Author: Darren Kaberna

Everyone is very familiar with the notion that your team can either elevate you to where you want to be or sink an organization.  Having a team of “A Players” is critical if you plan on growing your dental practice. 

What are the different types of players on your team?

The A Player

• Understands the expectation of their role
• Shares a similar vision for success
• Consistently accomplishes goals
• Genuinely does a good job

The B Player

• Understands the expectation of their role
• Desires more training for success
• Accomplishes goals
• Wants to do a good job

The C Player

• Understands the expectation of their role
• Not interested in training
• Accomplishes minimal goals
• Doesn’t care to do a good job

If you can work towards having a team of all “A Players” and “B Players” you will see how quickly things can thrive. 

One of the most detrimental things you can do to your practice is…..

• Keep people that do not pull their own weight
• Feel held hostage by team members
• Employ team members that do not care to do a good job
• Continue to employ team members only because they have been there the longest

As a small business owner you have a very important job in making sure that your business is profitable.  When your practice is small and young, it’s very likely that you do not have space to employ people that are not serving the long term mission of your company. 

We hear all the time that it is “hard to fire people” and for many people that do not have experience doing it, we won’t lie, it can be tough. The first step is changing your mindset around the words “firing someone”. 

Can we move into 2020 with the mind set that you are giving them an opportunity to flourish in an environment that serves them better and allowing your company a thrive by building a team that will best serve your goals and mission.

Are you strategizing or 2020 in your dental practice yet? Maybe the better question is, have you planned for the last quarter of the year yet? 

Business owners routinely find themselves working in their business and not necessary working on their business.  With that being said, we’ve provied a framework below that will help in planning appropriately for the last quarter of the year. 

Here are a few things to think about:

• Have you met your goals for the first three quarters of the year yet? 
• How do you plan to make up for any deficiencies in the last three quarters? Scaling?
• Asses the team and their work in 2019 thus far and what establish expectations to finish the year strong? 
• Do you have a forecasted budget for 2020?
• What are your 2020 goals? Farther-more, have you presented them to your team yet? 

If the answer is no to any of these, I would suggest we start talking! 

The first step to pulling all of this together is simply analyzing all of your data thus far for 2019.  You want to get an idea/understanding of the current status of your business goals and if you are on target to meet them. Understanding what needs to happen in the fourth quarter of the year to finish where you wanted to be. 

Every dental office will of course have different goals, but some data to think about could include your net production, collection totals, accounts receivable balances, outstanding Insurance balances, the percent of unscheduled treatment that is on the books or the percent of patient that have been reactivated.  After you have done this you want to analyze and identify where your largest opportunities lie and create a strategic plan for the fourth quarter.  After you have identified what your focus will be make sure that you share the specific goals with your team and track their progress accordingly.

Topical vs. Systemic Fluoride: What Patients Need to Know

By

 Spring Hatfield, RDH

 –

October 29, 2018

A study published online in Environmental Health Perspective on July 20, 2012, written by Anna Choi, a research scientist in the Department of Environmental Health at Harvard, claimed, “Children in high-fluoride areas had significantly lower IQ scores than those who lived in low fluoride areas.”¹ This publication fueled the fire for the anti-fluoride movement.

In March of 2013, another article was published in Environmental Health Perspective questioning the validity of the previously published article. This article stated, “As Choi et al. (2012) pointed out in their conclusion, there is a “possibility of an adverse effect of high fluoride exposure on children’s neurodevelopment.” Such a conclusion can be considered an ecological fallacy, which can easily lead to misinterpretation of the results.”² Naturally, this article did not go viral on social media, in the same manner as the first article.

I believe patients have a right to refuse treatment, such as fluoride. However, I also believe it is important they make an informed decision. The following are the primary things I like to share with patients in regards to fluoride use and in-office fluoride treatments.

Systemic Fluoride

I encourage patients to research the difference between systemic fluoride and topically applied fluoride. Many patients do not realize there is a difference. The mode of action, as well as the delivery of systemic and topical fluoride, are quite different.

Systemic fluoride’s cariostatic effect is attributed to the reduced solubility of the enamel due to the incorporation of fluoride into the enamel minerals during tooth formation.³ Systemic fluoride, also referred to as water fluoridation in the U.S. (other countries use fluoridated salt and milk to help reduce caries risk), is often what patients are thinking of when they are concerned about poisoning and neurotoxicity. What patients fail to realize is fluoride occurs naturally in our environment; exposure can occur through dietary intake and respiration.

Just like any other substance, we are exposed to (oxygen, water, table salt), fluoride can be toxic in certain quantities.⁵ For comparison’s sake, let’s look at fluoride levels in some everyday foods and drinks:

• Black tea: 3-5mg/L = 3-5 ppm of fluoride
• Shellfish: 2-3 mg/L = 2-3 ppm of fluoride
• Wine: 1-2mg/L = 1-2 ppm of fluoride
• Beer: 0.5mg/L = 0.5 ppm of fluoride
• Tap water: 0.25-1mg/L = 0.25-1 ppm of fluoride

These are just a few examples; the USDA has a very comprehensive spreadsheet on their website with more information.^5,6

Any substance can be lethal at a certain dose, even water. A lethal dose of fluoride for a child is 16 mg per 2.2 lbs of body weight and a lethal dose for an adult is 32 mg per 2.2 lbs of body weight. A toxic dose for children and adults is 5 mg per 2.2 lbs of body weight; with a little math, you can see reaching a toxic or lethal dose would be very difficult.⁷ For instance, a child weighing 45 pounds would need to ingest 4 tubes of toothpaste to reach a lethal dose. An adult weighing 150 pounds would need to consume 13 tubes of toothpaste to reach a lethal dose. I would like to add, for acute toxicity, or a lethal dose, the fluoride must be consumed in a relatively short period of time. Most cases of toxic or lethal doses of fluoride occur when a child ingests a large quantity of toothpaste or other over the counter dental products.

Another common concern I hear from patients is the fear of fluorosis. Dental fluorosis is generally associated with chronic fluoride toxicity. Enamel fluorosis and primary dentin fluorosis can only occur when teeth are forming. Therefore, fluoride exposure that contributes to fluorosis occurs during childhood. The severity of fluorosis is directly related to the dose, time, and duration of exposure.^8,9  

It is important to understand fluoride metabolism. Fluoride metabolism includes absorption, distribution, and excretion, where each step depends on the pH. After ingestion, plasma fluoride reaches a peak within 20–60 minutes, followed by a rapid decline as a result of both uptake in calcified tissues and urine excretion. The small intestine also contributes to fluoride absorption in a pH-independent mechanism. Non-absorbed fluoride is excreted in feces.

From plasma, fluoride is distributed to both hard and soft tissues followed by its renal excretion. A minor portion of absorbed fluoride is found in soft tissues through a steady-state distribution between extracellular and intracellular fluids. However, about 50% of the absorbed fluoride is incorporated in calcified tissues, mainly in bone, where 99% of the fluoride content in the body is found.

Fluoride renal excretion is one of the most important mechanisms for the regulation of fluoride levels in the body. About 60% of the daily ingested fluoride is excreted in urine of healthy adults and children. Many factors can modify fluoride metabolism such as chronic or acute acid-base disturbances, hematocrit, altitude, physical activity, circadian rhythm, hormones, nutritional status, diet, and genetic predisposition.¹⁰

Although dental professionals have no control over the amount of systemic fluoride a patient ingests, it is important to understand the mechanism to educate patients better.

Topical Fluoride

The CDC named community water fluoridation one of 10 great public health achievements of the 20^th century.¹¹ However, recent studies have determined that fluoride primarily works after teeth have erupted, which indicate adults also benefit from topical fluoride, rather than only children, as previously assumed.⁴

Applying fluoride gel or varnish containing a high concentration of fluoride to the teeth leaves a temporary layer of calcium-fluoride-like material on the enamel surface. The fluoride in this material is released when the pH drops in the mouth in response to acid production and is then available to remineralize enamel.¹²

A typical application of fluoride varnish requires 0.2-0.5 mL, resulting in total fluoride ion application of approximately 5-11 mg. Proper application technique reduces the possibility a patient will swallow the varnish during its application, and limits the total amount of fluoride swallowed as the varnish wears off the teeth over a period of hours.¹³ To reach a toxic dose of fluoride via topical fluoride varnish, a patient weighing 22 lbs (age 1-2 yrs) would have to ingest the entire dose from 5 varnish applications; the amount needed to cause a toxic dose increases as the weight of the patient increases.

A recent study to assess urinary fluoride excretion after topical application of fluoride varnish in preschool children concluded a single topical fluoride varnish treatment did not significantly increase the urinary fluoride excretion compared with placebo.¹⁴ As mentioned previously, fluoride is metabolized in the kidneys, making urinalysis a highly reliable test for increased fluoride exposure. This study further supports that minimal fluoride is swallowed, during and after, fluoride varnish application.

A survey was conducted to asses caregivers understanding of fluoride varnish. Of the 140 responses, 22.1 percent of the responses indicated lack of knowledge about fluoride varnish, 23.6 percent stated that it was for teeth, 8.6 percent stated it was something in toothpaste or water, and 45.7 percent stated it is something that helps teeth. About 52.7 percent of responses indicated lack of knowledge, incomplete, or incorrect understanding. At the caregiver-level, 50.4 percent did not know what fluoride varnish was or provided an incorrect or incomplete response. This indicates many caregivers have an incomplete or inaccurate understanding of fluoride varnish.¹⁵

Although a lot of attention has been focused on caregiver refusal of vaccines, little attention has highlighted topical fluoride refusal. In the past, it has been reported topical fluoride and vaccine refusal are correlated.¹⁶ Findings indicate that correlations between topical fluoride and vaccine-specific concerns are related to disease severity and internet-based, information-seeking behaviors. The clinical relevance of caregivers’ refusal of preventative care has become a problem which leads to greater disease burden for children and peers, potentially higher cost to the health care system, and preventable suffering.¹⁷ This, clearly, indicates healthcare providers need to educate patients on the benefits of preventive care.

Preventive care has changed medicine and dentistry over the years. We live in a time that many diseases have been eradicated due to preventive care. Though I believe patients and caregivers have the right to refuse preventive treatment, with the proper education and science-based evidence, I can’t imagine why they would. The amount of misinformation available on the internet will always be an obstacle, but preventive care professionals should not let that discourage them from spreading the facts. Not everyone will believe you or trust the science; however, you can rest easy at night knowing you did your part to help patients make informed decisions about their health and the health of their children.

SEE ALSO: Fluoride Varnish Shown to Prevent Dental Caries in Young Children

DON’T MISS: The History of Fluoride and Why It’s So Important

References

1. Anna L Choi, Guifan Sun, Ying Zhang, and Phillippe Grandjean. Develeopmental Fluoride Neurotoxicity: A Systemic Review and Meta-Analysis. Environ Health Perspect. 2012 Oct;120(10):1362-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22820538
2. Siamak Sabour and Zahra Ghorbani. Development Fluoride Neurotoxocity: Clinical Importance versus Statistical Significance. Environ Health Perspect. 2013 Mar; 121(3): a70. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621182/
3. K. Rosin-Grget and I. Lincir Current Concept on the Anticaries Fluoride Mechanism of Action. Coll. Antropol. 25 (2001) 2: 703-712. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11811302
4. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
5. Domen Kanduti, Petra Sterbenk, and Barbara Artnik. Fluoride: A Review on Use and Effects on Health. Mater Sociomed 2016 Apr; 28(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4851520/
6. United States Department of Agriculture. Retrieved from https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/nutrient-data-laboratory/docs/usda-national-fluoride-database-of-selected-beverages-and-foods-release-2-2005/
7. Rizwan Ullah, Muhammad Sohail Zafar, and Nazish Shahani. Potential fluoride toxicity from oral medicaments: A review. Iran J Basic Med Sci. 2017 Aug; 20(8): 841-848. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5651468/
8. Pamela DenBesten and Wu Li. Chronic Fluoride Toxicity: Dental Fluorosis. Monogr Oral Sci. 2011; 22: 81-96. Retrived from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3433161/
9. Peres Buzalaf, Camila & Leite, Aline & Buzalaf, Marília. (2015). Fluoride Metabolism. 54-74. Retrieved from https://www.researchgate.net/publication/283794601_Fluoride_Metabolism
10. 10.Buzalaf MA, and Whitford GM. Fluoride Metabolism. Monogr Oral Sci. 2011; 22:20-36. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21701189
11. 11.Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4850bx.htm
12. 12.Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
13. 13.American Dental Association. Retrieved from https://www.ada.org/en/member-center/oral-health-topics/fluoride-topical-and-systemic-supplements
14. 14.Twetman S, and Stecksen-Blicks C. Urinary Fluoride Excretion after a Single Application of Fluoride Varnish in Preschool Children. Oral Health Prev Dent. 2018; 16(4):351-354. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30175333
15. 15.Chi DL, Richman J, Senturia K, Zahlis E. Caregivers’ understanding of fluoride varnis: implications for Future Clinical Strategies and Research on Preventative Care Decision Making. J Public Health Dent. 2018 Aug 28. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30152869
16. 16.Chi DL. Caregivers who refuse preventive care for their children: the relationship between immunization and topical fluoride refusal. Am J Public Health 2014 Jul; 104(7): 1327-33. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24832428
17. 17.Richard M. Carpiano and Donald L Chi. Parents’ attitudes towards topical fluoride and vaccines for children: Are these distinct or overlapping phenomena? Prev Med Rep. 2018 Jun; 10: 123-128. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5945909/

In dealing with Insurance companies in the dental offices we serve, there is a cycle, if you would. The last blog went into depth about the Dental Patient Revenue Cycle, if you haven’t gotten the chance to read that head on over.

THE STEPS OF THE PROCESS

1. Treatment plan the patient
2. Create an insurance billing document
3. Send the Document, get a response
4. Response is different than proposal
5. Send a patient a statement with the balance
6. Patient is mad they have a balance

WHAT DO YOU DO?

• Collect the balance?
• Adjust the balance?

Your front office person gets in the middle of the mucky water, asking the Doc what to do. Often times, the Doc quickly says, just write it off.

For all of you reading this right now, this may sound awkwardly bold; You can not legally excuse a balance when dealing with insurance IF you discount the patient portion after the insurance has paid. The patient balance is fully theirs to pay. Key here – fully. If adjustments or write offs are done after insurance, this is insurance fraud. 

If this sounds harsh or makes you feel uncomfortable, allow us to be clear. It may be the adage of “everybody does this” and it could be true. We are here to share the rules of the trade. Our intent is for you to understand the responsibility the Doctor has taken to be credentialed to an insurance and to obey by the governing rules. 

WHAT IS RIGHT?

So, what do we do? What is right? The reality of this issue is if you are going to offer a discount to patients attached to insurance, you must do this prior to insurance submission and you must collect the patient portion. You do not have the right to write balances off. 

One way to get around this is to do a service pro bono. This way, there is no insurance involved. Again, to be clear, you can provide free care. You cannot discount patient portions when insurance is involved. 

In numeric terms, discounting insurance can work if done this way. Say the $1000 crown is discounted by you for Suzie before Insurance to $800. Submitted at $800 instead of $1000, the insurance payment of 50% would be $400 not $500 and the same discount to the patient. If this is done prior to filing insurance, this is legal. You must discount the insurance end as well. 

Avoid stripes at all costs! Ask one of our AMP Coaches about this for more information.

Watch Darren Kaberna, AMP CEO go into the in-depth details about the legalities of Patient Courtesy.

https://www.beckersasc.com/pdfs/articles/Ch316896.pdf

https://www.cda.org/news-events/dental-benefits-101-proper-billing-waiving-co-payments

https://www.medicalbillingstudycourse.com/tips/truth-about-waiving-copays/

It can be very eye opening to walk into a dental office, print the dental patient balance totals over 60 days and simply show it to a doctor. This is one area of the practice that is simply easy to maintain and control.

Back to the beginning

How does this get out of control in the first place? Take a look at the Dental Patient Revenue Cycle graphic to the right. This is typically what we see in dental practices when we look at the revenue cycle.

How to control & collect payment

• There is no reason to bill dental insurance companies and balance bill dental patients. This is possibly the easiest way to slip into uncontrollable accounts receivable problems. How do you change this? It is simple, ask patients to pay their anticipated patient due portions at the time of treatment.

• When it comes to courtesies the lines typically become a little more blurry as we all know and understand why doctors need to/want to extend courtesies to certain people. To control this area of your accounts receivable is it possible to put yourself on a “courtesy budget” per month. Also, remember, if you are kind enough to extend a courtesy to someone it is not too much to ask/expect their portion of the payment at the time of service. There are lots of legalities around this topic that as a business owner you need to make sure to understand. To read more about this click this link.

• Address the fact that insurance companies at times do not pay what you expect. Potentially meaning there may be a more out of pocket expense. That is what pre-determinations are for. There are tools that to use that will come close and many times have a clear understanding of what they will pay so you know what to collect.

• The tickle down effect of raising healthcare cost, issues with coverage and more out of pocket expense. We always suggest that this be addressed with patients so they simply have the expectation prior to going into some kinds of treatment.

If you can control these factors in your practice you will see that your accounts receivable will likely be more under control. Now, what do we do about those old balances that are sitting out there and need collected?

Old Balances

The answer may seem simple and there are many different approaches. There are many ways to get your accounts receivable under control. Believe it or not there are also ways to make sure it never gets out of control.

• Expect payment prior to being seen
• Make payment arrangements for patients that need to pay off their balances over a selected time period
• Implement a system of calls/letters to work on collection concerns or you can utilize a third party to assist.

Darren Kaberna describes the entire process in the video below.

Retirement is something we are asked about often in the dental coaching world. How can I get to retirement faster? Am I funding my retirement the way I should be in order to live the way I am now? At what age should I be thinking about retirement?

These are all great questions and the answers depend on you. 

Many people are fearful of retirement because they view it as the end of life or when they have decided to “throw in the towel”. But it doesn’t have to be that way. If we prepare and follow a plan of action on how to get to retirement when and how we want, the opportunity to enjoy life without the hassles of owning a business or being employed will be welcomed with open ar. The following tips can help to get you on the right path. AFTC

Review your current debt and spending habits

• Cut back on current spending patterns
• Evaluate your savings & retirement funds
• Money allocation and what fees are assessed
• Seek assistance from a financial advisor

Know the Social Security and Medicare Milestones

(ADA News 6 Tips for Boomers Preparing for Retirement)

• 62 years – Begin taking social security at reduced payout amount rather than wait until full retirement age
• 65 years – Qualify for Medicare benefits (depending on work history)
• 66 or 67 years (depending on birth year) – Apply for full Social Security retirement benefits.
• 70.5 years – Begin taking required minimum distributions

You can have a long, successful, and productive retirement years before you may have even thought possible, and live longer as a result. Take the time to sit down and evaluate your situation, set boundaries, initiate goals, and stick to your plan. Put your eye on the prize and aim for the retirement everyone dreams of.

There was an article recently posted by the ADA about Lenny Kravitz along with his Manhattan-based dentist, Dr. Jonathan Levine, giving back to his home town on the island Eleuthera in the Bahamas. They arranged annual dental trips to help the people where he was raised by providing dental care to those in need, as there is only one dentist on the entire island.

“Dr. Levine’s GLO Good Foundation teamed up with musician Lenny Kravitz’s Let Love Rule Foundation to bring free dental care to more than 400 Eleuthera locals in 2019.”

Giving back to your community can be very fulfilling, allowing you to make a positive impact, while helping to improve the lives of those in need. Those who take the initiative to give their time to others typically find the leadership itself is very rewarding because it gives them the opportunity to share their passion, values, and inspiration with others. Not to mention, there are studies that prove that volunteering makes people feel physically healthier, keeps chronic health conditions managed, and lowers stress! Giving and being unselfish can actually protect your health and prolong your life. 

What can I do to give back to my community?

-Plan a food or toy drive around the holidays to donate to your local shelter or the Red Cross.

-Offer to donate a year of dental care to family in need.

-Make a donation to a foundation such as Oral Health America.

-Conduct a free “Oral Cancer Screening Day” in your office.

-Donate toothbrushes, toothpaste, and other items to missions’ trips or your local shelter.

Offering to give your services can help you find new opportunities for your own business. It gives you great exposure while allowing you to broaden your social network and discover other organizations in your community. 

Volunteering is a great outlet for meeting others, helping yourself stay healthy, and it just feels good! So why not get out there and give back?

Remember how different the world of communication was fifteen, twenty years ago? Actual conversations were had and screen distractions where limited. It seems that the world has gotten so much smaller with Texting, Instagram, Facebook, Twitter and whatever is coming next. Do we join the rage, or do we hold true to our old methods of communication. Those that proved reliable then.

While technology seems to do everything except slice bread, good old customer service with a smile and kind words still holds a solid place in business. Chick Filet spends a lot of time, effort and energy making sure their employees greet each customer and answer with “it is my pleasure” “Please” and “Thank you”

Just what Grandma Sandy told us growing up.

As stated in a recent article by Business Insider (January 2019):

“While small pleasantries are easy to dismiss in the multi-billion-dollar restaurant business, these little things have played a key role in setting Chick-fil-A apart from the competition.

In 2015, Chick-fil-A generated more revenue per restaurant than any other fast-food chain in the US. The chain’s average sales per restaurant reached nearly $4 million.

Meanwhile, the average KFC sold $1 million in 2015.

Analysts have said that customer service is key to Chick-fil-A’s success. Superior customer service drives higher sales per unit, contributing to the chain’s ability to generate greater revenue than chains such as KFC, Pizza Hut, and Domino’s with more than twice as many US locations.”

Technology does, most certainly have its’ place in business. However, personal attention, being polite, remembering peoples names may be the best way to set you apart from the competition. There are over 200,000 practicing dentists in the United States, a top priority needs to be differentiation. Grandma Sandy taught us many many years ago to “Mind our Manners,” and no matter how our world, or technology changes that still rings true.

Just like Chick-Fil-A, those manners maybe what helps you make your first million!

Call and Thank Grandma Sandy!

Preparing for an interview can be a mission. Having spoken to a handful of doctors that are in the process, they all have the same concern and focus. “Getting it right”.

Below are a few guidelines to developing an interviewing process that are guaranteed to help find the perfect candidate!

Things to Remember

1. Be prepared to discuss the specific job description that you are hiring for
2. Know who you are interviewing by reviewing their resume before the appointment
3. Prepare KEY interview questions prior to the appointment

Examples of GOOD Questions to Ask

When deciding on what questions to ask, make sure to understand why you’re asking those specific questions. This is your process and your practice, so make sure you’re asking questions that are important to you! Not just something you’ve read in a blog, or online.

1. “Describe your perfect job”– Gain insight on if they like a challenge or if they are trying to find the patch of least resistance.
2. “Why did you get into dentistry?” – Doctors may want to ask this to see just how passionate they are about Dentistry. Possibly even discover if they are just looking for another job.
3. “What motivates you?” – Asking open ended questions like this can help doctors learn what drives them. This can be a great tool to use during the mentoring of employees.

Here’s a little trick. Mirror the body language or physical language of the person you are interviewing. Often in the first five minutes, generally you can tell if the candidate that you are interviewing is the right person or not. Aligning the right questions to ask means that you’ll be spending the rest of your time in the interview simply confirming your decision as to if this is the right or the wrong person.

Always remember that someone that has experience interviewing will say things that will stall you if they need time to think about an answer; for example, “That is a really good questions..” or “I am glad you asked that…” With a little practice, interviewing will become second nature.

Just remember, you want someone that can think quickly, answer a wide range of questions and is comfortable talking in front of you.