Impact of the COVID-19 pandemic on oral health care use in the United States through December 2021

The study, Impact of the COVID-19 pandemic on oral health care use in the United States through December 2021, showed that there were significant decreases in preventive dental services that persisted for more than a year, particularly across all age groups under 65. These could reflect, in part, anecdotal reports of loss of employer-sponsored dental benefits, reluctance to seek care due to concerns about COVID-19 exposure, or staff shortages at dental offices. Study authors also found a significant increase in the delivery of night guards to adult patients. This may indicate a rise in stress-related teeth grinding that can crack or fracture teeth.

“This data tells us that, while we’re through the pandemic, we’re just beginning to understand the long-term impacts it could have on the nation’s oral and overall health,” said Joseph Dill, DDS, MBA, chief dental officer, Delta Dental Plans Association and head of dental science, Delta Dental Institute. “The reduction in preventive procedures seen across age groups could lead to an increase in caries or deterioration of periodontal status, particularly for people who require regular preventive and maintenance care. This can exacerbate other health problems, like risk of stroke, high blood pressure, and diabetes.”

Key takeaways from the study include:

• The COVID-19 pandemic has had both direct and indirect effects on oral health care, including prevention, treatments, and procedures.
  • Direct effects on oral health care include the closure of dental practices and ensuing interruption of care. For those requiring regular preventive and maintenance care, these delays could lead to an increase in caries (cavities) or worsening of periodontal disease.
• The decrease in preventive services from pre-pandemic levels raises concerns about long-term health impacts.
  • Reductions in preventive procedure volumes across age groups younger than 65 years may have longer-term effects on oral and overall health.
• There was a significant increase in the number of occlusal night guards delivered to adult patients and an increase in crowns in patients 65 years and older.
  • This likely indicates an increase in stress-related bruxing (teeth grinding), which may also have led to an increase in cracked or fractured teeth in seniors. However, the claims data could not confirm anecdotal reports of an increase in cracked or fractured teeth.

The research assessed the effects of the COVID-19 pandemic on oral health care using national insurance claims data. The research team analyzed claims by quarter from 2017 to 2019 and from July 2020 to December 2021, including 600 million submitted procedure codes.

Delta Dental conducts important research using national dental care claims data to uncover trends in oral health care and to help instruct avenues for intervention.

The study team intends to conduct follow-up research that will explore national oral health claims data from 2022.

About the Delta Dental Institute

The Delta Dental Institute is dedicated to advancing oral health for all Americans in partnership with Delta Dental companies and dedicated partners across the country. With expertise rooted in Delta Dental’s rich history of oral health leadership, we engage in and support oral health research, community outreach, and advocacy, striving to ensure that everyone understands the importance of oral health to overall health and has access to the care they need.

Visit deltadentalinstitute.com for more information.

About Delta Dental Plans Association

Based in Chicago, Illinois, Delta Dental Plans Association is the not-for-profit national association of the 39 independent Delta Dental companies. Through these companies, Delta Dental is the nation’s largest dental benefits provider, covering more than 89 million Americans and offering the country’s largest dental network with approximately 152,000 participating dentists.

Over the last decade, Delta Dental companies and their foundations invested over $1.9 billion to improve the oral and overall health of our communities.

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.

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.

These are interesting times we are living in. Between a global pandemic, the political climate, and major social issues, we have still had to continue keeping our dental practices open, managing staff, and caring for our patients, no small feat, to say the least. I have had the opportunity to work with many dental practices during this time and one of the biggest lessons I have learned is that every single dental practice needs to implement the role of an infection control coordinator (ICC). You are possibly wondering why or, maybe not, since the pandemic has already brought you some awareness as to why you might need one. One thing is for sure, having an ICC in your practice has many benefits, and some might even surprise you. Read on as I share the top 5 reasons why every dental practice needs an ICC and how this role could potentially save you a lot of time and money.

Reason 1. Avoid a “Doctor Down Day”

ICCs have a lot of responsibilities, but the most important one is to manage the infection prevention program. It is no small task as it includes everything from maintaining appropriate regulatory and guidance documents to overseeing clinical equipment maintenance. The latter brings us to the first reason why every dental practice needs an ICC: avoiding a “doctor down day.” Doctor down day is not a common term, but it basically refers to the loss of valuable production time. Pretty much every dental practice has experienced this at least once, and the effect it can have on a patient schedule can be disastrous. Having an ICC oversee equipment maintenance can help avoid issues that could arise from malfunctioning equipment and cause slower workflows and production loss.

Reason 2. Reduce Expenses

As a dental practice owner, it can be a balancing act to deliver quality dentistry and stay within a budget. With the exorbitant costs of dental supplies since the start of the pandemic, now more than ever, it is essential to be able to maintain compliance within a budget. Unfortunately, although supply chains have been restored, it doesn’t look like supply costs are returning to pre-pandemic pricing.

So, what can we do?

The answer: implement an ICC into your practice. This role is responsible for organizing workflows and standard operating procedures that help to reduce expenses and save time. The ICC can streamline protocols such as creating a system that regulates ordering supplies to eliminate overbuying or waste. They can execute protocols that train teams to use supplies more wisely and still maintain compliance. For instance, having clinical team members wear the OSHA-required utility gloves when “turning over” their operatories and reprocessing their contaminated instruments can significantly reduce the number of exam gloves used per patient. With the rising costs of gloves, that one modification can potentially save a dental practice thousands annually.

Reason 3.
Escape Temping Disasters

Since the pandemic, there has been a considerable shortage of clinical team members, and employing guest dental hygienists and dental assistants has been at an all-time high in some areas across the United States. Although having the patient schedule covered can prevent the loss of production, employing temporary team members can be pretty hectic and can double your workload. Sometimes it is a lottery, and you never know who will be arriving that day. Are they a new graduate or a seasoned clinician?

Do they know how to use all of the equipment in your practice? Do they know how to perform infection prevention protocols properly? We often have no idea who will show up, and we hope they at least know how to pick up an instrument. I once heard of a practice that employed a guest hygienist who was not familiar with the type of piezo system the practice used and ended up breaking the equipment, costing the practice owner several thousand dollars in repair costs.

Now think about it from the temporary clinician’s perspective. They walk into the office and have no idea where anything is located, nor do they know your practice protocols. And then what happens? They run late for every appointment, the existing team is frustrated as well as the temporary clinician, and sometimes there are even patient complaints.

Who wants to deal with that when you can implement an ICC to avoid temping disasters. The ICC can create a quick protocol that includes a one-page overview of the practice workflow, locations of supplies, the patient journey, and overall daily operations for the patient schedule. I suggest adding a quick tour to ensure that the temporary clinician is clear how things operate in your practice.

Remember, a lot of these clinicians visit various practices with different protocols. This one addition can help avoid incidents and ensure that compliance is maintained regardless of who is working for you for the day.

Reason 4. Maintain a Strong Infection Control Program

One of the biggest pain points I see when speaking to practice owners about compliance is the fact that it can be overwhelming and confusing. Sometimes it is as simple as not knowing where to start or as complicated as starting from scratch every time there is staff turnover. Having a properly trained ICC who can create and manage an infection control (IC) program strengthens the program’s sustainability regardless of changes among team members.

A strong IC program also enables new hires to be trained effectively in the practice’s infection control protocols and gets them to work more quickly. According to the Brandon Hall Group, a research and analyst firm focused on talent acquisition, a strong onboarding program can “decrease time-to-productivity by up to 70%,”  decreasing the burden of working short-staffed. Lastly, it is essential to have a sustainable program to avoid infection control breaches whenever there is staff turnover.

I have visited many practices where owners are unsure of the IC program status and therefore do not know if the compliance program has been maintained. This can be very detrimental from a risk management standpoint should your practice ever experience an inspection from a legal entity. A strong IC program implemented among the entire team helps prevent breaches when a new team member is hired should he or she be the one taking on the ICC role. 

Reason 5. Differentiate and Get New Patients

Since the pandemic began, patients are now more aware than ever when it comes to infection control. They are asking questions, researching online, and watching us like hawks. With the advent of the internet, patients are more educated, and their dental IQ is much higher. They want to know they are in a sanitary environment and that we are safely delivering dentistry. Having an established and well-organized IC program allows you an opportunity to promote and shine a light on your dental practice.

It offers you a moment to highlight your stringent protocols and the lengths to which you are going to protect your team and patients. One way to share what you are doing is to record a video of all of the infection control protocols being implemented throughout the practice and share it on your website and/or social media channels. This approach could potentially calm the fears of new patients and increase referrals from existing patients. Either way, it is a win-win.

The goal of the ICC role is to create a dental practice that is championing infection prevention. We all have a role in fighting against pathogens and making our workplaces safer.

The pandemic has been dreadful, but the silver lining is we now know better, and when you know better, you do better.

ABOUT THE AUTHOR

Ms. Chance is a registered dental hygienist, certified compliance consultant, and authorized OSHA trainer providing continuing education courses on infection prevention and safety in the workplace environment. She owns Learn2Prevent, LLC, a compliance company that supports dental practices in meeting compliance requirements for OSHA, HIPAA, and infection control, and co-owns Level Up Infection Prevention, LLC, a company that provides resources to ICC roles.

Currently, she serves as a CDC Inspector for the Maryland State Dental Board, Maryland State Dental Association Foundation Board Member, Dentsply/Sirona KOL Infection Prevention Speaker, and a Brand Ambassador for Dimensions of Dental Hygiene.

She can be reached at info@learn2prevent.com.

Disclosure: Ms. Chance reports no disclosures. 

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.

bttn., a HealthTech startup providing a B2B e-commerce platform for purchasing medical supplies, today announced a massive expansion to its product catalog with the addition of 93 PlastCare USA products for dental practitioners. bttn. has seen a dramatic increase in the number of dental practices utilizing its medical supply platform in recent months. The addition of the PlastCare catalog fleshes out bttn.’s dental supply offerings and brings 23 new dental product categories to customers of the rapidly growing e-commerce platform. 

“We are thrilled PlastCare has chosen to offer its products to the bttn. ecosystem.  As a trusted name in dental supplies, the PlastCare vote of confidence assures both our growing customer base and strategic healthcare associations that the bttn. promise — to provide peace of mind to practitioners seeking medical supplies — is one they can believe,” said JT Garwood, CEO and Co-Founder of bttn. “We are adding new suppliers and customers at a rapid pace and feedback from both is incredibly positive.”

PlastCare USA is a family-owned business, founded in Los Angeles, California, and has quickly become one of the leading manufacturers of FDA approved disposable dental supplies in the USA. Its products are researched and developed by dentists for dentists with a focus on utility and reliability in the clinic environment. By establishing long-term relationships with dental professionals, PlastCare’s quality and consistency has made it the preferred wholesale distributor to major dental systems across the country.

“E-Commerce is the major element of the future of medical sales, and we believe that bttn. will be a large part of that future,” said Jason J, PlastCare.  “Like us, they are committed to establishing meaningful, long-term relationships with the members of their ecosystem and back that commitment with a customer experience based on frictionless supply acquisition. We are looking forward to an endearing and mutually beneficial relationship.” 

Tracking Market Dynamics

With a mission to reduce the cost of medical supplies, the bttn. data-rich analytics platform offers customers, strategic partners, and suppliers:

• Insight into buying trends
• Information on potential price surges and supply constraints
• Cost savings

As the COVID-19 pandemic wears on, the bttn. ecosystem is relying on purchasing data, made on www.bttnusa.com, to make strategic purchasing decisions while managing inventory.

About bttn. 

bttn. serves healthcare practitioners by lowering the cost of healthcare. Our platform automates purchasing of medical supplies at direct-from-manufacturer prices. Additionally, bttn. provides market-based data reports to customers to promote market transparency. By streamlining the ordering process, and moving it to an e-commerce platform, bttn. enables customers to save on their medical supply bill while delivering faster than typical medical supply channels. bttn. is headquartered in Seattle, WA, growing rapidly, and hiring. Visit www.bttnusa.com to automate your medical supply today.

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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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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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A new worldwide consumer oral health awareness survey across 15 countries has revealed an amazing snapshot of oral health, habits, concerns and desires across the globe.

In the largest survey of its kind totalling 15,000 respondents, findings range from the countries best at brushing teeth twice a day with fluoride toothpaste, to the top worst dental habits and most common dental issues.

The inaugural 2021 Global Healthy Thinking Report by international oral healthcare company, Sunstar, with brands including GUM, Butler and Ora2, also provides insight into which countries have seen the worst oral health impact during the pandemic, which countries are looking after their teeth best, and those who have the best smile satisfaction.

Worldwide findings include:

Most and least oral health issues – Thailand has the most and worst problems with oral health, just 1 in ten have no problems and just 5% are happy with their teeth. The UK ranked the highest, 40%, for not having any problems with their teeth.

Worst habits you would like to give up – Germany and Spain ranked equally the highest at 27% for smoking as the worst habit harmful to their dental health. 22% of Italians, Indonesians and Brazilians said drinking coffee, tea and staining drinks was their worst habit, while China ranks highest for sweets as their worst habit, 31%.

Most forgetful toothbrushers – Indonesians were the most forgetful at brushing their teeth, 45%, while Brazil ranked next highest at 40%. 33% of Italians, Argentinians and Britons said they never forget to brush their teeth. Germans forget the least, 20%.

Best for cleaning between teeth – China leads the way on cleaning between teeth at 21%, followed by Italy, 20% and Spain 18%. Indonesia ranked the lowest at just 7% for those who use an interdental cleaner, electric airflosser or floss.

Smile satisfaction – People in the Netherlands are the happiest with their teeth, and 18% would not want any cosmetic treatment to improve their smile. While just 5% of Thai, Spanish, Italians and Brazilians said they would not choose one cosmetic smile treatment. The US was one of the lowest, only 7% said they would not want any cosmetic treatment and are happy with their teeth.

Understanding of the mouth/body link – 76% of Argentinians understood smoking affected dental health, while just 39% of Singaporeans understood the mouth/body link.  While the Japanese have the best understanding that dental health can also affect life expectancy, 38%, just 12% of British do.

Which countries reported most bad breath? Asian countries reported bad breath when describing their oral health more commonly than elsewhere in the world, with the worst in Japan, 34%. Brazil reported the least, just 8%. In Europe, bad breath is most common in Italy, 15% and least in the UK, 10%.

Which countries have seen the worst oral health impact during the pandemic? Argentinians have missed the most dental appointments during the pandemic, 44%. Just 12% of Japan have missed dental appointments, the lowest worldwide. Americans said they have experienced more tooth sensitivity during the pandemic, 25%. Indonesians ranked highest, 45%, for choosing to now clean their teeth more regularly as a result, followed by China at 38%.

Comments Martijn Verhulst, Medical Liaison Manager, Sunstar Scientific Affairs, on the survey findings: “We are proud to have conducted this largest survey of its kind to further our knowledge into consumer oral health.

“Positive findings included the numbers of people worldwide who are keeping their mouth healthy and fresh by brushing their teeth twice a day, using fluoride toothpaste and tongue brushing.

“But there did seem to be less understanding globally of the overall mouth/health link and the impact oral health has on your overall well-being, or how habits like smoking can impact your oral health. While this link is better known in Japan, for example at Sunstar we say “100 years mouth, 100 years health”, there does seem to be a need for greater understanding of this connection.

“We strongly advise that consumers get their teeth checked twice a year by a qualified professional to assess their oral health and any dental decay or gum disease. Regular dental checks are also important for identifying any issues early and before they can cause wider harm. A reputable dentist is also likely to spot signs of other medical conditions such as oral cancer or even diabetes if they can monitor your oral health frequently.”

A copy of the 2021 Sunstar Global Healthy Thinking report containing all the survey findings and analysis can be downloaded here https://www.sunstar.com/healthy-thinking-report/oral-survey-2021/

About the Research

15 countries surveyed across Europe, North/South America and Asia comprising;

– UK, Germany, France, Spain, Italy and Netherlands

– US, Mexico, Argentina, Brazil

– Japan, China, Singapore, Thailand and Indonesia

(Nationally representative sample, 1,000 minimum per country, 18-65 age group, equal gender split).

ABOUT SUNSTAR

SUNSTAR is a multinational company headquartered in Switzerland and founded in 1932 in Osaka, Japan. Today, SUNSTAR is a leading global company in the Mouth & Body Care field, a major presence in the Health & Beauty Care and the Environment & Amenity business fields, and a world leader in the Safety Support & High Technology field. In fiscal year 2019, consolidated net sales of the SUNSTAR Group totalled over 1.2 billion Swiss Francs. The products and services of SUNSTAR are distributed in more than 100 countries, and the company has 4000+ employees worldwide. Under the motto “Always strive to help people everywhere achieve better health and enhance their quality of life”, SUNSTAR continuously provides high-value-added products and services all over the world. www.sunstar.com

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