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Articles

Company’s flagship LCD printer re-engineered to be faster, more efficient than ever.

Photocentric’s New Liquid Crystal Magna v.2 Printer Now Available

The Sanders Sisters are back, and this month they're talking all about arthritis! Arthritis affects about 1 in 4 adults, meaning it has far-reaching health implications for millions of people. The sisters discuss how healthcare professionals can intervene.

Read the article mentioned in the episode at: 


Hi, I'm Dr. Elizabeth Sanders, a foot and ankle surgeon and assistant professor at Boston University Medical Center.

Hi, I'm Katrina Sanders. I'm a registered dental hygienist, consultant, international speaker, and wine lover.

I grew up looking up to my big sister Katrina.

And now I look up to my lady boss physician sister Elizabeth.

Together, we are working to unite the dental and medical communities in unique and exciting ways.

Welcome to Floss & Flip-Flops with Sanders sisters, our monthly podcast

where we unpack all things health related from your mouth to your toes.

Hello, everyone, and welcome back to an episode of Floss & Flip-Flops with your favorite ginger sisters, the amazing Dr. Elizabeth Sanders, and me your ginger hygenist. Katrina. How are you today, doc? Are you good?

I'm doing so good. I've had a very productive day. How about you?

You've had a productive day? What is a productive day look like in the world of Dr Sanders?

I mean, today I did just a lot of research and finished an article that I was working on. So I'm pretty happy about that. Yeah.

Good. That's so good. Oh, good! I've just been bopping around you know, keeping myself busy and out of trouble. Because you know me, trouble will find me! So, just been keeping busy all day, which is so great.

I still don't know why you don't have a camera follow you everywhere.

Literally, I don't know, either. I know, I always think about that. Like, why why do I not have like some sort of MTV, E! True Hollywood Story about what's happening in my world? Some of the things I'm like, 'Does this happen to anybody else?' You know? So, it just cracks me up. And so before we dive into this episode, do you remember when we were kids? And you know, it was like maybe like the early 90s. And we all had like a favorite boy band? Right?

You did like Brian, I was more of a Howie D. girl myself. But the reason why I bring up boy bands is because one of my favorite songs from a boy band, NSYNC, is it's gonna be May. And what I mean by that is...

Elizabeth Sanders, DPM 2:39
You're too much!

May is Arthritis Awareness Month. How exciting is that? I know it's such a great journey for us. So today, today's episode is really going to take a look at the ramifications of arthritis, and what we know about arthritis currently. And of course, more than anything, why it's important for us to talk about how it impacts our dental patients, our podiatric patients and how it affects the community in general. So let's just take a look. Because when we have a dialogue about some of these comorbidities, which you're going to start hearing us kind of trickle-down episode by episode and we talk about these comorbidities, it's really important for us to understand why it's so important for us to even have this dialogue. So arthritis, a few things to know, it is a leading cause of disability. For clinicians, you know, we understand that the prevalence of something like arthritis is ebbing and flowing as we're seeing our patients experiencing more and more comorbidities. So not always, but oftentimes we will see that things like rheumatoid arthritis, which I know we're going to deep dive into a bit that we can oftentimes see a lot of these types of modalities move in tandem with some of these comorbidities. Arthritis affects about 1 in 4 adults. So that's about 58 million United States Americans. And about half of these adults report a limit to their everyday activities because of their arthritis. So these are simple things like holding on to your wine glass. I struggle with not because of how much I love wine. But you know, simple things that, you know, oftentimes we take for granted, like being able to hold on to a grocery bag or getting yourself up out of your own seat walking to a chair, for example. And we also know that arthritis can cause catastrophic issues. Individuals with arthritis are nearly twice as likely to experience an injury associated with a fall. Interestingly enough, adults who live in rural areas have about 3x greater affinity or prevalence of arthritis as compared to those who live in a more urban or industrialized area. I don't know,

It's kind of weird. And I think, you know, part of it, as we start to look at some of the risk factors around arthritis that perhaps—and I know, like, we'll talk about gout being a component of arthritis as well—that, you know, diet, exercise, physical activity, sedentary lifestyle, all of these things can be contributory factors. So maybe that's a component of it.

Probably the more sedentary lifestyle in the rural environment. Yeah, for sure.

You know, the costs associated with the management of arthritis are upwards of about $81 billion, just in direct medical costs. And we also know that arthritis is an inflammatory condition. And because of that, this becomes a comorbidity in which our patients do struggle to manage modalities like cardiovascular disease, diabetes, and even obesity. So, about half of adults with heart disease and half of adults with diabetes, have arthritis. That's an incredible statistic, by the way, like, that's incredible data for us to wrap our minds around, right? Like, because I'm putting myself...I'm putting myself in the shoes of a hygienist. I am a hygienist. So, I'm just going to put my shoes on and wear them. But as a hygienist, you know, we do see a lot of people that sit down in our chairs that have cardiovascular disease, have diabetes, or report that they are pre-diabetic, we get a lot of those pre-diabetic patients that come in, and they'll say, "I'm on Metformin for my pre-diabetes}, and it's like, oh, is it pre? Are you like already starting to swing over into activity of diabetes? And to think about half of those individuals have arthritis? You know, how does arthritis typically bubble up? And you know, we'll talk about it. But, you know, these are patients that are complaining about symptomatic issues, you know, and so this is really where we start to look at, are we in the business of healthcare? Or are we in the business of sick care, when we see patients who do have cardiovascular disease or diabetes, perhaps it's, you know, something to consider dental hygienists, preventive specialists out, there, doctors out there to start asking the patients if they are also experiencing sign stages or symptoms of arthritis. So, you know, we know that it's difficult for individuals who have arthritis to be physically active. So, it's one of those things like physical activity that can stave off or push away the risk of arthritis. But then once arthritis comes into play, there's, you know, pain in the joints. You know, there is a fear that if there are advanced amounts of physical activity, there will be additional pain. And of course, there's also a lack of knowledge around what types of physical activity, low impact physical activity, for example, you know, that are going to be optimal. I'll tell you when we talk about physical activity. And we'll get to that in a minute, it's really important for us to support our patients in exploring physical activity that is low impact, but still can provide them with optimal means of keeping themselves healthy because 

 of those who are obese also have arthritis, which is just incredible. So I think as we start to look at the importance of awareness around it, and the role that we have, as preventive specialists in helping patients identify earlier stages of arthritis, or, you know, maybe even hearing some of the symptoms that our patients are describing to us, and, you know, encouraging our patients to, you know, go through evaluation for arthritis is really critical. I want to do a way-back playback, if you don't mind, some hardcore history, if you will. Elizabeth, tell us a little bit about some of the history of arthritis, like where did this come from? What do we know? How has it been managed over the years, etc?

Yeah, it was really interesting. I was doing a little bit of research on arthritis in general. And it's very interesting, what has come to arise to make us diagnose people with different types of arthritis. You really started, I saw some articles on the 19th century where patients, specifically women were diagnosed with or they had basically very swollen hand joints and different deformities to their hands. And back then they didn't really know what it was. And bloodletting was a very interesting way of trying to treat these patients. And it was based on this humoral theory, where people have four key hue morals and basically are liquids throughout our body and basically there's an imbalance of those throughout our body, the four hue morels being blood, black bile, yellow bile, and phlegm.

Sounds like a cocktail. This is what I love about the humoral theory, though, because bloodletting for people who don't know, bloodletting is where you would go to some type of a specialist back in like the, you know, the 1800s or whatever. And they would literally, like, open up a major artery, right? And they would just, like, let you they let you bleed out.

And there are different ways you could either do it through your veins, I guess, or your arteries. Yeah, this is insane.

And yes, and by the way, they would, so they would, they would, you would drain your own blood. And then sometimes they would do infusions or transfusions rather with sheep's blood, like, can you imagine like being like half sheep?

No. I mean, it's almost like a dialysis session. Correct? Like sheep blood. Unbelievable.

Very weird. And do you know who actually did bloodletting by the way? Barbers. Barbers were the ones that did bloodletting. So you know, when you see those, like, white and red bars, like bands outside of a barber shop that indicate like, "Oh, this is a barber shop." That's why the so the red band or the swirly circle thing down.

Exactly yeah, the same one that's at the North Pole. But I think that one's supposed to emulate like a candy cane, not blood. But, yes, that red band indicates the blood. And the white band indicates the gauze that they used to stop the bloodletting when they thought that they had led out enough blood.

It's so weird. But so so interesting that basically are they think that our bodies are not in the correct balance? Because which I mean, it's not all that incorrect to think about. So, you know, that was a very interesting thought process. And they thought that these imbalances of the, of the different humors, were responsible for different physical and even mental ailments. So people Yeah, they would go and say, you know, I'm, I'm ready to get blood let. And then we move on to like 1897 when Bayer first created aspirin, which is basically the first onset, and it's now a very widely used and said to treat arthritic pain, we use it for blood thinners, very widely used, then if we move on to the 1930s. This is when gold injections were highly, highly used.

I love this. Wait, so they took gold and they just injected like gold metal into your body? Is that correct?

But of course, it had, you know, pretty severe side effects and eventually, out of favor. I saw this document from 1948, where the doctors in the Mayo Clinic were treating patients with an extract of the adrenal gland called compound E is very interesting. They documented this woman who was given a certain substance, but then she, it sounds like she had a sort of rheumatoid arthritis. But she was just very, very, very sick, they gave her compound E and she got better within maybe one or two days. But then a week later, just felt really, really sick and had some serious side effects. But that's kind of where we start to look at the idea of treating these patients with steroids. And then now we come to nowadays, and fast forward, fast forward. Now, there's this research article by Northwestern University, which confirms that about 10 minutes a day of brisk walking can actually help prevent arthritis, especially in your knee, hips, ankle or your feet. And that was published in April 2019. I found other documents that say that about two and a half hours, week of good exercise is definitely going to help you as well. So if you think about it, that's maybe 25 minutes a day, very doable for people. So I think that's very important that we understand that and that could be the reason why people who live in more rural areas are more affected. Whereas we in the urban areas, we do tend to walk a little bit more. And you mentioned that you said you know some patients, they know that the more they exercise, they're going to start feeling it afterward. And it's kind of discomforting to know that. But it's very important that we do get people moving.

I love that. And in fact, I'm actually going to challenge everybody listening to this podcast that if you are in a space where you are able to put some earbuds Then, and walk while you're listening to the rest of this episode, whether it's like taking your dog Darby for a "dubs", or a W-A-L-K, okay. Or, if you're able to just like stroll around the block, pour yourself to go a glass of wine and just like see the sights and breathe in the fresh air and soak up some vitamin D. And I would even encourage you, for future episodes, anytime you listen to us walk around, you know, get those blood vessels moving. Because you are going to, of course, prevent arthritic pain in your knee, hip, ankle, or foot. And you're doing your body such good by being able to do that. So I'm going to challenge you to do that. And when you do, by the way, post a selfie of yourself on social media, don't forget to tag our friends at Dental Products Report, tag them and let them know that you're walking around and listening to our episode, I really want to create that sense of awareness in the dental and the medical communities that we are echoing and emulating what we are preaching to our patients. So get moving everybody. And with that, I want to hear from you, Dr. E, about the different types of arthritis. So, you know, arthritis is a very broad term, right. And it's just kind of an umbrella term that talks about inflammatory conditions of joint areas I'm assuming, but walk us through what are some of the major types of arthritis and what differentiates those different types?

Sure, of course, there are, of course, many different types of arthritis. But I'll kind of go over the more common ones. Osteoarthritis is the most common form of arthritis. It, in fact, affects about 32 and a half million Americans. And it's essentially known as a degenerative joint disease, which occurs more frequently in the hands, the hips, and the knees. It's essentially the cartilage of your joints actually breaking down causing pain, stiffness, swelling, and decreased range of motion. Rheumatoid arthritis is a little bit different because it's actually an autoimmune response that your body is essentially attacking itself. It's an inflammatory disease, which, in which the immune system attacks the healthy cells in your body by mistake, and it creates a great deal of inflammation. It's a horrible disease. It affects multiple joints most commonly in the hands, the wrists, the knees, the spine, and the feet is other as well as the lungs, the heart, and the eyes. So don't forget about those things. Rheumatoid arthritis typically is genetic, but environmental factors do play a role. For example, patients' age, sex genetics, if they smoke, early life exposure, or obesity. For me, personally, as a podiatrist, I do see it quite often in the feet and the ankles. Usually, I'll try to manage it conservatively, and if not surgery sometimes is an option. Of course, we have to talk about gout. Gout is an inflammatory condition caused by elevated uric acid in the body. Either your body breaks down pure rains too quickly and creates monosodium urate in excess. Or there's another way which is actually it's actually the most common, where you cannot excrete the monosodium urate. And this creates uric acid that builds up in your joints and your fluids and your tissues. So of course, I'll see it from a podiatrist perspective. I'll see someone coming in with this red hot, swollen, great toe joint and they're like, Man, I can't even you know, even the bedsheets bother me. They have a great deal of pain. People say, "Oh, you just have a bunion. Yeah, and it's no big deal." But really, it probably is a gout attack. I usually start people right off the bat with like a steroid, or an anti-inflammatory. But of course, you still want to talk to the patient about things like diet and life modifications, of course avoiding high purine diets like red meat, seafood, limit your alcohol...

Every time I go on vacation I'm like, "I'm gonna get gout!" Don't they call it the like cruise ship diet?

Yeah, absolutely. No, whatever it is. Yeah. As you get meat and seafood, you get your wine, get your beer or your you know, liquor. Yeah, absolutely. A lot of people come back from vacations get it. And of course, like right, like I said, right off the bat. You do want to make sure you're telling the people about their diet, drink more water, you know, exercise, things like that. I will give them steroids or an anti-inflammatory some, in fact, another really big cause of it, well may lead to it is patients who are chronically on diuretics. So that can, of course, lead to it. Sometimes patients do eventually need to go on medications. But if let's say they present you with an acute gouty attack for the first time, there's no indication or really put them on an Allopurinol or Probenecid or anything like that. Usually, they need to have a few attacks before you actually consider a medication like that. And that's when a referral to a rheumatologist might be indicated. Another one we could talk about is lupus. Lupus is a very difficult condition to treat. And that's where definitely a rheumatologist needs to diagnose you with something like that, or a PCP. It's an autoimmune disease that can affect multiple joints, it can affect your skin, kidneys, blood cells, your brain, and your lungs. In fact, I didn't realize this, but I guess more than 200,000 cases are diagnosed in the United States per year. From what I remember, it's almost a diagnosis of exclusion. It's really difficult to diagnose, you know, but some of these patients, they just look so miserable, you feel so bad. A lot of these patients present with chronic fatigue, joint pain, and rash, especially that rash on the face that butterfly rash. They may get fevers, and patients may get flare-ups every once in a while, but then they tend to improve. Unfortunately, there's no cure for it. But the current treatments are mainly focused on improving the quality of life, lifestyle modifications, sun protection, diet, anti-inflammatory steroids, and disease-modifying anti-rheumatic drugs may help. Another big form of arthritis that we'll talk about juvenile idiopathic arthritis or juvenile rheumatoid arthritis. Very difficult in children, because you know, that's the time of your life when you're supposed to be playing and enjoying and having fun. But it is a very difficult condition, it may cause physical, permanent damage to your joints, there really is no cure. But children may achieve permanent remission actually, by modifying their lifestyle. Symptoms do include joint pain, swelling, fever, stiffness, rash, fatigue, loss of appetite, eye inflammation, and difficulty with daily living activities. So as I was doing a lot of research on arthritis in general, of course, my search always comes to and I want to ask you, What is my favorite condition to do surgery on

Do you remember when you came to a conference of mine, and they were presenting they're like, "This patient came to the emergency room and was diagnosed with nothing." But what do you see on the x-ray? What did you say?

So basically, but it's not a form of arthritis, but it is a form of a terrible deformity. That can affect the foot, the ankle, and the knees. I know it's not necessarily part of this, but it's one of my favorite conditions to treat because it's so there's not much known about it. It's basically an osteoarthropathy Very common in diabetic patients. So on that note, I mean, I know you are a podiatrist. By the way, that was one of the most proud moments I've been at any conference sitting next to you and you diagnosing Charcot that someone else could not diagnose. But they don't know any better. So Katrina, tell me about the oral or the dental implications of arthritis, and what do you see in your dental chair?


Yeah, so you know, it's interesting because in hygiene school, particularly, we are not taught a ton about arthritis index. The main thing that we're really taught about arthritis is that if the patient has osteoarthritis, they may struggle to hold on to a toothbrush, or dexterity manual dexterity is going to be an issue. So for a patient that has arthritic issues or joint inflammatory issues, they're not gonna be able to floss very well. So you're going to prescribe some other inner dental aid and tooth brushing either you know, drilling a little hole into a tennis ball and then inserting a toothbrush into that so that you've got a bigger grip or an electric toothbrush is always ideal, right? Like we love those electric toothbrushes because they really do help. So we were really taught that manual dexterity is our biggest challenge with regards to arthritic patients and that's again specific to our osteoarthritic patients. But now we're starting to unpack quite a bit of information about gout and particularly rheumatoid arthritis. In fact, we're starting to see our perio entities looking at rheumatoid arthritis as a major marker for particularly periodontal disease. So we know that periodontal disease and rheumatoid arthritis share many common risk factors like tobacco status, socioeconomic status, obesity, etc. We know that arthritis and periodontitis both cause destruction of hard and soft tissue, they use very similar pathways around those what we call pro-inflammatory cytokines or those, you know, chemical markers that are released from our mast cells in the state of the inflammatory process, of course, and in both situations, these inflammatory cells will result in gingival, collagen or even bone destruction, you know, so that, of course, creates a lot of that kind of multifaceted or multi-layered relationship, particularly rheumatoid arthritis with it being an autoimmune disorder, but arthritic challenges in general, being inflammatory components and periodontal disease have that association with a higher inflammatory burden. So patients that have arthritis will oftentimes demonstrate higher levels of bleeding upon probing, and higher concentrations of inflammatory cytokines, if you were in a practice that measured that. So that would be like interleukin one tumor necrosis factor-alpha, within that gingival crevicular fluid and then higher concentrations, of course of your good old C reactive proteins. Who doesn't love that, right? So, when we take a look at some of those links back and forth between oral disease and periodontal disease, one of the things that we've found in our research, there's still some inconsistency there. But we have found some details that have indicated that if a patient who has arthritis receives non-surgical periodontal therapy, we have been able to trace a reduction in gingival crevicular, fluid levels of interleukin one, and serum levels of tumor necrosis factor-alpha, which is really important for us, of course, to take a look at, you know, in addition, we're starting to see that host modulation therapies. So any type of anti-inflammatory therapies, something that we are doing from a periodontal standpoint, can also provide some simultaneous mitigation of arthritic challenges as well. So I think that's just a really beautiful segue for us to kind of dive into because I know we're talking about, you know, what are some of the things that we can do to treat arthritis. One of those things being yes, periodontal therapy, because we know is going to certainly drain on the systemic burden of inflammation. But, you know, what are some other things that we can do Doctor Sanders to treat arthritic patients?

We talked about more exercise, and I really liked how you certainly specified the type of exercise as well. So don't be like our brother and go for a marathon. But, but certainly, you know, just walking 25 minutes a day. And getting that moderate exercise in physical therapy can definitely help weight loss to try to take the weight off of your joints, good diet, and I'll kind of talk about a little bit about some things in your diet and supplements that are really helpful for avoiding arthritis. Disease Management. So I saw something too, that disease management education programs can really help patients, although actually only about 10% of adults who are diagnosed with arthritis actually participate in these programs. And actually, adults who are more are more likely to attend if they are recommended by a provider. So that's something that we really can have patients participate in and we can make recommendations. Certainly supportive devices like crutches or a cane, but for example, like me, if I have a patient with ankle arthritis, yeah, I'll give them a brace but they can't be in a brace for the rest of their life. They do still need to get some motion to that ankle. But certainly, those can help you and we talked about different medications that may help as well like anti-inflammatories, although you cannot be on that too long. steroids may be beneficial. But if you're going to be on long-term steroids, I do recommend a referral to rheumatology or endocrinology. And then of course, sometimes surgery is an option and you know, I can certainly talk about the foot and ankle surgery and that's a whole nother topic. And we talked about the different medications and Said's DMARDs or rheumatoid arthritis, lupus, psoriatic arthritis, or any inflammatory diseases, and sometimes biological response modifiers are an option as well.


You know, one thing I want to share when you talk about DMARDs, by the way, so that is a Disease-Modifying Anti-Rheumatic Drug (DMARDs) is what that is for our viewers at home. So, I'm going to in the show notes include an article that I wrote alongside the amazing Dr Mia Geissinger, about RA and periodontal disease, because one of the things that we found, and I can't stress it enough, I just had to wrap it up on the medication side is that we're starting to see a demonstration where patients who have chronic periodontitis demonstrated a significantly less improvement in their arthritis when compared with healthy patients. So it is postulated that although we're putting patients on these medications, again, dental professionals are listening to this think through this. So you've got a patient and they are arthritic, and they are on medications for it. So these are the primary things we ask in a medical history, right? What medications are you on? Oh, okay, so it's controlled. And then you evaluate their gum tissues and they have periodontitis. We know or it is readily postulated in research at this time, that if a patient has inflammation due to periodontitis, that inflammation may actually dampen the effects of the medication therapy. So by us performing active curry Donal therapy, we could theoretically be yielding better results with our patients that are on some of these medications to address this disease process.

Isn't that unbelievably amazing? And that, that alongside you know, any diabetes medications or heart medications are anything that is unbelievable. I just remember reading that article. It was a while ago, and it was a while ago. And by it, I need to read it again. Because it's a great article. I


Thank you. But Mia Geissinger really is just the rock star in that article. She is just a boss babe, which I love. So we talked about medications. But you and I both are on a very similar belief mechanism, that food is really the best medicine food can make you sick. But food can also heal you and we've talked about that quite a bit during our nutrition episode. So yes, we talked about that quite a bit there. But what are some foods that are specific to fighting arthritis that we could theoretically counsel our patients on?

Yeah, I like how you ask that because I really do believe in I know, you do believe we really are what we eat. I think you can manage a lot of things. And it's easy to say, oh, no, I can't afford that. You know, but you can afford your diabetes medications. Sure, for the rest, you know. So it really is important. And we talk last time on our podcast about the anti-inflammatory diet as well. And a lot of these things, the anti-inflammatory foods do also help with fighting arthritis. So we'll just talk about some things. So tart cherries have been known to offer anti-inflammatory and antioxidant benefits. It may also lower your risk of gout flare so that's great. But also other purple fruits like strawberries, raspberries, blueberries, and blackberries. These are all anti-inflammatory superfoods, which are awesome, 

The darker the berry, the sweeter the juice. And also the more anti-inflammatory it is. 

I like that! I mean, what's our favorite thing to share, Katrina, when we go to The Gladly? Our vegetable plate with colorful vegetables like carrots, red or green peppers, squash, sweet potatoes. These all have abundant Vitamin C which can preserve your bone and bone health and protect your cartilage. Of course, seafood like salmon, tuna, and sardines—these are all great because they have omega-three fatty acids which are essential. And soybeans, tofu, and edamame, you know don't I don't mind that. They contain great three fatty acids as well. They're also low in fat and high in protein and fiber which is great. Different oils like extra virgin olive oil, avocados, and things like that. They help lower your cholesterol. Certainly nuts like walnuts, pine nuts, and almonds. They're high in alpha-linoleic acid, which is a type of anti-inflammatory. They also may help lower your cholesterol and relax your blood vessels and reduce your blood pressure. Garlic. We all know that garlic is great.

Great, amazing breath great if you're dating a vampire

Elizabeth Sanders, DPM 34:58
to funny but it really is great for fighting pain, and inflammation. We talk about low-fat dairy products like milk, yogurt, and cheese, these are just packed with calcium and vitamin D which can help with bone strength and assist with calcium absorption. But I like how you mentioned that we do need vitamin D. So make sure you're going outside and getting your sun that can, it can also help with your immune system. If dairy does not really agree with you, like me and Katrina, leafy green veggies like spinach are really gonna help you. Broccoli —love broccoli, it's rich in Vitamins K and C and contains a component called sola 14, which researchers have found that do prevent or slow the progression of osteoarthritis. We know green tea is very good for you because it contains polyphenols and antioxidants to reduce inflammation. Citrus fruits are very helpful because they are rich in vitamin C, which may prevent inflammatory arthritis and maintain healthy joints in arthritis and osteoarthritis. Whole grains like oatmeal, and brown rice, they're excellent sources as well. And then beans like kidney beans, pinto beans, they're great. And they also have excellent sources of protein. They're Richard folic acid, magnesium, iron, zinc, and potassium.


I love that, you know, I think it's it's when we take a look at the nutritional component like this right? One thing to remember when you're talking to a patient, and you're you know, and they're explaining to you about their arthritis is that, although I mean, what an arsenal of foods that you just gave us, right, like what an arsenal foods! Yeah, you know, I like the vast majority of these foods like I would eat a lot of these things myself, just because I love these things. So I must eat a low glycemic index or low-inflammatory diet just in general, right? But not all of our patients are going to love all of these things. So the idea being you want to educate your patient and then offer up to them like, what of these sounds feasible? Because I'm sorry, if we're looking at this, and my patient is like, "I hate seafood, right? I hate salmon. I hate tuna." You know, okay, we need you to still get your linolenic fatty acids, right, your omega threes. So that's what we're talking about. Maybe soybeans, tofu, edamame, and then suggesting something like that? Would you be open to maybe infusing something like this into your diet, and really allowing the patient to be able to guide what their diet looks like, is really critical. Now one other thing, too, that I want to ask you about is and I mentioned him earlier, my 15-year-old pug Beagle mix. Darby has arthritis. He's an old man. So now we need to like I have to lift him up onto the bed and things like that. I'm definitely seeing that decline in his joints. But he does take supplements that have been prescribed to him by his veterinarian. So what types of supplements are going to be optimal for our patients? Or for our little furry friends that have arthritis? Yeah, sure. Pay attention, Darby. Pay attention.

He's there listening, although he can't hear too.


Well. That's right. Yeah, he's not hearing very well, unless you open a stringy cheese packet. And then you can hear that no matter where he is in the house. He hears that.

Selective hearing. Yeah, so I'm always open to trying to suggest to my patients different supplements, especially when they're like, but what about the pain? And it's like, well, I can't just give you narcotics, especially here in Boston, where narcotics is a huge problem, a huge problem. And, you know, I can Yeah, I can give you an anti-inflammatory, but I would really like to try something natural. And some of my patients opt for that. So it's specifically for people with arthritis. I've been suggesting glucosamine and chondroitin. These are actually over the counter. And they actually are components of cartilage. Research on these different supplements has been very mixed, including like why do we mix them and the type of glucosamine that actually should be included. But to be honest with you, most trials are pretty promising. And they even find that the combination of these two supplements together is as effective as an NSAID which is fantastic. We talked about fish, so if you don't like fish, taking fish oil supplements is very helpful. And I tell people it's also very helpful for your nerve health. So my patients with neuropathy, I tell them to take these polyunsaturated omega-three fatty acids found in fish have been found to be anti-inflammatory. And in fact, it's considered to be better in rheumatoid arthritis as opposed to osteoarthritis, probably because of the inflammatory component of rheumatoid arthritis. So this is something that I haven't really had much experience with but something called S-adenosyl-L-methionine (SAMe) is a natural compound in the body that has anti-inflammatory and cartilage protective behaviors as well as pain-relieving effects, which is pretty awesome. It also does have an anti-depressant effect, which I found very interesting. Something I tell all my patients, especially the ones that do not want to take any anti-inflammatory, I tell them to take Tumeric or curcumin, which are the active compounds in the spice of Tumeric. And it's a very powerful anti-inflammatory agent and it blocks the same enzyme actually, as Cox two inhibitors. I swear by it, I should be taking it. But if I take it regularly, I feel like a champion. 

I don't know if you do, but I swear by it. 


Yeah, it just comes incapsulated, doesn't it? 

Yes, it does. it will stain your hand a little bit. But no worries. If it makes you feel great, do it. 


And studies have shown that it is as effective as Motrin, without the GI side effects. One side effect is that it is hard for the body to absorb. So make sure you're taking it along with some source of fat, or I guess with some black pepper, how random you know, just a little Tumeric and little pepper, yummy. And then, of course, we know that several vitamins have you know, have been studied for their effects on arthritis, like Vitamins A, C, E, D, and K. No studies really demonstrate that taking these supplements actually improved arthritis symptoms. But of course, eating a diet rich in these nutrients is just great for your health overall. Vitamins D and K, like we talked about are really important for your bone health and your cartilage, so those are some things that you can even recommend to your patients as well as yourself and your friends and your family. So Katrina, what are some other things that we as healthcare providers can be doing for our patients?


Yeah, so well, a few things. You know, we talked about it, I hate to be the squeaky wheel here as the hygienist who's like, hello, what about us, but really as a health care provider, knowing that oral inflammation which periodontal disease by the way is the second most frequent modifiable inflammatory condition. So we know that periodontal disease, you know, certainly is an inflammatory component that can contribute to, you know, arthritic bouts. One thing that we're starting to see now is the use of the DAS 28. Score. So DAS is the Disease Activity Score, particularly for our RA patients and dental professionals may be asked moving forward to ask the patient what their DAS 28 score is, it's calculated based on the number of joints that they have, there's a 28 version, which is kind of the original DAS 28 score. Now, we're looking at about 44 different joints, but the DAS 28 score looks at the amount of swollen joints, the amount of tender joints, as well as, you know, blood evaluation to look at C reactive protein markers and erythrocyte sedimentation rate. As you know, as components, we do believe that DAS 28 score could give us a lot of information about the perceived inflammation that our patients have. So we may be screening for that that is a vital signs that we will likely be expected to ask our arthritic patients when we talk about counseling our patients after we know this information, and after we've evaluated their level of oral inflammation, encouraging our patients to be physically active, and you absolutely unpacked that. Take a look at things that are low impact. So like I taught water aerobics, in college, water aerobics, swimming, anything in the water is going to be low impact, which is just absolutely wonderful. I also do this activity called Canggu, where you wear these little moon boot things, the boots have a spring in them, and you're jumping on them. Now the springs absorb all of the shock when you're hitting it when you're moving around. So it's actually a low-impact way to be able to work out. But we know that physical activity is really important because we know that it reduces inflammation, period. We know that it's really great for maintaining a healthy weight and then easing the amount of weight that is getting put on those joints. Darby, did you hear that you're going for a "dubs" in a minute. In addition, also, you know knowing what local educational programs you have available. I do believe that sometimes dietary counseling is an opportunity. You know, looking at educational programs, even around referring the patient to a personal trainer, there are stretch labs that allow for stretching. Anything that you can do to continue to create motility and movement in those joints in a comfortable way, is a physical activity for the patient. And asking them about even anxiety or depression, you know, we forget about that with autoimmune disorders specifically, but anxiety and depression, mental health issues are a big challenge. And I mean, you know, you mentioned earlier with the juvenile rheumatoid arthritis, like a little kiddo who gets sore and can't run and play in the snow forts, and jump in the piles of leaves and all those things that kids just love to do that, you know, there can be some additional ramifications associated with that. So, you know, those are all opportunities to consider, you know, when we counsel our patients on not just arthritis, but really any inflammatory condition, or an autoimmune disorder that requires us to be able to step into our power. Well, one thing I like that you do, I think is important. And you said something earlier, that just really struck me, and that was patients will be a lot more compliant. And it was hard for us to even think about, right, because we all are like, okay, but patients are more inclined to be compliant or to move forward with taking certain supplements or whatever, if they are prescribed by a dental professional, a medical professional, somebody who they respect, who's in a white lab coat with a lot of credentials, and alphabet soup after their name, saying this is important for you. And so I think it's this is our opportunity to, you know, be authorities for our patients in this disease process and helping them understand the why.

Now, that's really good, because, you know, you think yourself, Oh, I'm a podiatrist, you know, it's I'm one of many appointments that they have, or I'm a dental hygienist, I'm one of the many appointments that they have. But truthfully, you could be one person that they see in a few months, and they're coming to you with a problem. And now this is your opportunity to talk to them about other things. Sure, um, other things that would really help their health overall. And sometimes they do ask you for things that are going to help you because you're absolutely right. They see someone with a white coat in front of them. And I and I just love that you things that you think are just standard, because we talk about it all the time, but they don't really know. And it's so great. So I really loved this topic now. Yeah, it was kind of done. It was kind of a daunting tap topic at first, right? Arthritis, but very interesting. And I think there are a lot of other things we can unpack with this.


Oh, 100%. And I know that we've got an awesome arsenal for the rest of this year in some incredible topics. So I'm actually super excited about next month's topic, we got a little surprise for everybody. But you'll have to tune in to find out with that little surprise. So with that, thank you for tuning into another episode of floss and flip flops with the sander sisters, produced by Kristin Hohman and brought to you by our friends at Modern Hygenist. Join us next time as we brush up on more oral-systemic content.

Thank you for joining us for another monthly episode of Floss & Flip-Flops with the Sanders sisters.

Thank you for being part of the change we need to see in the medical and dental profession.


Join us next month for another sister-to-sister chat about other unique, interesting, and perhaps provocative and disruptive health topics.

Don't forget to like and subscribe and maybe even leave a fabulous review!

And we'll catch you next month for another episode of Floss & Flip-Flops with the Sanders sisters!

Podcasts

The Sanders Sisters are back, and this month they're talking all about arthritis! 

Floss & Flip-Flops Episode 5: Arthritis 

Weave and Sunbit Partner Up for Buy Now, Pay Layer Option Expansion


Communications platform Weave has announced that it is partnering with buy now, pay later (BNPL) solutions company Sunbit to make BNPL technology more accessible for dental patients, according to a press release from Weave. This partnership will integrate BNPL with Weave’s patient communication platform, letting patients pay for treatment and therapies over time rather than all at once. This is said to alleviate financial burden from the patient, according to Weave’s Chief Product Officer, Branden Neish.

“Collecting payments is one of the most important patient interactions in a small healthcare practice,” said Neish in the press release. “Bringing Weave’s communications platform and Sunbit’s Buy Now, Pay Layer technology together creates a solution that helps practices provide a better patient experience while driving more financing revenue each month.”

Head of Platform Partnership at Sunbit Oded Vakrat, says that payment and financing solutions may encourage patients who have been putting off care.

“Too many patients are delaying dental care, new eyeglasses, or necessary pet surgery because of the upfront cost,” said Vakrat in the press release. “We’re excited to partner with Weave so that practices can focus on delivering top-notch care to more patients who now don’t have to worry about how they’ll pay for it. With Sunbit technology, 90% of patients are approved, and they can split their costs into manageable payments.”

This is a multi-year integration partnership between Sunbit and Weave.

Weave will integrate Sunbit’s Buy Now, Pay Later technology into its dental patient communication platform. 


Weave and Sunbit Partner Up for Buy Now, Pay Layer Option Expansion

Perrin DesPortes is one of the co-founders of Polaris Healthcare Partners. He attended Washington & Lee University for undergrad and earned his MBA from the Darla Moore School of Business at the University of South Carolina. Perrin has over 25 years of experience in the business side of dentistry, having started as a 4th generation family member of Thompson Dental Company, then as a General Manager of 15 yeras with Patterson Dental Supply where he ran 3 different businesses for them. In 2017, he and Diwakar Sinha departed to launch Polaris. Perrin is happily married and has an 8 year-old daughter at home. In his spare time, he is an avid cyclist and tennis player; enjoys cooking and reading; and loves good red wine and strong coffee. 

Creating Sustainable Success in Attracting and Retaining Associates at a Group Dental Practice. Photo courtesy of fizkes/stock.adobe.com. 


Owning and operating a group dental practice brings with it a myriad of challenges, but arguably the greatest centers around associates. Success often means creating and executing a plan to minimize associate turnover. Too many—from enterprise-level dental service organization (DSOs) down to emerging, doctor-founded groups—seem to be a revolving door with dramatic turnover rates.

Where do you even start? Maybe right here…

We’ve all seen the statistics from the American Dental Education Association (ADEA) as well as other agencies. The ADEA research from 2020 states that 82% of dental school seniors graduated carrying an average of almost $305,000 in educational debt. That’s staggering, and probably accounts for the reason that “30% of the graduating seniors plan to join a DSO” (ADA’s HPI), up from 12% only 5 years ago.

 I don’t blame them for not wanting to buy their own practice and add on a significant amount more to their already sizeable debt load.

In my role at Polaris where we help entrepreneurial dentists build and exit successful group practices, I get to work with practices facing these challenges every day, and I can see the pressures facing both new dentists and growing dental practices.

Since 1997 we have added 13 new dental schools and 2020 saw a record of first year enrollments at over 6,300. Couple that with the fact that, for the first time ever, less than half of dentists now own a solo private practice.

The conclusion is inescapable: for those who building group practices, you’re going to have a lot of associates to potentially hire.

Is recruiting one of your top 3 priories, or is it an afterthought until you’re in need? Be honest with yourself.

The best companies—be they corporate America or group dental practices‑—make recruiting a priority. They realize it’s a never-ending process. The goal is to always have more viable candidates than you have openings. Those candidates must come from a variety of sources: referrals from current associates; study clubs and dental societies; the military; dental schools other than the one closest to you; 3rd party advisors; recruiting agencies; social media, etc. How many sources do you have in your network?

To access an exclusive whitepaper and webinar from Polaris Healthcare Partners, 

Young Associates are in high demand, and they know it. The question you must solve is: Why should they choose you?

Most professionals don’t react well to uncertainty, so create clarity for them.

 You pay 30% of collections whereas the other group is offering 35%, but if your first year Associates average $800,000 in collections compared to the other group’s average of $600,000, where will they make more income? Back up your comp plan with take-home income data.

 What happens during their first 12 weeks on the job? Who is their mentor, and what about the skill and experience of their dental support team? Show them how quickly you will integrate them into the team.

 Beyond onboarding, what is your clinical development plan for them over their first 2 to 3 years? Most want to “master their craft,” so lay out what that path looks like in terms of advanced skill development along with timeframes and investment (from both sides). They’re not too far out of school, so think “curriculum” here.

 We all want to be part of a winning team, so share your vision for where you want the business to be in 3 to 5 years, then relate it in terms of how you see them being a part of it.

 Do you really want someone who doesn’t care about your core values? Peter Drucker’s quote, “Culture eats strategy for breakfast,” has never been more true. If it doesn’t matter to you, don’t expect it to matter to them.

 Most dentists are entrepreneurs at heart and they desire to be business owners. They want to have a stake in the future they’re helping create, so you’re at a disadvantage if you don’t have a structure that facilitates them earning in or buying in to your business.

There’s a lot more than just what I’ve outlined above, but the key is that you want them to want to be part of what you’re building. Help them see themselves being a part of it. Make it so they can’t imagine working anywhere else.

If you’re building a group practice, you’re competing against seasoned HR professionals at the top of their game. Verbally walking a candidate through everything about your business, then giving them a copy of the comp plan with an employment contract isn’t going to cut it.

Have everything about your business laid out coherently in a 10+ page presentation that answers the question: Why you? 

Make a PDF of it. Print it with a clear cover and spiral binding. And then give them a copy to take with them, so they can refer back to it (hopefully often). People learn visually and don’t retain nearly as much audibly, so always have something to give them that represents you long after you’re gone. Honestly building this presentation is one of the most fun aspects of my role at Polaris working with clients because it brings to life aspects of their business that are special, but they often take for granted.

I noted earlier how much debt the typical new dentist is carrying and that they probably didn’t want to add more to it by buying their own business. However, that doesn’t mean they don’t want to become an owner. Quite the contrary, they do, and they will, just maybe not with you if you don’t have a way to make that happen.

There are basically 3 ways to crack the associate equity nut: traditional buy-in; earn in through Restricted Stock Units; or earn in through Profits Interest Units.

This is pretty straight-forward. Your business is valued at $10,000,000. You offer me the opportunity to become a 10% partner. I borrow $1,000,000 from a bank to buy in. Depending on the loan covenants on your existing debt, you may not be able to “pocket” that $1,000,000 from my buy in and may have to use those proceeds to pay down existing debt. Also, while I (as the Associate) would personally guarantee the loan, the business would ultimately back-stop it, which could create complications on the overall amount of debt you could borrow for future expansion. Something to think about, depending on how quickly you intend to grow and what your current leverage scenario is. As you can probably imagine, we work with clients frequently on debt recapitalization in an effort to secure more committed growth capital as well as cap table mergers and/or Associate buy ins.

I was the beneficiary of these during my time in Corporate America and they’re quite popular in publicly traded companies. RSUs are “real equity” and not phantom equity. They’re performance based and they have a vesting schedule (“golden handcuffs”).

In a group practice, the concept is that the Associate has a collection goal and for every dollar above that goal, they earn some percentage in company stock. The goal goes up every year, so they can’t “ring the bell and coast.” Every share of stock they earn has a vesting schedule, so it becomes theirs gradually over time (usually 3 to 5 years). If they leave, they forfeit the unvested shares – which is the built-in retention mechanism. The founder ultimately takes dilution, but the increase in the value of the shares should offset any dilutive impact. Think of it this way: Would you rather be the 100% owner of a business valued at $5,000,000 or the 80% owner of a business valued at $10,000,000? There are a lot more details, but you probably get the idea. These models work very well for growing groups with established practices.

Similar to RSUs in terms of a goal and the vesting concept, but arguably better suited to a De Novo model. The goal is more of a threshold of EBITDA and Valuation. Every dollar of value below the goal accrues to the founder, but they split any dollars above the threshold with the Associate. The split percentages are a variable in the model as are the thresholds. Again, a vesting schedule ensures you retain the Associate for the long haul. As with RSUs, there are a lot more details, but hopefully you get the concept.

The overall point here is that in today’s world of associate turnover, you really must have a partnership solution in place. It won’t cure your turnover 100%, but you’ll arguably be able to recruit a higher level of candidate who will work harder and stay longer.

And if you can do that, it’s better for patient care; the continuity of the business; and your sanity. 

Munsen, Bradley. The Changing Dentist Workforce. American Dental Association Health Policy Institute. March, 2022. Accessed May 20, 2022. https://www.ada.org/resources/research/health-policy-institute/dentist-workforce/the-changing-dentist-workforce.

There are myriad ways to bring in and retain associates for group practices, beginning with becoming a better recruiter. 

Creating Sustainable Success in Attracting and Retaining Associates at a Group Dental Practice

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Ormco Announces Sole Distribution of OrthoPulse Gen.2 Medical Device


 has announced that it will be the sole distributor of the OrthoPulse

 generation 2 medical device in the United States. The OrthoPulse device is designed to help patients accelerate orthodontic treatment by using low levels of light energy to stimulate bone and move teeth, according to a press release from Ormco. The second generation OrthoPulse has a variety of improved features over the first generation such as more battery life, a water protectant design for both the charging case and mouthpiece, a more flexible mouthpiece, and an improved mobile application.

“Thanks to the innovative technology of OrthoPulse, my patients can safely and effectively accelerate their orthodontic treatment,” said Ormco customer Dr Jeff Summers in the press release. “OrthoPulse integrates easily into their daily routine, and we are also seeing that it is gentle and comfortable to help reduce pain and discomfort associated with treatment.”

Generation 2 is said to reduce treatment time for braces and clear aligners by up to 50%, and is approved by the United States Food and Drug Administration for all users. Patients can use at home every day for best results. This will be a boon for both patient and practitioner, according to Ormco President Jim McGillivary. 

“Through modification of a patient’s biological response to treatment and hence shortening the orthodontic timeline, patients and doctors find this device invaluable which is why we are so excited to announce that Ormco is the sole U.S. Distributor for the latest version of the already popular OrthoPulse device,” said McGillivary in the press release. “Giving fixed and aligner patients more comfort and significantly lessening treatment time while shortening chair time and increasing predictive outcomes are all important aspects of our core business.”

Ormco will act as the sole U.S. Distributor for the second generation orthodontic treatment accelerating device OrthoPulse. 

Ormco Announces Sole Distribution of OrthoPulse Gen.2 Medical Device 

Lisa Newburger, a master's level social worker supervisor, helps audiences find humor in talking about tough topics. Her "in-your-face" style of presentations and writing will make you smile or just shock you into taking some action. Either way, she is very effective at empowering others to reach their goals and feel better about themselves. Her entertaining workshops are available for national and international audiences. Writing for the dental industry since 2010, she uses an alterego (Diana Directive) to illustrate her points in a sarcastic but effective way. Presentations can be scheduled by contacting Lisa at www.discussdirectives.com/dental.html.

The Sounds of Dentistry. Photo courtesy of DragonImages/stock.adobe.com.


As a patient, what do you hear? Entering the building, people greet me and make a comment about the beautiful weather. I search for the office I am looking for on the board and Security says, “Can I help you?” I know where I am going, so I just thank him and head to the elevators.

The elevators are on the small side and, with COVID-19 looming, I am not comfortable entering a small box with the 2 others waiting. So, I head for the stairs. When the door slams behind me in the stairwell, the echo reverberates up the empty stairwell. I start to question if I should turn around and jump on the elevator, but I am in it this far. I am late, but I can get to the third floor faster by retracing my steps to the elevator.

The challenge is that I am in heels. The "click click" of me moving up the stairs as quickly and safely as I can creates a hollow sound like someone running down an empty hallway in a hospital after hours, but I am determined. My breathing is labored, and I am winded when I get to the third floor. Again, the door is heavy and loud when it slams after me.

I arrive in the office and there is only 1 other patient, or maybe Uber driver, sitting there. The television is humming along with a nature documentary. What is with these offices wanting peaceful non-threatening programs in their waiting rooms? They take my name and ask me to have a seat. I see the Keurig

 coffee machine and watch the other patient make herself coffee. Boy would that taste good right about now. I hear the whirring of the machine and salivate as I watch her nurse her coffee. I tell myself I will grab some on my way out.

I hear, “Lisa” and look around the room. Oh wait, that is me. I really am not a fan of being called my first name unless we are in a conversation. It feels very personal, but that is a bone to pick another day.

I follow the dental assistant into the office and have that awkward moment where she is holding the door open for me. I have no idea which way to go when I walk past her. We do our little dance, and she gets ahead of me and leads me to the room. Thank goodness she did not ask me to get on the scale like other doctor appointments. But who knows…that time may come in dentistry? Ok, I digress.

I hear the crinkle of the paper as the assistant starts to set up the room and instructs me to hang my purse on the hook and climb up on the chair. I hear the drill going in the room next to me. (I hate that sound). There is the hum of low voices as they work on that patient. Unfortunately, I can hear that it is not going as smoothly as they hoped for.

Suddenly, I hear a crash of metal hitting the linoleum floor. Is the patient having a seizure or something? Voices get louder. People come running. I am curious, but figure it is not my place to jump off the chair to gape around the corner. Someone yells “Call 911.” This is all a little too much for me. I just wanted my teeth cleaned.

Now Emergency Medical Services is arriving. You can hear the cart banging against the wall as it is tight in here. Meanwhile, no one has come back in to check to see if the patients like me are ok. Everyone is just standing around frozen in time watching the paramedics.

Things do not sound good. I hear, “Stand back.” The patient’s heart has stopped and needs to be shocked. Then you hear that horrid sound of the defibrillator. I know, it is saving a life, but it is truly a retched sound. Then you hear that the heart is working again. Who would think something like this happens at a dentist office? Well, it did.

I stop my story at this point to ask you: do you ever listen to what is going on in your office? Just sit down in the waiting room or in an empty dental chair and be silent? If you have not, you should try it. We do not realize what patients are hearing. These offices are not soundproof. Most do not even have doors. We need to be aware of the sounds of a dental office. Do what you can to make it a peaceful atmosphere. That is a challenge for all of us!

Sounds are a part of every experience that a patient has a dental practice. Are you doing what you can in your practice to mitigate sound-based stressors? 

The Sounds of Dentistry

Planmeca USA Announces Henry Schein One DDX Integration with Romexis


Planmeca USA has announced its Romexis®software will be integrated with Henry Schein One’s web service, Digital Dental Exchange (DDX®). Romexis is a diagnosis and treatment planning open software platform, containing patient data modules such as videos, PDFS, and 2D/3D images in a central database.

Now, with this integration into DDX, clinicians can create new cases using the Romexis-populated patient information, and more easily send this information to labs in a quick and secure manner, according to a press release from Planmeca.

“With DDX’s easy-to-use interface and integrated workflow, we make it easy for practitioners to manage the creation of correct scan-to-patient-to-treatment plans. This frees up time to provide quality care for patients,” said Mike Baird, CEO, Henry Schein One. “Because DDX is an interoperative network that connects with other digital dentistry technologies, it simplifies the clinical workflow among dentists, labs, and specialists.”

Dentists and orthodontists using Reveal® clear aligners from Henry Schein Orthodontics can utilize Romexis to demonstrate potential clear aligner case results to orthodontic patients. Case progress can be tracked through this integration.

This integration will connect practitioner and lab with a robust software solution.

Planmeca USA will integrate its Romexis software with the Digital Dental Exchange from Henry Schein One to better connect dental practices to dental labs. 

Planmeca USA Announces Henry Schein One DDX Integration with Romexis

Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.

What We Know Now about Infection Control in the Dental Practice. Photo courtesy of Yakobchuk Olena/stock.adobe.com.


Like it or not, science is a moving target. As we learn more about the world – and as more things happen to us, like a pandemic – processes and protocols necessarily change. That is certainly the case with infection control in dentistry.

For instance, most dentists used to practice “wet-fingered dentistry”, meaning that they didn’t wear gloves while treating patients. That all changed in the mid-1980s with the HIV epidemic. Wearing gloves became standard practice to protect oneself (and patients) from the spread of bloodborne disease. Because of this new threat, healthcare professionals took a closer look at their daily practices and reevaluated protection.

But it isn’t just epidemics and pandemics that have spurred change.

Infection control, for the most part, is static. That is, things don’t tend to change unless something big happens, but that doesn’t mean that they never change.

“I think the general principles stay relatively constant,” Douglas Risk, DDS, says. Dr Risk is the Compliance Manager and private practitioner at Tidewater Dental in Southern Maryland, serves on the Executive Board of Directors for the Organization for Safety, Asepsis, and Prevention, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists. “In other words, we have the 2003 dental guidelines from the Centers for Disease Control (CDC), and those still have a lot of merit. We’re not going to change a lot of that information, because it was well researched and is still valid. But between now and the last almost 19 years, we’ve taken the guidelines that we wrote and then we’ve applied them to different situations where we’ve made a concerted effort to categorize a situation, according to the guidelines or the Spaulding Classification or to the type of desired outcome that we want, thereby refining the proper protocol in those situations.”

One of the things that has changed is patient awareness, requiring team members to be able to discuss infection control with lay people.

“Infection control has come such to the forefront and patients have become very savvy,” infection prevention consultant Katherine Schrubbe, RDH, BS, MEd, PhD says. “Patients are asking a lot of questions. They ask, ‘Do you have HEPA filters? And do you throw those items away or do you reuse them?’ So, I believe infection control, in general, has become more important to both patients and teams.”

For all the infection prevention measures that seem to be added, Dr Risk observes that the bigger changes seem to be in the things that the dental industry should no longer do.

“Some things that used to be commonplace should have been discontinued a while ago,” Dr Risk says. “For instance, wiping down instruments that go in the mouth. That’s really something that we should not be doing. Be it impression trays, anything that’s single use, or anything you can’t throw in a sterilizer. You can’t wipe it off and use it again. You must realize that that’s a single use for a single patient and you can’t try 1 on and then go over and clean it, disinfect it, and use it on somebody else. Another area is cold sterilization. There are so many issues with the glutaraldehyde and even the safe solutions. We really should not be using any kind of cold sterilization processes anymore, because they’re just not reliable and they’re dangerous for the environment. There are very few instruments that require cold sterilization, that don’t have an alternative that either can be sterilized or are disposable.”

Other practices that have evolved, Dr Risk observes, include:

Sterilization of all components of handpieces and motors is required now.

Standard precautions have expanded according to the CDC into 7 different areas — it used to be focused on personal protective equipment (PPE) and Occupational Safety and Health Administration (OSHA).

Semi-critical tissues, such as mucous membranes, are taken much more seriously than previously. The CDC recommends instruments that touch mucous membranes in dentistry be sterilized and aseptically prepared for use.

Decontamination and sterilization instructions may be different for different instruments, and the directions for use should include what procedures are required.

Infection control takes training and continuous updating, just like the CDC guidelines that are continuously updated e.g., HICPAC guidelines for Disinfection and Sterilization in Health Care Facilities, 2008, updated May 2019

In December 2021, the World Health Organization (WHO) deemed COVID-19 an airborne transmissible virus, which has led to more focus and attention on ventilation systems and the third level of National Institute for Occupational Safety and Health’s (NIOSH) Hierarchy of Controls – Engineering Controls.

“General workplace ventilation in our practices is important,” Dr Schrubbe says. “It’s really not something that’s been a topic of discussion in dental practices very much, but now OSHA has a document titled, COVID-19 Guidance on Ventilation in the Workplace. It applies to all workplaces and there is guidance related to your HVAC system – is it working efficiently?’ Is your practice using high filtration, MERV-13 filters? We know that if there is effective air movement, it is part of our mitigation strategies to reduce the risk of acquiring the virus.”

“With the COVID-19 introduction, now we’ve got this airborne battle that we’re fighting,” Dr Risk adds. “And so, you’ve tweaked it from, ‘Yes, PPE is important.’ And then you go and say, ‘Well, PPE isn’t that effective, so let’s go back and look at the Hierarchy of Controls.’ Are there situations that we can actually eliminate and not be exposed at all to this situation? Are there ways to mitigate the exposure? Using a rubber dam reduces the amount of exposure to oral fluids and that becomes safer. And then you go through the line: Are there situations where, yes, this situation would be okay to be exposed, but this situation’s not. And so, we put in our engineering controls.”

As public health threats present themselves, dental practices have responded in ways that, in retrospect, should always have been in place. One such strategy is to screen patients before they are seen.

“The funny thing was that we decided, back in 2003 or so, that we should be taking information and data from patients and applying that to a risk assessment as to whether they are a carrier of disease. That kind of fell by the wayside. And then it’s back, with COVID and, then it falls off by the wayside again,” Dr Risk adds. “So, yes, there are things that we see from COVID that should be 100% all the time. We should always be asking patients, have they traveled to a region of the world that is highly endemic for a certain disease, like tuberculosis or anything like that. Then checking for symptoms and then using the appropriate protocols to mitigate any risks to the staff. We did the same thing with the H1N1 outbreak in 2009. We said everybody should be asked whether they’re sick or not at the front desk. Taking temperatures at the front desk is never a bad idea, but there’s a lot of offices and a lot of places that say, ‘We no longer have to do that, because the immediate threat is over with.’ Or people – whether they’re sick or not – will tell us, but is that really true?”

The silver lining of public health threats seems to be more laser-sharp focus on infection prevention.

“COVID drove dental to do a better screening for respiratory illness, but COVID isn’t going to be the last respiratory virus or strange thing or novel thing that we probably have to deal with,” Dr Schrubbe observes. “And although levels are down, the infectivity of the virus is still high. It’s not going to go away. And the question is always, ‘What’s next?’ It’s a good thing that we continue in dentistry, because regardless of the respiratory agent we’re dealing with, we aerosolize viruses and bacteria, and we have a potential for high risk.”

Will that screening continue even after dental practices are given the all-clear from COVID-19?

“Based on what we’ve learned, it would be a good thing if we continue that in dentistry,” Dr Schrubbe says. “Whatever the guidance comes out with in the future, many practices have been doing it now for a couple years. Why should we stop that? It’s such a great screening device to make sure that for the providers and the other patients that might be in the reception area, we going to continue to offer people protection.”

Certainly, COVID-19 has caused dental practices to reevaluate their protective measures. However, infection control is a constantly evolving field, whether there’s a pandemic or not.

Taking a look at infection control’s continual evolution as we navigate future potential global health events. 

What We Know Now about Infection Control in the Dental Practice

Parkell has introduced its new Predicta® Bioactive Cement, which is designed to fill and seal microgaps with hydroxyapatite formation at the margin. This is said to prevent microleakage, which is otherwise associated with recurrent decay, according to a press release from the company.

By combining all the properties and performance benefits of premium universal resin cements with bioactivity, Predicta Bioactive is said to offer a cement that gives crown margins protection against secondary caries. It is a self-adhesive, self-etching, dual-cure resin cement indicated for luting crowns, bridges, inlays, onlays, and posts (prefabricated metal/non-metal/fiber posts). It is said to offer outstanding bond strengths across a full range of indications, including zirconia, without the need for printers. It also contains MDP for strong bonds to zirconia.

Predicta Bioactive Cement is formulated to provide optimal viscosity and consistency for easy handling and easy cleanup. It is highly radiopaque and has a low film thickness for complete seating of restorations with no post-op sensitivity. It is currently available in translucent and A2 shades.

The new Predicta Bioactive Cement is designed to fill and seal microgaps.