COVID-19 Pandemic Ignites Fundamental Innovations in Digital Orthodontics

Dr. Ki Beom Kim, a key figure at CADE, emphasized that the pandemic heightened the demand for digital orthodontics, given lockdowns and movement restrictions. The pandemic’s impact accelerated the adoption of digital solutions, transforming service delivery methods.

SLU researchers collaborated with Graphy, a South Korean 3D printing material company, over three years to test direct 3D-printed aligners. This approach, unlike Invisalign’s use of thermoforming plastic sheets, directly controls aligner material dimensions and structure. The benefits of this method include faster tooth movement, reduced waste, and improved precision. The research was detailed in a Progress in Orthodontics paper titled “Force Profile Assessment of Direct-Printed Aligners Versus Thermoformed Aligners and the Effects of Non-Engaged Surface Patterns.”

Dr. Kim sees this advancement as significant, potentially claiming a substantial portion of Invisalign’s market share, which exceeds $25 billion. SLU’s pioneering work with Graphy sets it apart as the first institution to achieve this breakthrough.

Retaining orthodontic adjustments has historically posed challenges. To address this, YOAT, a Seattle-based medical technology manufacturer, collaborated with SLU to develop an on-site retainer-bending machine. This innovation promises precise retainers in less time, enhancing patient stability compared to traditional methods. YOAT’s partnership with SLU also extends to creating a finishing wire bending machine, set for testing in the near future. This machine is expected to further enhance orthodontic care by offering customized finishing wire options.

The collaborative research involved multiple individuals, including Dr. Evan Hertan, Dr. Julie McCray, and Dr. Brent Bankhead from Saint Louis University.

FEATURED IMAGE CREDIT: Martin Sanchez on Unsplash.

With the rapidly evolving use of teledentistry, a new study conducted by the Oral Health Workforce Research Center (OHWRC) at the University at Albany’s Center for Health Workforce Studies (CHWS) conducted case studies on the use of teledentistry following the COVID-19 pandemic in 4 states—California, Maine, Pennsylvania, and Wisconsin.

Key findings include:

• Regardless of the status of teledentistry in the state, teledentistry was adopted faster due to COVID-19 than it would have been otherwise.
• Emergency regulations expanding telehealth use to dentistry allowed dentists to bill codes D9995 and D9996 for synchronous and asynchronous telehealth service.
• States allowed for more liberal use of teledentistry, such as permitting the use of audio-only visits for certain services.
• Teledentistry was utilized to guide parents in the administration and application of fluoride varnish over video for their children, to triage patients, and to control clinic capacity for emergency care.

“Dentistry has been slow to take up telehealth modalities when compared to other fields, that is until the COVID-19 pandemic hit,” says OHWRC Senior Investigator Elizabeth Mertz. “By examining regulation around teledentistry and the changes brought on by the pandemic, we can develop strategic approaches for the future of oral health policy and practice.”

To view the report, visit the CHWS website at chwsny.org.

For more information about the Oral Health Workforce Research Center, visit oralhealthworkforce.org.

About the CHWS

Established in 1996, CHWS is an academic research organization, based at the School of Public Health, University at Albany, State University of New York (SUNY). The mission of CHWS is to provide timely, accurate data and conduct policy relevant research about the health workforce. The research conducted by CHWS supports and promotes health workforce planning and policymaking at local, regional, state, and national levels.

Today, CHWS is a national leader in the field of health workforce studies, and the only HRSA-sponsored center with a unique focus on the oral health workforce.

About the OHWRC

The OHWRC is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $450,000 with 0% financed with non-governmental sources. The content of this report are those of the authors and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US government.

For more information, please visit HRSA.gov.

HOW DID WE GET HERE?

While the original version of this quote can be found in a book about dating, I feel it applies to where many people find themselves, just over two years before all our lives collectively changed. Despite everyone’s stated desire to move on, for many people, the break-up, like in any toxic relationship, is just not so easy.

Everyone had their own way of coping with the sudden challenge that presented itself.

A never-ending game of Whac-A-Mole was in play, where just as one challenge was overcome, a fresh one reared its ugly head.

Learning to deal with a constant and ever-changing uncertainty in our lives had an impact, in varying degrees, and continues to do so, even if on a subconscious level. Whether or not you found yourself scrubbing your groceries, we all had to learn to deal with this invisible foe in our own way.

Our nemesis did not play favourites and was indiscriminate in its target, affecting everyone, whether they want to admit it or not.

Moving on from the lousiest partner ever appears to be exacting a toll for many who struggle to break free.

LETTING GO

Easier said than done, it seems, despite what the song says. Conversations about COVID are about as welcome as those with a friend who drones on endlessly with their laundry list of  complaints about their ex. So now that we clearly see the light at the end of the proverbial tunnel, why do some folks find this break-up so difficult? We continue to be bombarded by information, misinformation, and inconsistent information. While it is difficult to not lose the plot, the Backfire Effect is in full swing.

Lewendowsky and team discussed this phenomenon where a cognitive bias can lead people, who encounter evidence that challenges their beliefs to reject said evidence, leading them to cling even more strongly to their misconceptions.

Why does this happen?

This cognitive bias not only affects one’s ability to change another’s opinion but your own capacity to rationally process information.

Whatever narrative, true/false/true-ish/kind-of-not true, people clung to over the last two years, the pandemic, the invisible foe that led us to question so many of your beliefs, and those of everyone else, could not have cared less about our challenges, and still doesn’t.

Like a sociopathic ex-partner, the pandemic has gone on its merry way, doing its thing, without a concern for anyone.

STOCKHOLM SYNDROME

In an article by Daniel Neidtch, he discusses the issue of COVID Stockholm Syndrome.

Originally, Stockholm Syndrome, Neidtch writes, was the term coined after the behavior of the hostages of a bank-robbery in Sweden and is used to describe the effects of trauma in captivity, on hostages or survivors of abuse, where, with time, they start to identify with their captors, developing an emotional or psychological connection.

While, as Neidtch explains, the pandemic was not a kidnapper but a virus, and people were not expressing sympathies with it, they become accustomed to the extended lockdowns, physical distancing, and masking. Some people moved out of cities and made similar drastic and abrupt changes to their lives.

Many people, despite the changes in our ability to manage the virus, simply cannot let go of the fear that prompted all this handwringing, hand washing, and sanitizing.

Additionally, for some, the pandemic has provided a convenient reason to avoid addressing some of the challenges they face both personally and professionally, with the oft heard lament, “when the pandemic is over, I will….”

This excuse to avoid adressing some of the big issues in life can only be used for so long.

WHERE DO WE GO FROM HERE?

The mental health impact of the pandemic will serve as the basis of PhD theses for decades. Break-ups are never easy, even though the soon-to-be-ex is a total jerk (feel free to substitute your expletive of choice).  Everyone processes trauma in their own way.

We all need to be patient with each other, and ourselves.  Despite all our time and effort, we realize this most uncaring of partners is just not that into us and will continue to do its thing, and be a constant in our lives, in some form, without the slightest consideration of how we feel.  We need to be kind to one another as we all move on with our lives, each at our own pace, continuing to support our healthcare workers, vulnerable citizens, and those for whom the symptoms of the illness linger.

We also need to figure a way forward that puts science over politics, ensuring access to any information that leads to productive, and not toxic, discourse.

Dante, as Italians do, had the perfect way to describe what we have been through with his positive view of what lies beyond.

After his journey through hell, he wrote: “E quindi uscimmo a riverder le stelle,” and we emerged and saw the stars once again.

ABOUT THE AUTHOR

Dr. Bruce Freeman is an honours graduate of the University Of Toronto. He completed the AEGD program at the Eastman Dental Center in Rochester and returned to U of T to complete his Diploma in Orthodontics and his Master of Science degree in the field of orofacial pain. 

He is also co-director of the Facial Pain Unit and Hospital Dental Residency Program at Mount Sinai Hospital and lectures internationally on clinical orthodontics, facial pain, patient experience, and virtual surgical planning. He is the director of patient experience for dentalcorp supporting clinical and educational programs to support the patient experience. Bruce is a certified yoga instructor with additional training in breathing techniques, meditation, and trauma informed movement, emphasizing how self-care leads to the best patient care.

Dr. Freeman can be reached at bruce@drbvf.com.

FEATURED IMAGE CREDIT: Juraj Varga from Pixabay.

As dentists and other healthcare providers continue to navigate the COVID pandemic and the emerging variants, an easy-to-use tool is now available to help them conveniently and accurately assess the ventilation rates of their treatment and waiting rooms.

Eastman Institute for Oral Health research published in the Journal of Dentistry showed that if a room’s ventilation rate is low, respiratory aerosol particles can remain in the indoor air for a long time, making it critical to facilitate respiratory aerosol removal from the indoor environment to minimize potential exposures of airborne viruses such as COVID to patients and providers.

Part of the University of Rochester Medical Center, Eastman Institute for Oral Health has developed a calculator along with a simple process and other tools to help dentists easily determine the ventilation rate, measured in air changes per hour, for any room.

“Knowing what the ventilation rate is for individual dental treatment rooms will help providers understand what steps they can take, if necessary, to improve ventilation,” said Yanfang Ren, DDS, PhD, MPH, an EIOH professor whose research about dental treatment provision, aerosol behavior and ventilation, has been widely cited throughout the pandemic.

“We found that carbon dioxide levels in dental treatment rooms are directly associated with ventilation rate and the number of people in the room,” Dr. Ren said. This study—the basis for developing the ventilation calculator—was published in the Journal of Dental Research.

Using a CO₂ monitor, as well as household baking soda and vinegar, providers can follow the process that includes a calculator suitable for imperial or metric measurements to determine a room’s current air change rate. These tools, a video demonstration, as well as an email address to send questions, are available on the EIOH Covid Safety & Resources webpage.

Because dentists perform a wide variety of procedures that often produce spatters, droplets, and aerosols, Eastman Institute for Oral Health adopted this CDC recommendation and developed strategies to improve the ventilation rate to 15 air changes per hour in its dental treatment rooms.

“Many factors play a role in the ventilation rate for any given room, including the HVAC system, size and design of the rooms, and structure and age of the building,” said Dr. Ren. “Improving a room’s ventilation could be as easy as adding a portable air cleaner.”

When adding a portable air cleaner, it’s important to know its Clean Air Delivery Rate, to ensure it helps reach the desired air change rate. The EIOH Covid Safety & Resources website also provides guidance and custom tools to help users understand the Clean Air Delivery Rate and how to calculate the Air Change Rate for their portable air cleaner.

“The higher the Clean Air Delivery Rate, the faster the portable air cleaner cleans the air,” Dr. Ren explained. “When selecting a portable air cleaner for dental treatment rooms, use the rating for tobacco smoke, which represents the sizes of small dental aerosols that are the most difficult to clean.”

Improved ventilation and air filtration are important steps in a multi-layered approach for safe delivery of dental care during an infectious respiratory disease pandemic. Pre-appointment screening for signs and symptoms, proper physical distancing, pre-procedural mouth rinses, proper use of personal protective equipment including N95 masks and protective goggles or face-shields, and thorough disinfection and cleaning, are all important layers against potential spread of COVID-19 in dental settings.

Founded in 1917, Eastman Institute for Oral Health at the University of Rochester Medical Center, is a world leader in research, post-doctoral education and clinical care, and is consistently ranked in the top 10 of NIH/NIDCR funding.

INTRODUCTION

It’s all over the news: Dentists are treating more cracked teeth since the onset of the COVID-19 pandemic—sometimes at twice the typical rate.¹ The vast majority of dentists indicate that the prevalence of stress-related oral health conditions among their respective patients has increased since the beginning of the COVID-19 pandemic, according to the ADA Health Policy Institute’s latest data from its COVID-19 economic-impact tracking poll conducted the week of February 15.² More than 70% of dentists surveyed saw an increase of patients experiencing teeth grinding and clenching, conditions often associated with stress—up from just under 60% in the fall. Dentists also reported increases in chipped teeth (63%); cracked teeth (63%); and temporomandibular joint disorder symptoms (62%), which includes headaches and jaw pain.²

Pandemic stress, quarantine fatigue, mask burnout, online overload—whatever you want to call it, it’s added stress that people across the globe are experiencing. Stress comes out in many different ways, and each person responds differently, but there is definitely a trend of stress-related issues in dentistry. Management of this stress is a primary concern. Whether you practice mindfulness, begin a yoga habit, or seek professional medical help, addressing the feelings you’re having now is as important as treating the symptoms they are causing.³ The key to any successful treatment plan is understanding the cause of the current condition. This allows you to arrive at the correct diagnosis and develop a treatment plan that will have a predictable, long-term, successful outcome. So, on the surface, the treatment of a cracked tooth may seem simple: Restore the crack with a crown or another appropriate restoration, and that is it. However, if the underlying cause has not been addressed, your treatment is susceptible to failure.⁴ 

Cracked teeth and the various complications that arise with this particular type of case can be one of the most significant challenges facing the preventive, restorative dentist today. They present a clinical challenge due to their complex diagnosis and unpredictable prognosis. Treatment often varies depending on the nature of the crack and the clinical experience of the operator. Cracked teeth are challenging to diagnose clinically because of the complicated and diverse symptoms associated with this condition and the challenge in locating crack lines. There is no consensus among dental practitioners regarding the best approach to treat cracked teeth. But what we do know is the treatment and outcome for a cracked or fractured tooth is dependent on the location, direction, type, and size of the crack.^5,6 Being able to distinguish these differences can aid in a diagnosis that will ultimately lead to proper care and treatment. The American Association of Endodontists has classified 5 types of cracks in teeth⁷: 

1. Craze lines 
2. Fractured cusp 
3. Cracked tooth 
4. Split tooth 
5. Vertical fracture

These 5 categories of dental fractures have been devised to provide global definitions that researchers and clinicians can use to decrease this confusion. Combining this knowledge with a proper dental history, clinical examination, and radiographic assessment, as well as a periodontal and occlusal evaluation, can help one determine the proper course of treatment for a particular case.⁸

The following case presentation will highlight the treatment of an incomplete fracture of an upper second premolar. Though there were many ways to approach the treatment of this particular case, the modality chosen focused on a minimally invasive approach involving immediate dentin seal and its emphasis on crack repair.⁹

CASE REPORT

A 60-year-old male patient in good physical health with no underlying medical complications presented complaining of discomfort when biting on his upper left side for approximately the previous 10 days. A radiograph, as well as a visual examination, was conducted, along with a periodontal and endodontic evaluation. It was determined rather quickly that the upper right second premolar was the culprit. Utilizing a transillumination device (AdDent), the large fracture running mesial to distal was easily visualized (Figure 1). Radiographically, there was no sign of pathology, and all vitality testing came back within normal limits. Periodontally, the same can be said regarding the lack of significant findings, as all probe readings were in the normal range of 2 to 3 mm. Treatment options, and the understanding of the complexities of treating a fractured tooth like this, were discussed with the patient. He understood that there was no guarantee that this tooth could be saved with 100% predictability. An integral part of dealing with cracked teeth is that the patient fully understands the situation and has total buy-in when deciding on the course of treatment. 

The area was then anesthetized (4% articaine, 1:100,000 epinephrine [Septodont]). Isolation was achieved utilizing a DryShield evacuation system to help achieve an optimal working environment. Being a virgin tooth, the fractured premolar was then explored by utilizing a pear-shaped diamond bur (Meisinger) to begin to evaluate the depth of the fracture. Approaching this fundamentally, the design principles involved in minimally invasive dentistry, combined with a biomimetic approach, helped me establish a protocol when chasing a fracture. The ideal goal was to chase the fracture to a depth of 5 mm from the occlusal surface and a depth of 3 mm interproximally from the axial wall.¹⁰ I tried to be careful not to remove too much of the cracked dentin and cause a pupal exposure. The preparation felt complete after I flattened out both the buccal and lingual cusps utilizing an 856 diamond bur (Meisinger) to create a cusp clearance of approximately 1.5 mm. I utilized a large enamel band to help take this preparation from a predominantly tensile position to one of compression, enabling the support to be transferred away from the remaining fractured dentin (Figure 2). Feeling comfortable with my preparation, a marginal elevation band (Garrison Dental Solutions) was placed and secured with 2 interproximal wedges (Palodent Plus System [Dentsply Sirona]) (Figure 3). The band is being utilized to help me raise the interproximal margins slightly supragingival, as well as support the bio base at the interproximal. The fracture was still partially in the dentin-enamel complex, and I was not comfortable chasing that fracture any further. With the band in place, CLEARFIL Universal Bond Quick (Kuraray) was applied to the tooth in an agitated fashion for roughly 10 seconds, then air thinned with a dedicated air line to help reduce contaminants, and then light cured for 20 seconds with an LED curing light (PinkWave [Vista Apex]) (Figure 4). CLEARFIL MAJESTY Flow (Kuraray) was then applied to the entire dentin-bonded surface at a depth of 0.5 mm in a horizontal fashion and light cured for 20 seconds. Some everX Flow (GC America) was applied directly over the fractured portion of the preparation at a depth of approximately 1 mm. This is a short fiber-reinforced flowable composite that increases the fracture toughness of the tooth and should prevent the existing dentin crack from propagating and causing failure (Figure 5).¹¹ The multidirectional fibers found in everX Flow helped bridge the crack and transferred the stresses to regions of greater structural integrity. Finally, a thin layer of CLEARFIL MAJESTY Flow was placed over the everX Flow to ensure a smooth transition and polymerized for the final time for 20 seconds. The band was removed, and the surface was polished with Enhance Finishing Cups (Dentsply Sirona) to remove any flash or possible discrepancies prior to taking our final scan (Figures 6 and 7). The temporary was cemented and the tooth was taken slightly out of occlusion in all excursions. Detailed instructions were given to the patient in regard to home care and management of that area while the permanent restoration was being fabricated.

Upon returning to the office, the patient was happy to report there were no signs of discomfort or anything to lead us to believe that we were on the wrong path to a successful outcome. The area was once again anesthetized (4% articaine, 1:100,000 epinephrine [Septodont]), and a DryShield Evacuation System was placed to help in the removal of the temporary and in the bonding protocol of our final restoration. After removal of the temporary, a large piece of Teflon tape was wrapped around the preparation to help protect the gingiva, and air abrasion was performed with the PrepStart H₂O (Zest Dental Solutions) utilizing 50-µm aluminum oxide to clean the immediate dentin seal-coated surface (Figure 8). The zirconia restoration (Argen) was then tried in and adjusted to our specific needs. It was then taken to the lab, where it was air abraded for 5 to 6 seconds with 27-µm aluminum oxide to ensure a clean intaglio surface was achieved (Figure 9). In order to bond zirconia restorations, it is critical one achieves an activated surface free of any contaminants that can hinder the chemical interaction. This can be achieved with the introduction of the phosphate monomer MDP.¹² The MDP monomer has a very strong affinity to phosphate, which is the predominant component in freshly cleaned zirconia. CLEARFIL CERAMIC PRIMER PLUS (Kuraray), the MDP-containing primer used in our case, was applied to the intaglio surface and allowed to dwell (Figure 10).

With the restoration now ready, the tooth was then prepared by placing 35% phosphoric acid in a total-etch technique for 20 seconds, and then it was rinsed and dried. CLEARFIL Universal Bond Quick (Kuraray) was placed on the tooth and scrubbed and agitated for 10 seconds prior to air thinning until a lack of bonding agent movement was seen along the preparation (Figure 11). PANAVIA SA Universal Cement (Kuraray) was placed directly on the uncured bonding agent, and the restoration was then seated (Figure 12).

One of the unique features and reasons as to why this cement combination was chosen was because of the built-in dual-cure formulation between CLEARFIL Universal Bond Quick and PANAVIA SA Universal. By not having to polymerize the bonding agent prior to cementation, this ensured that there would be no pooling anywhere along the preparation to create an insufficient seating of the restoration. The restoration was then tack-cured for 3 seconds, and excess cement was removed facially and lingually as well as interproximally with floss. After all excess cement was removed, the restoration was then light cured from all directions for 20 seconds. Enhance Finishing Cups were used to polish the facial and lingual surfaces before checking occlusion. A fine diamond (Meisinger) was used to adjust, and the final polish was completed with a 3-step intraoral zirconia-polishing system (Meisinger) (Figure 13). Postoperative instructions were discussed with the patient, and a final radiograph was taken to ensure complete seating of the restoration and integration with our prior marginal elevation (Figure 14).

CLOSING COMMENTS

The protocol for preventing and treating cracked teeth is advanced yet simplified. By choosing a treatment modality that replaces lost or damaged tooth structure with proper materials and maximum bond strengths while minimizing the stress, we can ultimately achieve a durable and maintainable restoration. Today’s materials provide all of that in reliable bonding technology and flexural strengths, allowing us to prepare non-geometric, retentive preparations that take advantage of the built-in physical properties of natural tooth structure while avoiding the ever-destructive 360° margin preparations. Using biomimetic restorative protocols and concepts increases the longevity of restorative dental treatments and reduces or eliminates future cycles of retreatment, a concept that both the dentist as well as the patient can enjoy every day. 

REFERENCES

1. American Dental Association. HPI poll: Dentists see increase in patients’ stress-related oral health conditions. September 28, 2020. 

2. American Dental Association. HPI poll: Dentists see increased prevalence of stress-related oral health conditions. March 2, 2021. 

3. Harvard Health Publishing. Best ways to manage stress. January 8, 2015. 

4. Mamoun JS, Napoletano D. Cracked tooth diagnosis and treatment: An alternative paradigm. Eur J Dent. 2015;9(2):293-303. doi:10.4103/1305-7456.156840

5. Lee JJ, Kwon JY, Chai H, et al. Fracture modes in human teeth. J Dent Res. 2009;88(3):224–8. doi: 10.1177/0022034508330055

6. Seo DG, Yi YA, Shin SJ, et al. Analysis of factors associated with cracked teeth. J Endod. 2012;38:288–92. doi:10.1016/j.joen.2011.11.017

7. American Association of Endodontists. Cracking the cracked tooth code: detection and treatment of various longitudinal tooth fractures. Summer 2008. 

8. Abou-Rass M. Crack lines: the precursors of tooth fractures-their diagnosis and treatment. Quintessence Int Dent Dig. 1983;14:437–47.

9. Magne P. Esthetic and Biomimetic Restorative Dentistry: Manual for Posterior Esthetic Restorations. University of Southern California School of Dentistry; 2006.

10. Alleman DS, Magne P. A systematic approach to deep caries removal end points: the peripheral seal concept in adhesive dentistry. Quintessence Int. 2012;43(3):197-208. 

11. Garoushi S, Sungur S, Boz Y, et al. Influence of short-fiber composite base on fracture behavior of direct and indirect restorations. Clin Oral Investig. 2021;25(7):4543-4552. doi:10.1007/s00784-020-03768-6

12. Blatz MB, Alvarez M, Sawyer K, et al. How to bond zirconia: the APC concept. Compend Contin Educ Dent. 2016;37(9):611-617; quiz 618. 

ABOUT THE AUTHOR

Dr. Schmedding graduated from the University of Puget Sound prior to getting his DDS degree at the University of the Pacific, Arthur A. Dugoni School of Dentistry. For 17 years, Dr. Schmedding practiced in Seattle prior to relocating to California. He held a position as an assistant professor in the Department of Integrated Reconstructive Dental Sciences at the University of the Pacific, Arthur A. Dugoni School of Dentistry. In addition to his pursuits in academia, Dr. Schmedding enjoys his private practice in Walnut Creek, Calif, and lectures nationally and internationally on topics ranging from advanced dental materials and products to complex restorative procedures. He has published articles both nationally and internationally regarding dental restorative materials and procedures. Dr. Schmedding is a current member of the ADA, the California Dental Association, and the American Academy of Cosmetic Dentistry. He is one of 450 dentists worldwide to be an accredited member of the American Academy of Cosmetics. He can be reached at troy.schmedding.dds@gmail.com. 

Disclosure: Dr. Schmedding received an honorarium from Kuraray Noritake for writing this article.  

A member of the Dental Resource Program of America’s ToothFairy, Holly Jorgenson, RDH, of Let’s Smile, Inc., delivers a virtual presentation on oral health to students in Minnesota. Although more children received educational services than in years past, less received screenings, sealants, and fluoride varnish applications due to restrictions on school-based dental programs.

Last month, the World Health Organization (WHO) acknowledged that preventive dental care and the treatment of tooth decay are vitally important when they added fluoride, glass ionomer cement, and silver diamine fluoride to their list of essential medications. Why would the WHO be concerned about oral health when it seems that COVID-19 should be the focus?

According to a recent study conducted by the British Dental Association and published in the British Dental Journal, after excluding older or obese subjects, Covid patients with poor oral health are more likely to experience severe and/or longer lasting symptoms. It stands to reason then, that improving oral health is part of the strategy to reduce the impact of Covid. The problem is, people who are at higher risk of developing severe cases of Covid–people of color and those living below the poverty level–also face extra barriers to access dental care.

Before the pandemic, school-based dental programs were proven to be an effective strategy to help children living in low-income homes and rural communities get preventive care and connect them and their families to a dental home. Research shows that screenings, sealants, fluoride varnish, and oral health education received through school-based programs reduced cavities by 50%. As the pandemic lingers on, the children who benefited from these school-based programs are facing barriers to care once again.

“Most people dealt with delays in dental care for a short time while dental offices were shut down or only offering emergency treatment. We’re 19 months into this pandemic and many of the children who depend on school-based dental programs are still waiting in many cases,” said Jill Malmgren, Executive Director of America’s ToothFairy, a nonprofit organization that provides resources for safety-net dental clinics and organizations delivering preventive services to underserved communities.

The organization has been keeping a close eye on the impact the coronavirus shutdowns have had on children who need dental services the most, and the community organizations that are struggling to provide the care they need.

Through their Dental Resource Program (DRP), 64 nonprofit dental clinic members in 25 states receive dental supplies and equipment, educational materials, and grants to support the delivery of care. 82% of DRP members provide care through school-based programs.

“42% of our member safety net clinics report that the majority of their patients receive dental care at school–that’s as many as 450,000 kids,” Malmgren explained. “It’s only a snapshot of safety-net clinics across the U.S. At this time, only 18% of our members have access to schools at the same level that they had before Covid.”

According to a survey of its member clinics, America’s ToothFairy reports that 63% of its members have some access to schools, but not at the same level as before. While 14% are still not allowed to visit schools to provide essential dental services. Clinics with unrestricted access were more likely to be in rural areas in states like South Carolina, Minnesota, and West Virginia, while those in more urban areas in states like California are more likely to have limited access or are completely cut-off from school settings.

Even in states like Missouri, where clinics can access students at school, coordination has become more complicated.

“The biggest challenge is that the school nurses are overburdened with Covid-related problems, such as contact tracing and managing quarantines,” one clinic responded in the survey. “Our capacity is already reduced, plus we are trying to do more to lessen the burden on nurses. Several of our larger districts have chosen not to participate in our school-based screening program this year, which will significantly reduce the number of students receiving screenings and care coordination as well as preventive fluoride treatments.”

Overall, since 2019, America’s ToothFairy has seen a 25% reduction in the number of kids who received fluoride varnish and sealants, and a 27% drop in the number of kids who were screened for emergent dental needs through their program partners–numbers that do not sit well with Ms. Malmgren.

“While this has been a very challenging and frustrating time, we are encouraged by the creative ways our Dental Resource Program member clinics have found to reach kids with oral health education through virtual presentations and small-group instruction,” Malmgren pointed out. “In fact, last year our members reached more kids than ever mostly due to educational outreach. Oral health education is important, and is a major component of our mission, but it’s not a substitute for dental services. Kids still need screenings and preventive treatments.”

Another obstacle for school-based programs is concern from school personnel and parents that receiving dental treatment at school is too risky during the pandemic.

“Our first school event is scheduled for late October,” a clinic in Minnesota noted in their survey response. “We are anticipating a lower participation rate… We have sent communication home with families to share the safety measures we have set in place to assure families know that dental care is safe to receive in a school setting.”

It is important to note that dental care providers were already practicing strict infection control protocols before Covid. The clinics that oversee school-based programs have implemented more precautions in addition to their existing safety protocols such as the use of additional PPE (which can be difficult to procure) and restricting the number of students who receive services in the same spaces.

“We have always implemented safety first while treating patients; however, we had to implement a few changes to go that extra mile to make everyone feel safe,” a member from Missouri reported. “Prior to Covid, our teams could go inside the schools to retrieve children from their classrooms. Now many schools would prefer that their staff assist in this area. The number of children that we would normally service daily has changed to continue practicing the social distancing requirements.”

To overcome these additional barriers, DRP members are going out of their way to deliver care to kids in need. A clinic located in Vermont cannot enter schools but has worked with the school system to coordinate transportation to bring students to their facility during school hours.

Another from New Jersey delivered “Tooth Brushing Stations” kits to schools for children with developmental disabilities, to reinforce daily oral hygiene routines for the students and their aides. Still others reported moving their services to Head Start programs or The Boys and Girls Club locations.

Malmgren is confident their program members could do much more with more resources.

“We are inspired every day by the optimism and dedication of our member clinics,” she said. “They are working with reduced budgets and staff, limited access to supplies and PPE, roadblock after roadblock, and still they come up with such creative work-arounds because they care so very much about these kids. They could do exceedingly more, and we could do so much more for them,with support from the dental community.”

For more information about America’s ToothFairy and the resources they provide to safety-net clinics and community oral health organizations, visit AmericasToothFairy.org.

A student from Central Community College Dental Hygiene program in Hastings, NE applies sealant to a young child’s teeth.

ABOUT THE AUTHOR

Jan Badger is the Communications Manager for America’s ToothFairy. She can be reached at communications@ncohf.org.

Prosperident has been in the business of investigating embezzlement committed against dentists since 1989. Over that time, we have seen many changes in both dentistry and the environment in which it operates.

If you need help with the word embezzlement, it refers to someone in a position of trust (often a staff member, but also potentially someone external like a bookkeeper) abusing that position and trust to steal.

The administration of practices has evolved greatly in the last 30 years. From the company’s initial pegboard investigations when few practices were computerized, to the rudimentary first- and second-generation practice management software, to the entry of the internet and connectivity into practices, the dental office of 2021 functions differently from its 1989 counterpart. 

And while these changes were unfolding, the world wasn’t exactly standing still. Interspersed among some economic booms were a couple of recessions; the occasional war; and, oh yes, the COVID-19 pandemic of 2020 to 2021. The people labeled by Tom Brokaw as “the Greatest Generation” viewed World War II as the defining moment in their lives. The pandemic and the disruption it caused to people’s lives are probably the global events that we will tell our children or grandchildren about in 30 years. 

As senior members of the world’s largest company specializing in investigating and protecting dentists against embezzlement, the authors have had front row seats observing the battle between dentists and those who wish to steal from them, and we have seen discernable changes concurrent with the pandemic. This article will discuss how embezzlement has been evolving and what practice owners should do to protect themselves.

First, the prevalence of embezzlement in dentistry is increasing. This increase is a long-term trend that was occurring well before we heard the word coronavirus. Similar studies done by the ADA 12 years apart showed a marked increase in surveyed dentists reporting that they had been victimized (35% reported having been embezzled in 2007 vs 47% in 2019.) Thus, in just over a decade, the reported incidence of embezzlement increased by more than a third.  

The 2019 study also asked victims how many times they had been embezzled. Results showed 5% reported never, 26% said once, 11% said twice,  2% said three times, and 8% said more than three times. 

While it is too soon to quantify the impact of the pandemic on the prevalence of embezzlement, we know from watching business cycles over many years that booms and busts each pressure a different kind of embezzler.

People normally steal for 2 reasons. Some embezzle because of perceived need. For whatever reason, these people are unable to meet their monthly financial obligations, and they fall further behind over time until their basic existence is threatened. They steal to avoid losing their house or car, for example. As you might expect, a sputtering economy puts more people in this situation.

In contrast, others steal because they feel that society is not rewarding them properly. This feeling intensifies when these greedy people perceive that others are getting ahead more quickly than they are. Behavioral studies suggest that these people often suffer from narcissistic personality disorder and may also display some elements of sociopathy. Greedy thieves believe they deserve the money they steal.

The COVID-19 era may be unprecedented in that it pressured both groups simultaneously. There was, and continues to be, massive displacement in the economy. Many industries, such as travel and hospitality, endured significant downsizing. Concurrently, the stock market, partially fueled by massive government spending and the pandemic-enhanced shift toward technology-driven businesses like Amazon and Uber, has galloped ahead. Therefore, we have created needier thieves while simultaneously increasing the dissonance that pressures covetous people to steal.

Needy people embezzle to fill a financial hole. The shortfall in their finances is finite, and they are simply trying to keep themselves housed and fed. The amounts needy thieves steal monthly tend to be modest, although the cumulative amount can be considerable over time. Because their financial objective from stealing has an upper limit, needy thieves get away with stealing that would be quite conspicuous if done in larger amounts. Theft by the needy may involve payroll tampering, borrowing the practice’s Amazon account for personal purchases, and similar activities. We often refer to theft that causes a practice to pay out more money than it should as expense-side stealing.

In contrast, thieves motivated by greed can be voracious. Their insatiable appetites often steer them away from expense-side activities, which generally have low thresholds for becoming conspicuous and are therefore self-limiting. For example, suppose that someone wanting to steal 4% of your revenue does so by padding their payroll. This theft will have the effect of increasing your staff expense ratio (ie, payroll costs divided by revenue) by that same 4%. With many practices having staff expense ratios in the 25% range, a 4% increase is sufficient to draw attention. On the other hand, if the same amount is stolen through diverting some of a practice’s revenue (commonly called skimming), the impact on the staff expense ratio is about 1%, which is well within the normal range of variability and, therefore, less likely to be flagged as anomalous.

In the same way that prudent investors lessen their risk by diversifying their portfolios, most thieves realize that they can reduce the probability of detection by not relying on a single embezzlement method. Virtually every thief we encounter uses 3 methods of stealing concurrently. Long-term thieves may develop and discard methods over time, but they tend to keep 3 methods active.

ACTION STEPS

Given the current climate, how should a busy practice owner protect his or her finances? Contrary to popular belief, you have powerful weapons, and using them will not make excessive demands on your time.

1. Hire carefully. More than 20% of our investigations involve serial embezzlers who have stolen elsewhere before. The irony is that usually information that would have disqualified these people from being hired was readily available if their victims only bothered to access it. The most critical background check is to speak with all former employers for the last 5 years. The second most important step is a criminal records check. Before you do either of these steps, you must definitively identify the applicant. The best practice is, when interviewing them, to check a picture ID, plus at least 2 secondary pieces of identification. Extensive background checks are meaningless if the applicant has borrowed someone else’s identity.

2. Monitor and review. Say this every morning before breakfast: Every staff member with financial responsibilities requires oversight. This supervision is particularly important for your office manager, who has the most opportunity to embezzle by virtue of position and authority. This supervision must be performed either by you, your spouse, or someone with no access to incoming funds or your checkbook, such as an external bookkeeper. Oversight includes the following:

a. Ensuring that collections, according to your practice management software, exactly match deposits made to your bank. Differences in the timing of recognition between the bank and your software for certain types of deposits complicate this activity. Still, every deposit should be able to be matched perfectly to practice management software. 

b. Reviewing every financial transaction made in your practice management software to look for deceptive or anomalous transactions.

3. Trust, but verify. Your oversight should be based on source information and not a document that someone has handed you. For example, the confirmation that the correct amount was deposited to your bank should be done by reviewing your online banking account, not by looking at a deposit slip that a staff member hands you, which could have been altered. Similarly, any review made of your practice management software should be done from reports you generated yourself. Allowing a staff member to print a report for you opens the door to selective reporting, in which information can be concealed from you.

CONCLUSION

While the events of the past year have changed the profiles of the embezzlers that we see, the basic business practices that a dentist can follow have not changed. Now is a good time to review and tighten yours. If the process of identifying and correcting areas of weakness in your practice’s control systems seems daunting, consider hiring professionals to do it for you. 

ABOUT THE AUTHORS

Ms. Webber is a senior fraud examiner for Prosperident, a company specializing in the investigation and control of embezzlement committed against dental practices. Mr. Harris, is CEO of Prosperident and Ms. Askins is a supervising examiner at Prosperident and heads its orthodontic investigation department. Harris resides in Halifax, NS, Canada and both Askins and Weber live in Texas. The authors can be reached at prosperident.com. 

Disclosure: Mr. Harris is CEO and a stockholder of Prosperident. Ms. Webber and Ms. Askins provide compensated services to the company.

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Artificial Intelligence and Its Use in Dentistry

Delaying dental care is not a new trend for dental patients during the pandemic. We’ve all heard how much anxiety patients can have about going to the dentist. However, the temptation to push off dental care did get prodigiously worse during the last year of lockdowns and COVID-19 fears. As we return to a more normalized state, patients that delayed care are returning to offices once more. The unfortunate case is that they are usually returning to deal with an immediate acute problem, like tooth pain or a broken crown. Whether their hesitancy to cross the dentist’s threshold comes from COVID fears or a deeper-rooted reluctance, these patients finally do darken their providers’ doorsteps. This gives dental providers a unique opportunity to educate patients on the perils of delayed care and encourage the patient to change their behavior. In essence, it is our job to convey that dental problems only get worse, not better. They become more extensive and more expensive. And neither the dentist nor the patient wants that to occur.

As clinicians, our chairside manner will make or break how patients respond to these conversations. The procrastinating patient provides a critical opportunity to guide patients towards better oral health. In terms of motivating action and decreasing patient-level fear, here are five steps we practice at Sage Dental to best engage patients in productive care conversations and successfully influence their dental behaviors moving forward.

Step 1: Engage through Teledentistry

Connecting with your patients via non-threatening virtual appointments is the quickest way to ease the stress of a return to the dental office after a long hiatus. Those appointments, whether real-time or asynchronous, convey a lot about your willingness to help and overall lack of judgment for their state of oral health. Patients love it, particularly new patients, which starts the process of getting the patient to pursue treatment.

Step 2: Transform the in-office experience to reflect co-discovery

Utilizing newer technologies, such as HelloPearl’s artificial intelligence Second Opinion platform or Dental Monitoring’s SmileMate virtual consultation iPhone scan, to give your patients a tech-forward, unbiased, and pain-free peak into their oral health condition can go a long way toward lessening the anxiety of a return to care. Fear of judgement is another valid fear that patients experience. Using such methods creates an unbiased assessment, which looks a lot less like a dentists’ judgment or “opinion.” Utilizing these AI iPhone scanning technologies is as simple as taking a selfie. And let’s face it, patients love selfies. Changing the patient’s perception of the visit changes the overall chairside experience into something far less threatening and less open to interpretation.

Step 3:  Take it in bite size pieces

First, we must address the immediate pain or problem the patient is experiencing. Avoidant patients have likely experienced days to months of acute pain or discomfort, so it is important to spend the bulk of the appointment addressing their immediate concerns with compassion and clinical precision. Providers know this. But the temptation is always there to share the entirety of dental disease that we see. Patients are not going to be receptive to any home health or in-office best practice messages their providers are sharing until they are out of pain. At Sage Dental, we make a point of building a solid foundation of patient-provider rapport using innovative new technologies and phased goals, which will ultimately help us get important messages across later.

Step 4: Plan ahead together: what got you here won’t get you there

Once the patient is comfortable, take the time to reflect on their oral health and share the correlations between overall health. Walk through what caused the issue they came in for. Was it a direct result of neglected or delayed care? Would coming in for the recommended semiannual appointments have caught this issue before it became debilitating? In most cases, the answer is yes. 

Once the patient has a clear understanding of the past behavior that brought them to this point, it is the perfect segue to discuss the current state of their oral health. Just because you as the provider dealt with their immediate oral care needs does not mean that their oral health is 100% restored. Now is the time to discuss any other lesions you and the other dental providers have observed in their mouth that are likely to result in future pain or issues if the patient continues to delay care. However, our chairside demeanor is critical to conveying this in a non-judging, forward-focused way. We can’t change yesterday for the patient, but we can certainly improve tomorrow with continued care.

Rather than dictate the patient’s best course of action (something that is sure to alienate them and discourage changed behavior), invite them into a conversation about making a plan that works forthem. Start by giving the patient a big-picture view into the state of their oral health and describing what might become an issue later, while also complimenting them on what they are doing right. In my experience, many providers neglect to point out the positives, and they nearly always exist. Make sure the patient clearly understands that they have options: different treatment plans can be tailored based on the patient’s aesthetic and financial expectations. At Sage Dental, we’ve found a great way to share this information with patients is by utilizes newer simulation technologies, and in turn, they often share these images on social media.

Step 5: Share cautious optimism

Finally, it is important to end with caution and optimism. Dental providers have a duty to communicate the seriousness of delayed care: the patient could wind up in the same (or more) pain than what forced them to seek dental care in the first place. Reminding the patient where the day started, the pain or issue they were experiencing (and would like to avoid moving forward) can be an effective tool to prompt future change. Remind the patient that without implementing a treatment plan, their oral health challenges will persist. Share how much you as their provider want them to never experience “a day like today again.” End by reiterating your hope that they will work with you to ensure that does not happen, and highlight your confidence that their dental experience will be a positive one as you implement the agreed upon treatment plan.

Whether dentists face another pandemic lockdown or not, patients will continue to find reasons to delay their dental care. As a result, even when the pandemic is long behind us, dental providers will be working to address patient hesitancy and the negative oral health consequences of delayed care. From COVID-clench to broken teeth to periodontal disease progression due to delayed care, clinicians will need to leverage excellent chairside manner to build positive rapport with patients. Only through innovative new technologies, strategic communication and strong relationships will patients be persuaded to change their behavior and ultimately elevate their oral health for the better long term.

ABOUT THE AUTHOR

Dr. Roark is the senior vice president and chief clinical officer at Sage Dental, responsible for overall clinical leadership, including enterprise-wide clinical strategic planning, developing and improving clinical protocols, researching new technologies and services, overseeing quality assurance, and providing professional development opportunities to 500 clinical team members and over 65 supported dental practices. 

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New Data Finds Most Americans Are Unaware that COVID-19 and
Other Serious Illnesses Can Be Connected to Poor Oral Health

ProHEALTH Dental, in collaboration with The Harris Poll, has officially released new data exploring American’s awareness of the correlation between oral health and one’s overall health. Conducted online and sampling over 2,000 Americans over the age of 18, the study asked questions related to their understanding of which common health issues are connected to poor oral health and if their awareness of this correlation will impact the likelihood that they visit the dentist. 

Over the course of the past year and a half, some Americans postponed dental visits due to health concerns related to the COVID-19 pandemic. With the most recent developments of the Delta variant, it’s important that people take necessary preventative actions, including maintaining good oral hygiene habits and regular dentist visits. In doing so, people can decrease the likelihood of catching a more serious diagnosis of this disease.

A recent study published in the British Dental Journal, provided evidence that poor oral health could impact the severity of COVID-19 including a delayed recovery period due to a more serious case of the disease. This new study conducted by ProHEALTH Dental found that 87% of Americans are unaware that COVID-19 can be connected to poor oral health. Furthermore, when examining how oral health can affect other major illnesses, most Americans were unaware that common health issues such as Alzheimer’s disease, cardiovascular disease, strokes, diabetes, and cancer are all related to poor oral health.

ProHEALTH Dental’s mission and model is to break down the barrier between medicine and dentistry and to educate the public about the importance of oral health as a key element of overall health. By conducting this study, the organization is helping to educate the public on the importance of oral health awareness and thereby increasing the likelihood that people will prioritize their oral health moving forward. Of the participants studied, three in five Americans would visit their dentist on the recommended schedule (typically twice a year) if they were made aware of how poor oral health can impact major medical conditions.

“The results from the study are reminiscent of what we have anecdotally heard from many of our patients,” said Norton Travis, CEO of ProHEALTH Dental. “Furthermore, the findings of this study demonstrate the importance of ProHEALTH Dental’s mission of medical and dental integration and education. Our non-invasive screenings help to bridge the gap between dental and medical health management, which are more important than ever before.”

Key Findings from the Study:

• 87% of Americans are unaware that COVID-19 can be connected to poor oral health
• 89% of Americans are unaware that Alzheimer’s Disease can be connected to poor oral health
• 72% of Americans are unaware that cardiovascular disease can be connected to poor oral health
• 84% of Americans are unaware that strokes can be connected to poor oral health
• 76% of Americans are unaware that diabetes can be connected to poor oral health
• 74% of Americans are unaware that cancer can be connected to poor oral health
• Three in five Americans would visit their dentist on the recommended schedule if they were made aware of how poor oral health can impact major medical conditions.

Survey Method:

This survey was conducted online within the United States by The Harris Poll on behalf of ProHEALTH Dental between June 10-14, 2021, among 2,066 adults ages 18+. This online survey is not based on a probability sample and therefore no estimate of theoretical sampling error can be calculated. For complete survey methodology, including weighting variables and subgroups sample sizes, please contact Jessica Apicella at jessica@buzz-creators.com. 

About ProHEALTH Dental:

Based in Lake Success, New York, ProHEALTH Dental affiliates with health systems and medical groups to coordinate dental services with primary care medical services and promote the oral and overall health and well-being of their patients. Under these affiliation arrangements, ProHEALTH Dental develops state-of-the-art dental offices to provide both preventative and restorative dentistry, as well as all needed specialty services, for both children and adults. ProHEALTH Dental currently operates offices in New York and New Jersey. For more information about ProHEALTH Dental, please visit www.phdental.com. 

About The Harris Poll:

Over the last five decades, Harris Polls have become media staples. With comprehensive experience and precise technique in public opinion polling, along with a proven track record of uncovering consumers’ motivations and behaviors, The Harris Poll has gained strong brand recognition around the world. The Harris Poll offers a diverse portfolio of proprietary client solutions to transform relevant insights into actionable foresight for a wide range of industries including health care, technology, public affairs, energy, telecommunications, financial services, insurance, media, retail, restaurant, and consumer packaged goods.

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ADA Publishes FAQ on COVID-19 Vaccines in the Dental Office

Today, the American Association for Dental, Oral, and Craniofacial Research (AADOCR) was one of 12 oral health care organizations issuing a statement calling on governmental executive, regulatory, and legislative entities to mandate that all oral health care workers, including oral health care students and residents, be vaccinated against COVID-19. The statement recognizes that a small minority of oral health care workers may not be able to be vaccinated due to medical contraindications.

To further clarify, the AADOCR considers any employee of an oral health care facility, such as a dental office, clinic, or academic dental institution, to be a health care worker and recommends COVID-19 vaccination as a condition of employment for their own health and to protect the health of their families, colleagues, and patients seeking oral health care in the facility. AADOCR also strongly recommends COVID-19 vaccination for non-employees of such facilities, including, but not limited to, students, residents, volunteers, part-time clinical faculty, and independent contractors. This position is consistent with a recent consensus statement developed by the Society for Healthcare Epidemiology of America.¹

The Federal and several State governments are also moving in this direction. The U.S. Health and Human Services (HHS) will require more than 25,000 members of its health care workforce to be vaccinated against COVID-19 and the Centers for Medicare & Medicaid Services (CMS) announced an emergency regulation requiring staff COVID-19 vaccinations within CMS-participating nursing homes. The Association of State and Territorial Health Officials (ASTHO) report several states and the District of Columbia have announced COVID-19 vaccine requirements for health care workers and/or for all state employees.

The August 23, 2021 announcement from the Food and Drug Administration granting full approval to the Pfizer-BioNTech COVID-19 vaccine for people 16 and older adds the highest level of support for the safety and efficacy of this vaccine. Full approval of the two other vaccines currently available under emergency use authorization is expected in the coming weeks. President Biden remarked at the time that business leaders and non-profit leaders should require their employees to be vaccinated or to face strict requirements.

“As leaders in health care and research, we must advocate for policies supported by the best available scientific evidence,” said AADOCR President Jacques Nör, University of Michigan, Ann Arbor. “In this case, the COVID-19 vaccine is clearly necessary for the health and safety of oral health care workers and for the health and safety of the patients we serve.”

ABOUT AADOCR

The American Association for Dental, Oral, and Craniofacial Research (AADOCR) is the leading professional community for multidisciplinary scientists who advance dental, oral, and craniofacial research. Previously the American Association for Dental Research, the 3,000-member organization connects the scientific community of professionals who champion research that contributes to overall health and well-being. Learn more at www.aadocr.org.

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