Stat. § 501.171(6)(a).

5. Penalties for nondisclosure may be from the AG and/or from the data owners in some states

New Hampshire:  Any person injured by violation may bring an action for damages and/or an injunction. AG may also bring action. N.H. Rev. Stat. § 359-C:21.

For the insurance industry: Penalties may include suspension of license or a fine of up to $2,500 per violation. N.H. Rev. Stat. § 420-P:12.

Disclaimer: The information provided on this website and in the article is for informational purposes only and should not be construed as legal advice. You should not act or refrain from acting on the basis of any content included herein without seeking legal advice from a licensed attorney in your jurisdiction.

ABOUT JOSH BROWER, DDS

Dr. Brower graduated with honors in 1997 from the University of Minnesota. He has more than 20 years of private practice experience as an owner, is a teacher/lecturer, and is an AGD PACE CE provider. He will graduate from law school this year and focuses on all aspects of health law, practice management, and training.

He can be reached at browerj@gmail.com or via the website getdentaltraining.com.

FEATURED IMAGE CREDIT: OneSideProFoto/Shutterstock.com.

ESB Professional/Shutterstock.com

Q: You are both a yoga instructor and a dentist. What led to you becoming a yoga instructor, and how has that changed the way you practice dentistry?

A: I first discovered yoga as a stressed-out dental student. I was looking for a way to decompress while also moving my body. I was a complete beginner at first, but after graduating dental school, I slowly began taking more yoga classes. What started as a hobby eventually became a passion as I began to notice the changes yoga was making in my life. Physically, my body started feeling better, and I avoided the aches and pains that are common to a dentistry career. Mentally, I started feeling lighter, calmer, and less anxious. Yoga helped me understand and uncover parts of myself I had hidden away for so long. I eventually decided to complete a 200-hour yoga teacher training program and started teaching yoga in 2021. Becoming a yoga teacher has had a significant impact on the way I view and practice dentistry. For one, it has allowed me to become more patient and understanding with both my patients and my staff. It has allowed me to become more aware of my emotions and reactions so that I can logically deal with them instead of letting them spiral out of control. And lastly, the physical benefits of yoga have allowed me to work pain-free without any limitations. 

Q: Why is it important for dentists to prioritize wellness?

A: According to the ADA’s 2021 Dentist Health and Well-Being Report, a majority of dentists have stated experiencing moderate or severe stress at work. As a result, many of us are dealing with anxiety, burnout, substance use disorders, and other conditions that may impair our abilities to practice at our best. The percentage of dentists diagnosed with anxiety more than tripled in 2021 compared to 2003, and we sadly continue to see the rate of suicide remain steady in our profession. It is time that we change the culture of how we practice dentistry. This profession does not have to be something stressful or overwhelming. We cannot always prevent things like burnout, back pain, and struggles with mental health. However, one thing that may help is to be honest with ourselves about our needs and set aside regular time for rest and self-maintenance. It is specifically important for new dentists to prioritize wellness because as life expectancy increases, so does the length of our careers. We may be working longer than the generation before us, so how can we ensure that we continue to feel happy and healthy throughout our lives?

Q: How does taking care of one’s wellness benefit a dentist’s practice of dentistry?

A: As healthcare professionals, taking care of our own mental and physical health helps us better care for others. When we focus on our well-being, we can better understand our triggers when it comes to stress and anxiety. Once we better understand ourselves, we are able to prevent outbursts of emotions that might lead to saying the wrong thing or making poor decisions. When we show up to work rested and fulfilled, we can better serve our patients and set an example to our staff of what it means to be well. 

Q: How can dentists prevent burnout?  

A: When most people think of self-care, what they are actually thinking of is “self-soothing.” Self-soothing feels good at the moment. It could be a massage, a vacation, or even spending time with a loved one. But true self-care shouldn’t be a one-time fix. It should be a regular part of our lives so that we can continue to show up as the best versions of ourselves. Our society tells us we can only be one thing and must be exceptional at it, but that isn’t realistic. We need to understand that there is more than one way to be a dentist. We can be driven without succumbing to comparison. We can work hard without leading to exhaustion. I always urge dentists to find more than one thing that makes them happy and to make time for rest. Having hobbies that allow us to feel creative rather than only doing things we “need” to do can teach us how to enjoy things again so that we can better show up for our patients, our families, and ourselves. 

Dr. Barrera is a general dentist and practices at Legacy Community Health Center in Houston. He is a member of various organizations, including the ADA, Hispanic Dental Association, Greater Houston Dental Association, and the Houston Equality Dental Network. He is the president and co-founder of the Houston Equality Dental Network, an organization that aims to improve the oral health of LGBTQ+ people through awareness, education, advocacy, and service. Dr. Barrera is a graduate of the ADA’s Institute for Diversity in Leadership and currently serves as a Wellness Ambassador for the ADA. As an ambassador, he serves as a peer support contact for dentists struggling with things like burnout, anxiety, depression, and substance abuse. He works toward incorporating his passion for yoga with dentistry by providing yoga classes and ergonomic exercises that can help alleviate common aches and pains that come with a career in dentistry. Dr. Barrera was recognized by the ADA in 2023 as a “10 Under 10” Award recipient and was awarded the Health Equity Hero award by DentaQuest in 2022. He can be reached via email at abarrera@legacycommunityhealth.org.

Michael Sonick, DMD

Q: What inspired you to write Treating People, Not Patients?

A: My motivation for writing this book stemmed from my personal journey as both a patient and a professional. A traumatic bike accident at 8 left me with 2 broken front teeth that remained unrepaired until I turned 18. This experience as a patient deepened my empathy and led me to develop a keen interest in anterior reconstruction with dental implants and bone grafting. My love of hospitality was shaped by my work in the restaurant industry—from a busser to waiter and as a cook. This background changed my perspective on patient care. I focus more on the patient’s experience as a person than solely on the procedure I am performing. 

Q: How do you see parallels between a restaurant and a dental practice?

A: When I opened my dental practice in 1985, a restaurant also opened next door. I was struck by their emphasis on ambiance, quality of food, and service. As a food enthusiast and someone who has worked in restaurants, I have always been attentive to details—be it the decor, the food, or the service standards. For many years, restaurants were evaluated by the Zagat Survey, which rated them based on 3 key criteria: food quality, decor, and service.

Similarly, dental practices, in my view, operate on analogous principles. While we provide dentistry instead of food, I assume that the dental care offered at most practices is comparable. Many patients do not differentiate practices by the quality of dental work since they lack the expertise to judge. Instead, they base their preferences on their overall experience—how they are treated and the ambiance of the clinic. The decor in a dental office plays a crucial role; patients note the cleanliness, the appearance of the staff, and even small touches like the quality of soaps in the restroom and the complimentary toothpaste and toothbrushes. Just as diners remember excellent service at a restaurant, dental patients recall their interactions with the staff and the overall experience more than the specifics of their dental procedures.

Both restaurants and dental offices thrive on the foundation of excellent service and a pleasant environment, whether the primary offering is food or dental care.

Q: How do you provide both excellent service to your patients and perform excellent clinical care?

A: While dental schools equip students with clinical skills—from extractions to crowns—they often overlook the human aspect of patient care. These institutions set requirements for procedural achievements, but they don’t emphasize the importance of patient experience. Drawing from my unique background as a patient and my experiences in the restaurant industry, I realized the significance of patient care beyond clinical procedures.

Patients who feel cared for are more relaxed, satisfied, and likely to refer others. But achieving this level of care is a collective effort. Before a patient meets me, he or she interacts with various elements of my practice, from our website to the physical ambiance of the clinic. By the time the patient sits in the dental chair, he or she has encountered multiple touchpoints, from receptionists on the phone and in person to dental assistants. The patient’s perception, shaped by these interactions, often dictates his or her willingness to undergo treatment.

The success of a dental practice hinges on its team. It is crucial to invest in team training and maintain open channels of communication. Regular meetings, be they daily, weekly, or monthly, ensure everyone is aligned with the practice’s goals and vision. Running an efficient, patient-centric practice isn’t just beneficial for the patient—it is also more fulfilling for the dental team. To achieve this balance between excellent clinical work and unmatched patient experience, it is imperative to operate as a cohesive unit, emphasizing both the clinical and personal touchpoints that shape a patient’s journey.

Q: How do you create an excellent team?

A: Building an exemplary team starts well before an individual comes to work. Our hiring process is rigorous and multi-phased:

1. Advertisement and resume review—We initiate with a carefully crafted job posting and meticulously screen applicants based on their resumes.
2. Culture index—Potential candidates undergo a “culture index” to ensure alignment with our office’s values and ethos.
3. Initial interviews—We conduct online FaceTime interviews, followed by a brief, in-person “blink” interview where I personally meet the candidate for a couple of minutes.
4. Working interview—If they pass the earlier stages, candidates then participate in a half- or full-day working interview in our practice.
5. Team involvement—Crucially, the decision to hire is not solely mine. Teammates hire teammates. For a candidate to join, they need to integrate seamlessly with the existing team, ensuring a harmonious working environment.

Our guiding principle is cultivating a “servant-hearted” team committed to delivering a standout experience for every patient. This dedication to service isn’t just a job requirement; it is embedded in our office culture. It is the culture, deeply ingrained and shared by all, that truly drives our practice. 

For a deeper dive into our practices and to assess your own, I recommend my book, Treating People, Not Patients, which offers detailed insights and questionnaires. Also, my online video series serves as an excellent training tool, complemented by a workbook for in-depth exploration. All these resources and more can be found at michaelsonick.com. 

ABOUT MICHAEL SONICK, DMD

Dr. Sonick is a highly regarded international authority in periodontology, dental implants, and the delivery of exceptional customer service. He is a Diplomate of the American Academy of Periodontology, International Congress of Oral Implantology, International Society of Periodontal Plastic Surgeons, an ITI fellow, and an Eagle Scout. He can be reached at mike@sonickdmd.com and michaelsonick.com

Q: How did you get your start in music? 

Dariel: Our introduction to music and playing the cello came first, when we were 4 years old. Our grandfather (who was standing by our sides when we auditioned on America’s Got Talent) is the one who taught us how to play. He is the reason we get to share our love for this beautiful instrument with the world, and he will always be our hero. We were fortunate enough to get daily cello lessons, which was a real gift—having been able to learn from somebody at such an elevated level of mastery of the craft was the ultimate privilege.

Emil: Growing up, we always played classical duets together until, one day, we realized we could have fun playing rock and metal music on these cellos. We decided to add a few cool toys like guitar amps and some drums, which was around the time we started posting videos on YouTube. When we started experimenting with things outside of the norm, we were not sure how our grandfather would react to all of this. To our surprise, he turned out to be a huge fan and said, “Keep doing this—it is awesome!” One thing led to the next, and we found ourselves on America’s Got Talent playing Radio City Music Hall.

Q: When was this?  

Dariel: In 2014, we were 13 and 16 years old. It was amazing and fun to play in front of such a large audience. Before this, we mostly played in front of small gatherings in libraries, restaurants, and the like. But then AGT really opened our horizons—it was life-changing.

Q: What is that like going on stage and looking around at the mass of people?

Emil: There are few things in life that can be as electrifying. There is just this rush of excitement. When you are playing music, you feel their energy. They feel your energy. It’s an exhilarating time.

Q: How do you get past those first 6 seconds of flutters? 

Dariel: Whenever I feel that jittery excitement, it pushes me to jump into it even more—like this is it. This is the moment, and just go out there.

Emil: The way I can relate to it now is thinking back to the first time you ever gave a mandibular block in dental school: There’s a little bit of stress before you start, but then, once you get going, the adrenaline kicks in.

Q: At the end of your last performance on AGT, you had a little issue with Simon Cowell. After you shared your dream of becoming a dentist, and not a star, he rolled his eyes and made a stabbing gesture to his chest with a pen. He then said, “you can’t just say you want to be a dentist.”

Dariel: Perhaps Simon did not understand how we were not pursuing a full-time career in the music/entertainment business. I said, “We come from a family of dentists (on our father’s side), and we want to follow that path. Our dream is to practice dentistry together as a team.” We are very proud to be in this profession, and Simon’s attempt at mocking our choice to pursue dentistry did not go down particularly well for him, which made some interesting headlines. The outpouring of support from the dental community (including the ADA), musicians, and fans was just incredible. You can find our performances by searching “AGT cello” online to see our journey on the show and the fun we had making it up to the final round. 

Q: So tell me about the dental journey. Emil, you are in a postgrad periodontal program at the University of Kentucky?

Emil: We are the third generation of dentists in our family, and the 2 of us are honored to continue our family’s legacy. I am currently a PGY-2 periodontology resident at the University of Kentucky. After Dariel is done with dental school at the University of North Carolina, he plans to pursue a residency in prosthodontics. We have a massive overlap in interests, particularly in implant dentistry; however, we also have our different talents and things we excel at individually. We have ambitious aspirations and are fully committed to our clinical training. Our ultimate dream is to have a “perio pros” practice together.

Q: How do you think you will be able to balance both dreams once your practice is established? I know that right now you cannot just drop your handpiece and grab your bows due to classes. 

Emil: Performing has taught us a lot about troubleshooting things on the fly. In a few of our live performances, we have had situations where we had to make quick decisions. Music has also taught us so much about nonverbal communication and emotional connection, which is such an important part of being a clinician. We will still find time to perform, share our message, and show that you do not have to fit inside a box.

Dariel: We never think of either/or. We love performing with our cellos and all the artistry that entails, and we love the hands-on, life-changing impact we can have through dentistry. We really feel blessed that we can share our message with the dental community and be an example of what is possible to kids who want to pursue a profession in health care while maintaining their artistic passions.

The above is excerpted from an interview with Dr. Paul Feuerstein.

Click here to watch the full video. 

FEATURED IMAGE CREDIT: PIRO from Pixabay.

Q: How common is biofilm? 

A: We educate patients about dental biofilm every hour, every day. Dental biofilm, or what we used to refer to as dental plaque, has its hands in preventive and restorative procedures and is a common factor for oral disease. From implant failures to gingival inflammation and bone loss to imperfect margins and more, oral health professionals live and breathe dental biofilm every day.

Much like the antagonist in any good story, dental biofilm continues to show up as the star nemesis in today’s clinical dentistry—we scale it, polish it, remove it, and dread it. But what do we actually know about these complex microbiological communities living within and around us? Are they always bad? Do they truly cause inflammation? Can we eliminate them completely?

Q: What exactly is dental biofilm?

A: The significance of biofilm and its correlations within the oral cavity are still very much a mystery. What we do know is that dental biofilm is directly correlated with gingival inflammation and disease, leading to restorative failures, relapses in periodontal therapy, and frustrated patients and providers. At its heart, biofilm comprises communities of micro-organisms that survive, adapt, create offspring, and grow. These communities are in constant flux, spending their days exchanging DNA, using cell-to-cell signaling, and attacking prey to compete for resources.

Q: When was biofilm discovered?

A: Prior to the 1900s, the current theory was that all microbes were planktonic—freely suspended cells. In the 1940s, it was discovered that microbes attach to surfaces and that these surface-associated cells had distinct characteristics, the ability to grow, and an ecosystem. Then, in 1978, Dr. Bill Costerton created the theory of biofilms. We now know that 95% of bacteria living in nature live in biofilms, and in 2002, the National Institutes of Health noted biofilm accounted for more than 80% of microbial infections in the body. 

Q: What surfaces can biofilm grow on?

A: Biofilm needs 3 things to survive: moisture, nutrients, and a surface. Essentially, biofilm can be found anywhere those 3 components collectively exist—living tissue, indwelling medical devices, contact lenses, industrial and potable water systems, natural aquatic centers, plant and animal tissues, catheters, pacemakers, implants, fossils, deep sea vents, and more. These microbial communities play a role in our dental unit waterlines, 3-in-1 syringes, and handpieces. Within the mouth, dental biofilm is found on virtually every surface: fixed and removable prostheses, restorations, and subgingivally on hard and soft tissues.

Q: What are the 4 components of biofilm?

A: All biofilm, whether inside or outside the mouth, is composed of 4 components: communities, microbial cells, extracellular polymeric substances (EPS), and waterways. Consisting of bacteria, fungi, and protists, these microbes live within the EPS, a gooey, sticky substance primarily made of polysaccharides. One of the most important aspects of this type of microbial community is the waterways, where waste is eliminated as well as where communication, seeding, and dispersal take place. 

Q: What makes biofilm adaptable?

A: Leave any liquid in a container for too long and what do you get? A slimy container and an unfortunate odor! This is partly due to the EPS—a gooey, sticky substance primarily made of polysaccharides. The EPS covering acts as a protective barrier against extreme temperatures and pH, shields against ultraviolet light, and also supplies nutrients. Harmful substances such as antimicrobials, bleach, and metals are also neutralized when they come in contact with EPS.

Q: What’s next for dental biofilm?

A: Recently, bioremediation has helped shine a different, more positive light on biofilm. Bioremediation was used to clean up the 2010 Deepwater Horizon oil spill. With bioremediation, biofilm is introduced into the environment to degrade oil molecules into less harmful compounds. Micro-organisms within the biofilm then consume the oil as their food source, thus entering the natural life cycle of the ecosystem.

Biofilm itself may remain a mystery to the dental professional, but we are great at understanding the need to reduce and control the oral bioburden by chemical and mechanical means. Regular removal of biofilm through brushing and flossing makes a significant impact, as well as reducing biofilm with xylitol, activated chlorine dioxide, and other biofilm-reducing ingredients. The introduction of restorative materials with antimicrobial properties is proving helpful, as is the utilization of salivary and plaque testing for personalized patient insights. Current biofilm research focuses on the medical-dental link and the systemic impact of pathogenic oral bacteria because oral disease often sets the stage for chronic, degenerative diseases and has definitive links to diabetes, cardiovascular disease, pneumonia, and Alzheimer’s disease.

The mystery of whether biofilm is the antagonist or protagonist in our story of oral health lies in this question: Is dental biofilm always bad? Could bioremediation have a significant impact on the treatment of oral disease? After all, if we’ve learned anything from our favorite villains—Voldemort, Darth Vader, the Joker—the best stories often blur the lines between the antagonist and protagonist!

Ms. Turner is a 20-year veteran dental hygienist and a sought-after fractional executive, consultant, dynamic speaker, and top millennial content creator. She is the founder and founding board member of multiple companies and partners with companies of all sizes—from pre-seed startups to large international brands—on brand strategy and product growth. She can be reached at melissakturner.com.

Q: First, what is an oral pathologist? 

A: An oral pathologist is a job description that is difficult to define, but we all have one thing in common: We are trained in microscopy to diagnose oral, skin, and jaw lesions. That is the most essential part of the profession that binds us all. We are also trained in clinical oral pathology—how to identify and manage oral diseases. Usually, oral pathologists work in academic institutions. This means we must do a combination of teaching, service, and research. 

After a decade in academia, I have chosen a transition to private practice, which is a bit rare for our profession. I spend my mornings driving around the city picking up biopsy specimens, then sign-in for cases that I receive from across the country. I also serve on a tumor board with my colleagues specializing in otolaryngology, radiology, speech therapy, prosthodontics, etc. Finally, I will provide about 70 continuing education courses/lectures this year (ranging from one to 16 hours long), which is more than normal. However, teaching is my favorite thing to do, so I tend to keep my schedule packed. 

Q: When should someone refer to an oral pathologist?

A: If you are lucky enough to have an oral pathologist (or an oral medicine specialist) in your area, the ideal cases to send are proliferative verrucous leukoplakia, troublesome xerostomia, burning mouth disorder, and chronic ulcerative conditions like lichen planus or mucous membrane pemphigoid. If you would like to send leukoplakia, fibromas, etc, to your oral pathologist, please ensure he or she does biopsies (some of us do not). Anything limited to radiographic findings should be sent to a surgeon for biopsy or an oral radiologist if you do not know whether it requires one.

Q: How does one become an oral pathologist?

A: There are a handful of training programs throughout the United States to which you can apply after obtaining a DDS or DMD degree (or a foreign-trained equivalent). Each are 3-year programs with at least 6 months of rotations in general pathology. Most of the day is spent looking at glass slides; about a half day per week is spent with live patients (depending on the training program). Other responsibilities include clinic consults, grossing specimens, etc. 

I would recommend to someone who is seriously interested in oral pathology to contact residency directors and express an interest; I would also demonstrate that interest by shadowing an oral pathologist. As a former residency director, when selecting applicants, I would consider a demonstrated interest in our field as much as I would consider academic achievements.

Q: Shifting gears, talk to me about how you form a differential diagnosis.

A: That is difficult for me to describe because it is akin to asking a general dentist how to diagnose a carious lesion: After so many years, it is just something you know due to seeing it all the time. Because my practice is limited to oral pathology, I would struggle diagnosing carious lesions properly now. I imagine many non-oral pathologists feel the same about diagnosing some oral lesions! That’s okay—it’s not so important that we know exactly what we are looking at; what is important for the patient is that we know what to do. 

When I worked in academia, I would ask my students 3 questions during differential diagnosis: (1) How would you describe this in your chart? (2) What is your differential diagnosis? (3) What is the treatment plan? The question that matters the most is the third question even though the second is the most intimidating. 

When I receive a biopsy specimen, I actually do not want a differential—I want the clinician to tell me what he or she thinks it is clinically. For example, an area of true leukoplakia can have a differential diagnosis ranging from benign hyperkeratosis to some form of dysplasia or squamous cell carcinoma. It is most helpful for me to know if the clinician thinks this looked worrisome or if it looked rather banal.

Q: In your experience, what is the most difficult oral pathologic lesion?

A: Definitely gingival carcinomas. These squamous cell carcinomas mimic a wide variety of benign and reactive lesions and may be overlooked. They are typically painless and have the least association with tobacco use. I would advise clinicians to treat gingival lesions as they have clinically diagnosed them. If, however, the lesion does not respond appropriately to therapy, the initial diagnosis must be revisited. A biopsy is typically indicated in this situation.

Q: Any last words of wisdom?

A: I would say to please do an oral cancer screening on every patient, every time—no matter the age. Tell the patient you are doing it! If you find anything suspicious, the new recommendation is to send for biopsy immediately—do not wait 2 weeks. I have diagnosed cancer in 20-year-olds with no risk factors; please do not ignore anything that does not belong. When in doubt, cut it out!

ABOUT ASHLEY CLARK, DDS

Ashley Clark, DDS

Dr. Clark is a board-certified oral pathologist currently serving as the vice president of CAMP Laboratory in Indianapolis after a nearly decade-long career in academia. She is on the professional board for Oral Cancer Cause and Digital Dental Notes and on the advisory board for General Dentistry. Dr. Clark has won several teaching awards, has provided more than 100 continuing education courses, and has authored more than 40 publications and book chapters. She can be reached at ashleyclarkdds@gmail.com.

Anne M. Duffy, RDH

Q: Is the future of dentistry female? 

A: The landscape of dentistry is changing as more women become involved in the field. Recent statistics show that 56% of graduating dentists, 93% of dental hygienists, 91% of dental assistants, and 90.3% of office managers are women. The numbers don’t lie—women are here, and we’re making our mark in dentistry. 

However, the future of dentistry isn’t limited by gender. Instead, we’ll be able to propel it forward by leaps and bounds when men and women come together to collaborate, in large part because men are still sitting in the drivers’ seats in companies, corporate entities, and leadership positions. We are learning from each other, and together, we are tackling the long-standing gender gap that exists in dentistry, breaking down stereotypes, and opening doors for more women to pursue dental careers and their dreams. 

Q: Why is female leadership important?

A: The saying is “men are from Mars, women are from Venus.” I believe it! And that is a great thing. Feminine leadership focuses on relationships and can help create a more diverse workplace where everyone feels included and respected. It is essential that women in positions of authority take the lead in providing an inclusive environment and empowering people of all backgrounds to succeed. Women must also support each other and champion one another’s ideas to create an atmosphere of success. 

One of the most amazing things about being human is the ability to learn from others’ success. Seeing women at the top gives us the knowledge that it is possible and the confidence to dream big. By embracing and incorporating the strengths of each individual in the organization, female leadership can inspire creativity, innovation, and progress. It is up to female leaders to promote a diverse workplace and ensure everyone can reach their full potential.

Q: How important is connection and community? 

A: Connection and community are everything. We do not thrive alone, and coming out of the COVID-19 pandemic, we realize how much we crave community. Women are natural at nurturing relationships and are intentional in seeking them out. Coming together in the community gives us the gift of support and collaboration, a sense of hope, and the possibility to truly effect change.

Now more than ever, it is imperative that we focus on lifting each other to further women’s empowerment and create a place of belonging. From movements focused on expanding roles to increasing the number of female business leaders, it has been inspiring to witness the many steps taken toward progress. The power of connection is evident in Women in Dentistry, founded by Dr. Effie Habsha; WinDSO, founded by Dr. Aman Kaur; Mommy Dentists in Business, founded by Dr. Grace Yum; AADOM, founded by Heather Colicchio; Guiding Leaders, founded by Stephenie Goddard; and many other organizations, such as ADHA and AAWD. My organization, Dental Entrepreneur Woman (DeW Life), supports them all!

Q: Do women have advantages in dentistry?

A: Historically, women were underrepresented in the industry, but the landscape of dentistry is changing. Female dentists are taking their rightful place in the industry, and the impact is evident. With women dentists on the rise, patients and teams can benefit from greater diversity and expertise in their oral health care. 

In contrast, dentists gain increased job opportunities and greater potential to express their talents and unique approaches to patient care. Women have been blessed with the power of creativity, intelligence, and resourcefulness. The possibilities for patient care and growth in the field have never been more promising. 

Q: What does “DeW” stand for?

A: “DeW” stands for “dental entrepreneur woman.” In my mind, all women are entrepreneurs. We spin at least 5 to 10 plates at any one time while wearing heels and dancing backward. That is my definition of an entrepreneur, and it is our nature. Women need other women in their lives. We thrive in relationships, and it is lonely without a tribe. Knowing many women in different segments of dentistry over my long career, I felt a need to bring love and an understanding of strengths to the forefront of dentistry. 

We open our arms and invite all women to sit at our table. It is only together that we can make a difference. Women in dentistry are powerful, brave, caring, collaborative, loving, beautiful, and unstoppable. As DeWs, we embrace our unique talents to become forces for good in the world. When you step out of your comfort zone and lean into your talents, it has a ripple effect on everyone around you. 

DeW inspires women to be their best and strive for greatness as a community because when one of us wins, we all win. 

Q: Do you have any last thoughts?

A: When I started DeW Life, my initial goal was to highlight women in dentistry. Quickly, our mission became a movement to empower, inspire, and connect women in dentistry to lead themselves and others. 

The notion of women’s empowerment has sparked a hopeful sense of vibrant change. Now more than ever, it is imperative that we focus on connecting all women in our profession, regardless of their career paths. When we lift each other up, we further women’s empowerment and create an equitable world. 

Together, we can do small things with great impact. Let’s DeW it!

ABOUT THE AUTHOR

Ms. Duffy is the founder and CEO of Dental Entrepreneur Media. She can be reached at anne@dentalentrepreneurmedia.com. 

Q: What is the correlation between a patient’s exposure to adverse childhood experiences (ACEs) and his or her long-term health, including dental health?

A: Exposure to traumatic events or ACEs is proven to increase a person’s overall risk of severe long-term health issues and at-risk behaviors.¹ Acknowledging these experiences can improve patient-clinician engagement and increase the likelihood of provision of the most effective treatment while also avoiding unintentional re-traumatization. These adverse experiences may include, but are not limited to, childhood sexual abuse, neglect, discrimination, combat history, and domestic violence, leaving patients with long-lasting psychological effects.² 

There are strong associations between poor dental health and exposure to ACEs. Research shows that tooth loss is significantly higher in those with 4 or more adverse childhood experiences. They are also more likely to have teeth that need filling and restorations.³ Those with high dental anxiety also often report higher pain levels during dental visits.⁴ However, despite this, TIC is not routinely taught in undergraduate education.⁵ 

Q: What is trauma-informed care, and how does it help clinicians adapt their approach to avoid re-traumatizing patients with a history of ACEs?

A: Poor oral health-related quality of life (OHRQoL) is closely associated with dental pain and anxiety, which, as clinicians, falls within our scope of practice to attempt to reduce.⁶ This does not mean we need to remedy the underlying trauma but to instead adapt our approach and responses by implementing TIC-focused practices. Women with sexual ACEs have reported suffering from memories of their original abuse during treatment. They have expressed their belief that the dentist should have known about their history before treatment to avoid it becoming a re-traumatizing experience.⁷  

TIC involves education to realize the impact, signs, and symptoms of trauma and integrate that knowledge into not just the dental practice but also the policies and procedures of all aspects of the patient experience. 

Q: What are some TIC strategies that clinicians can implement?

A: There are 6 key principles of TIC defined by the Substance Abuse and Mental Health Services Administration.⁸ 

1. Safety (physical and psychological)
2. Trustworthiness and transparency (being transparent in the decision-making process to build trust)
3. Peer support (mutual support for healing/recovery)
4. Collaboration and mutuality (ensuring little to no power differentials)
5. Empowerment, voice, and choice (promoting individuals’ strengths and autonomy)
6. Cultural, historical, and gender issues (acknowledging and addressing the impact of historical trauma, overt discrimination, and biases)

Adopting trauma-informed approaches based on these principles can avoid adding to the trauma burden of patients.⁹ 

Some TIC strategies suggested include creating a soothing office space, training staff to validate concerns, giving your patient as much control over what happens and when it happens as possible, explaining each procedure, and asking for consent before beginning.¹⁰ The prescreening of patients to gather information about potential traumatic history should be employed. Staff should receive training to recognize re-traumatization and, through coaching, attain de-escalation skills. 

Q: How can dental professionals promote a culture of awareness, understanding, and action that upholds trauma-informed principles?

A: Patient-centered and trauma-informed care do not cease once the client has left the clinic. Fostering a sense of empathy requires patients to be understood and not dehumanized, which is a cohesive effort and the duty of all staff at all times. Understanding a patient’s healthcare beliefs and values cultivates an increased sense of compassion, leading to greater patient adherence to treatment protocols and client satisfaction.¹¹  

Awareness, understanding, and action are critical to a trauma-informed clinical approach that begins and ends with the culture upheld within a clinic as a whole, not just while the patient is in attendance.¹² 

While we may not know which patients come to us with trauma history and which of those may not feel comfortable disclosing it during the prescreening process, assume that everyone has, at some point, experienced an adverse event that may impact his or her response to treatment. This is the best way to ensure the application of trauma-informed care as standard practice. This approach, in turn, will help us to do our part as ethical and responsible clinicians to increase OHRQoL for our clients. 

MORE ABOUT MICHELLE STRANGE, MSDH, RDH

Ms. Strange is a practicing hygienist, speaker, writer, content developer, and owner of Level Up Infection Prevention. She has a master’s in dental hygiene education, a certificate in dental infection control and prevention, and a belief in lifelong learning. She has also served in her community and on global mission trips. She believes deeply in sustainable, charitable dentistry and serves to bridge the gap in access to care.

She can be reached at levelupip.com or michellestrangerdh.com. 

REFERENCES

1. What is Trauma-Informed Care? University at Buffalo: Buffalo Center for Social Research. Accessed September 22, 2022.
2. Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: providing trauma-informed care. J Am Dent Assoc. 2014;145(3):238–45. doi:10.14219/jada.2013.30
3. Ford K, Brocklehurst P, Hughes K, et al. Understanding the association between self-reported poor oral health and exposure to adverse childhood experiences: a retrospective study. BMC Oral Health. 2020;20(1):51. doi:10.1186/s12903-020-1028-6
4. Nermo H, Willumsen T, Rognmo K, et al. Dental anxiety and potentially traumatic events: a cross-sectional study based on the Tromsø Study-Tromsø 7. BMC Oral Health. 2021;21(1):600. doi:10.1186/s12903-021-01968-4
5. Brown T, Mehta PK, Berman S, et al. A trauma-informed approach to the medical history: teaching trauma-informed communication skills to first-year medical and dental students. MedEdPORTAL. 2021;17:11160. doi:10.15766/mep_2374-8265.11160
6. Svensson L, Hakeberg M, Wide U. Dental pain and oral health-related quality of life in individuals with severe dental anxiety. Acta Odontol Scand. 2018;76(6):401–6. doi:10.1080/00016357.2018.1473892
7. Leeners B, Stiller R, Block E, et al. Consequences of childhood sexual abuse experiences on dental care. J Psychosom Res. 2007;62(5):581–8. doi:10.1016/j.jpsychores.2006.11.009
8. U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration. Kap Keys for Clinicians based on TIP 57: Trauma-informed care in behavioral health services. Accessed September 22, 2022.
9. McCarthy J. Trauma-informed dental care. Healthcentric Advisors. Accessed September 22, 2022.
10. Kennedy BM, Rehman M, Johnson WD, et al. Healthcare providers versus patients’ understanding of health beliefs and values. Patient Exp J. 2017;4(3):29-37.
11. Champine RB, Hoffman EE, Matlin SL, et al. “What does it mean to be trauma-informed?”: A mixed-methods study of a trauma-informed community initiative. J Child Fam Stud. 2022;31(2):459–72. doi:10.1007/s10826-021-02195-9