New whitening and fluoride treatment products from oral health developer OrVance® are described as the first to leverage clear retainers and aligner trays as an effective delivery device. The company says the 2 products were developed with the support of orthodontic and dental practices and are designed to provide the most effective, most convenient, and best value options for the growing population in clear retainers and aligner treatment.

Both of these OrVance products are formulated to provide safe and effective treatment with clear retainer and aligner trays, which already provide a custom fit and are worn with regularity.

The OrVance Whitening Treatment offers 10 applications per package and will be available to orthodontic and dental practices and to consumers from major online retailers. The company says there are plans to launch with brick and mortar retailers next year. The OrVance Fluoride Treatment will initially be sold primarily to orthodontic and dental practices and provides 3 applications formulated to strengthen tooth enamel and reduce sensitivity.

The 2 new products support OrVance’s goal of improving the orthodontic patient experience and to provide solutions to support longer-term compliance for smile retention. Clear aligner treatment is an attractive long-term growth segment driven by not only the growth of orthodontic treatment but also the improvement of longer-term compliance to retainers after treatment, according to the company. Whitening solutions during and after orthodontic treatment is the perfect time to introduce a long-term whitening option, says OrVance, and during the development of the OrVance Fluoride Treatment, company colleagues strongly agreed that a more convenient and cost-effective fluoride delivery system within orthodontics is also an important innovation to retain/strengthen tooth enamel and reduce sensitivity during and after treatment.

Articles

Two products developed with the support of orthodontists and dentists designed to be cost-effective options for the growing population in clear retainers and aligner treatment.

New Whitening, Fluoride Products Will Leverage Clear Retainers, Aligner Trays As Delivery Methods

Dr. Lorne Lavine, founder and president of The Digital Dentist, has more than 30 years invested in the dental and dental technology fields. A graduate of USC, he earned his DMD from Boston University and completed his residency at the Eastman Dental Center in Rochester, N.Y. He received his specialty training at the University of Washington and went into private practice in Vermont until moving to California in 2002 to establish TDD, a company that focuses on the specialized technological and HIPAA needs of the dental community. He can be reached at drlavine@thedigitaldentists.com or 866-204-3398.

The last 3 articles have focused on cybersecurity best practices. Although Health Insurance Portability and Accountability Act (HIPAA) compliance is still a critical issue for many offices, in recent years I have been emphasizing the need for dental practices to up their cybersecurity game. The biggest threat to dental offices is ransomware, the class of viruses that lock your files and demand you pay a ransom to get the unlock key. A ransomware infection would be devastating to most offices. Not only would you have days of downtime and have to pay a large sum of money to (hopefully) get your data back, but a ransomware infection is considered a breach and you would have to report it to your patients and the US Department of Health & Human Services.

Previous articles looked at ways to keep ransomware out of your network or to minimize damage by encrypting the data. In this article, I want to again examine the best way to recover from a ransomware attack without paying the ransom: having a solid backup and disaster recovery system.

If a patient goes to 10 dental offices, they will likely get 10 different treatment plans. If you ask information technology (IT) providers to recommend a good, HIPAA-compliant backup system, you are going to get different opinions. Below is the system that I have developed over 21 years of providing this service for our clients. It consists of 2 main components:

1. In almost all cases, your local backup will be the first line of defense. 

It resides in your office and will allow for the speediest recovery. The challenge for many dental offices is that although they may have thought through the process of backing up data, they have not planned for how to quickly recover the information. Many practices just back up the data, but this is a mistake. If your server goes down and you need to be up and running, what do you do? It would often require getting another server into the office (they are not sold at the local Best Buy), reinstalling all your program files, reconfiguring the network, then downloading the backed-up data to the new server. This is at best a 1- or 2-day process, likely longer. What I recommend is taking an “image” of the server, basically a snapshot of the entire server: data, programs, network settings, everything. Put that image on a local device and virtualize it. Now, if your server goes down, you fire up that virtual copy of the server and within minutes, not days, the rest of the computers will think the server is up and running again; you will be able to pull up the practice management system data, take x-rays, etc, while the main server is being repaired.

2. Notice I said almost all cases use the local backup to recover. You are going to need an offsite backup as well. 

There are, however, instances where that is not true: fire, flood, theft, anything that destroys the server and the local backup. You are going to need an offsite backup as well. This also happens to be a HIPAA requirement. In the past, many practices used external hard drives; they are inexpensive and easy to run. However, I recommend a cloud backup instead—the more you can minimize hands-on management of your backup by you and your staff, the better. Although there are some cheap options, you tend to get what you pay for. Many are not HIPAA compliant, do not offer monitoring and alerts to backup problems, or cannot get you the data quickly.

While many dentists do have the ability to do backups, when you consider how important they are, I usually suggest that you have an IT professional specializing in health care handle this for you.

Part 4 of our Cybersecurity Series looks at how backup data can save money and your practice’s reputation. 


Ransom Recovery

Ian McNickle leads WEO Media’s sales, marketing, consulting, and business development teams (

). He brings more than 20 years’ combined experience in technology, business development, sales, marketing, and operations. He lectures extensively throughout North America on all aspects of dental marketing and practice growth at dental conferences, study clubs, and continuing education events. In 2019, Ian published his first book, 

Mastering Practice Growth: The Definitive Guide for Growing Your Dental Practice or Dental Group

. In addition, he writes articles on a wide range of marketing and growth-related topics for publications such as 

Dental Economics, The Progressive Dentist

Cory Roletto leads the operations team at WEO Media, an award-winning dental marketing and web development agency (

). He brings more than 20 years’ combined experience in technology, business consulting, marketing, and operations. Cory began his career at Intel, where he served as a key member of the competitive marketing team. He received 12 awards at the divisional level or higher while at Intel and many of his engineering and marketing innovations are still used at Intel today. Cory has a BS in chemical engineering and an MBA from the University of Washington.

What is Google’s Mobile First Initiative?

Mobile First is a multiyear series of ranking algorithm changes to shift focus from desktop computers to mobile devices. For the past 5 years the volume of search on mobile devices has exceeded desktop traffic, so this move does make sense. The final transition is called Mobile First Indexing, which will be completed in March 2021. This will complete the transition from desktop to mobile algorithms.

Desktop Algorithm > Desktop Algorithm & Mobile Algorithm > Mobile Algorithm (March 2021)

At the highest level, Google’s intent is 2-fold:

Google split mobile and desktop search into 2 algorithms in 2016. This rewarded those who spent time to customize the user experience on desktop and mobile separately. Although good in theory, it took significant effort to maintain. Consolidating to 1 algorithm is less work.

With mobile search volume exceeding desktop, and the desire to move to 1 algorithm, shifting to the mobile algorithm made the most sense.

This is a departure from past algorithm changes, which primarily focused on improving user experience. Mobile First indexing is more about efficiency and reduced complexity for Google’s operations.

Website design technology and code change significantly about every 2 years, with much of it driven by screen size and resolution of devices as well as Google’s agenda.

Since April 21, 2015, when Google introduced “Mobile Friendly” tests into its algorithm,

 dedicated mobile websites have proven the best for user experience and conversion.

 They were concise, easier to navigate, quicker, and more readily provided information a person searching on a mobile device desired.

Google’s Mobile First initiative is massive. It is a total reversal from the original preference for dedicated mobile sites. Website designers and SEO agencies will need to ensure their sites do not fall into irrelevance by meeting Google’s mobile expectations.

According to Google, by March 2021 its algorithm will only consider content on the mobile website for ranking. It will ignore any content that only shows up on the desktop version of a website.

 However, content is still king, so the more unique content on a website the better. Gone are the days of being more concise or customizing content for a better mobile experience. Now you need to show everything on mobile.

If you have a fully responsive website with no customization for mobile visitors, then you will probably be fine. If there has been customization on your website, you may need to remove media calls that exclude content on mobile versus desktop and confirm the website still formats correctly.

If you have a dedicated mobile website, you probably will need to rebuild the entire website as soon as possible. If you have a desktop-only website, then it will be completely dropped from Google’s index.

 So if you care about being found in a Google search, you will need to build a new website as early as possible.

If you do not know the details of your mobile website, ask your website designer or SEO agency. Hopefully they have already contacted you about making sure your site is ready for Google’s search update. Any high quality website designer should be well-prepared for this change, just as they should have been prepared for the launch of the original Google mobile algorithm and then made the adjustment to responsive sites in recent years. Time is of the essence if changes need to be made, especially if you need to move away from a dedicated mobile or desktop only website.

Makino T, Phan D. Rolling out the mobile-friendly update. 

https://developers.google.com/search/blog/2015/04/rolling-out-mobile-friendly-update

Responsive web design, dedicated mobile site or mobile app—how to choose? 

https://www.digivate.com/blog/mobile/responsive-web-design-dedicated-mobile-site-or-mobile-app/

Montti R. Google Mobile First Index—zero desktop content March 2021. 

https://www.searchenginejournal.com/google-mobile-index-news-from-pubcon-virtual-2020/384111/

Starting in March, Google search rankings will index websites based on their appearance and performance on mobile devices.

Is Your Website Ready for Google’s Mobile First Initiative?

Bruce Bryen is a certified public accountant with over 45 years of experience and is a part of Baratz & Associates CPAs. He specializes in deferred compensation, such as retirement planning design; income and estate tax planning; determination of the proper organizational business structure; asset protection and structuring loan packages for presentation to financial institutions. He is experienced in providing litigation support services to dentists with Valuation and Expert Witness testimony in matrimonial and partnership dispute cases. He is also a financial writer for several dental journals. You may contact him at 609-502-0691 or at 

There are many states where their legislatures have passed laws that prohibit anyone not licensed as a professional dentist to be able to own a dental practice either directly or indirectly. The dental service organization (DSO) organizational structure typically has a licensed dentist or dentists owning and operating the clinical side of the DSO.

The management service side of the DSO may or may not have licensed dentists owning that part of it but may also have hedge funds, venture capital firms, investment bankers or other private investors within the ownership group. Sometimes the DSO employs 2 company structures so that the clinical side and the management side of the DSO are separate businesses.

The struggle for the DSO is to convince the state board of dentistry where they want to operate that their structure is legitimate with non-licensed dentists being part of the organization and they comply with the law. There is an incredible amount of money involved for the DSO in the short and long term where inevitably, an initial public offering may take place. The founders and early investors will earn an enormous amount of money when the final transition occurs, and they can “cash out.” One can be sure that the best attorneys and expert advisors will be retained by the DSO to present their case to the state board of dental examiners. They will attempt to convince the state board to allow their organizational structure to be acceptable. The designs and models used by these experts will attempt to circumvent what they see as glitches that may vary from the actual terminology in the legislative act of the state that may be denying access to the DSO.

What Are Some of the Problems and Potential Solutions?


There may be a myriad of problems potentially with some solutions but the basic rule is that the state boards of dentistry resisting the DSOs do not want non-licensed dentists to be owners. To overcome this problem, some of the DSOs will appoint a licensed dentist to be the owner with compensation and effectively offer that dentist a minimal role in the operations just so that he or she is designated as the owner. In an attempt to circumvent the specific guidelines of the legislative act, the model used by many of the DSOs is similar.

The DSOs want their MBAs and monied people to run the organization. The problem for the DSO occurs when the state does not want it this way and is willing to go to court to keep the DSO out. The state may feel as if the DSO has unlimited money to go to court and to stay in court until they prevail with a judge who may be willing to listen to business verbiage that legally overrides the law’s intent. The DSO will attempt to use a factual presentation that does comply with the law but not the intent of the statute. The attorneys representing the board of dentistry probably have a budgeted amount to spend and also a time frame to resolve the issues and to keep the DSO out of the state. Unfortunately for the state, the DSO will probably continue returning to it even if they incur losses in court until they eventually do win or the state’s dentists push their board to accept the DSO concept. The individual dentists may join after a marketing campaign by the DSO targeting them and describing their earnings potential. They may urge their board to allow the DSO to join the state and the state may feel that they will eventually lose the battle to keep them out anyway.


The typical dentist’s biggest source of aggravation is the management side of the practice. When they see that administration and management are mostly dispensed with by employing the DSO concept, many states see their dentists fall in line and start supporting the DSO. They then pressure their state legislature to adopt amendments to the current law so that by using certain guideline models, the DSO can operate in the state previously trying to keep them out. As mostly offered in any type of debate, it’s almost always about the money. DSOs are big business. Once the wining and dining of the local dentists begins, there is not much a state government can do to stop them. The attorneys and experts hired by the states will use the law as it is written to delay the DSOs from coming into the state. When the amendments take place to the legislative acts, the state’s attorneys don’t have that power on their side to support the previous arguments that were used successfully to retain the individual local concepts of dentistry and big business then takes over.

Reasons for Acceptance by the State and the Local Dentists of the DSO


Because the DSO concept offers excellent current income and no management headaches, the individual dentist sees a great invitation to continuing his or her career and working where the patient is, rather than with the attorney, accountant and other administrative advisors. The model includes a great exit strategy built into the organization and a transition agreement without the worry of finding a buyer. It isn’t long before the state concedes and the dentist practices dentistry and not economics and personnel management by joining the DSO.


Regulatory difficulties can create obstacles for DSOs when attempting to get access to operate in certain states.

Dentists Need to Be Aware of State Regulations When It Comes to DSOs

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.

We all want it. We all need it. And many feel like we never have enough of it. For most of us, that is SO true. I know this, because of you. My articles about money issues … asking for a raise … literally get the most hits. Why? Because this is how we are wired. This is what we think about. There is no shame in that, right? So, let us talk about it.

Is it the elephant in the room? When you were a little kid, did you know how much things cost? How much was the rent? How much did your family spend on groceries? When I was growing up, no one EVER talked about money. One of the rare times we ate in a restaurant, my dad refused to let us see the bill. Why? I know it costs money to go out to eat. But what is the big secret? It makes me wonder how we teach our kids about how much things cost. Why not have your kids figure out the tip and show them the bill? This can be a teachable moment on many levels.

What does this have to do with the dental office? Most employees working in a dental office have no idea what it costs to run the practice. They know how much procedures cost but do not have the total picture. I just spent $170 for 15 minutes with a TMJ specialist. He is booked up for months and yet, there are no other patients in his office when I am there. Yet, his 3 employees are hard at work. He has payroll, benefits, rent, insurance, equipment, and the list goes on and on.

For some of us who are not paid so well, the money boggles our minds. We see the dentist driving a nice car and living in an affluent community. You need to remember that the dentist is taking all the risk. She/he may have big debt from dental school tuition or large loans that seeded their practice. Unfortunately, there is a real tension in a practice between the haves (dentists, dental hygienists, etc.…) and the have-nots (front office staff, dental assistants, etc...) Do not get me wrong. I am not taking sides. I am just pointing out that sometimes, a low paid employee resents seeing others have financial success. (Oh, come on…this is not the first time you have heard of this.)

I am pointing out that there can be underlying tension in a practice … and it is over money. In a perfect world, we want our employees to be able to speak honestly about problems that are going on. But do we really want to hear it? There is a difference in education and services that different employees provide. I am not a big fan of upselling and the financial incentive of that for an employee. When you incentivize someone to sell more, it makes me wonder who is going to benefit. Will it be the patient? Or the employee and practice?

Last month, a friend shared how she had gone to a corporate dental practice as she had a gap in her mouth and was unhappy with how it looked. When she asked about braces, it was recommended that she have 6 healthy teeth removed instead. They would make her a bridge and quoted a price of $16,000. This stressed her terribly before she approached me. When I heard her story, I sent her to a dentist to evaluate her. His recommendation was to send her to an orthodontist and felt repulsed that a recommendation had been given to remove healthy teeth.

This is a danger of upselling. When you incentivize employees this way, it can be morally and ethically wrong. This patient did not need 6 healthy teeth removed. She needed someone to evaluate her and make recommendations without taking advantage of her. I share this story to have you think about the patient when it comes to upselling. We are not asking if you want “Fries with your burger.” We are talking about someone’s health and well-being.

Address the elephant in the room. Get comfortable talking about money and expenses. I am not telling you to share what your salary is with your staff. But, I am saying address the concerns. Let them know that you know what is important to them. That is money.

 if you have witnessed issues of upselling in your office that make you uncomfortable. I also like to hear the success stories that make you proud of where you work.

Is money the elephant in your room? It’s important to talk dollars, incentives and the risks of upselling with your staff.

Money and Upselling in the Dental Practice

Lorin Berland, DDS, was an internationally acclaimed cosmetic dentist and one of the most published clinical dentistry authors. With well over 100 articles, the best-selling Lorin Library Smile Style Guide as well as instructional videos, Dr Berland has made a lasting impact on dental education. He was the 1st Fellow of the AACD, included in the Top 100 CE Leaders for 19 consecutive years, and was recognized by the AACD for "Outstanding Contributions to the Arts & Science of Cosmetic Dentistry."

Dr Berland pioneered the Dental Spa concept and the multi-specialty group practice. He has been featured in 20/20, Time, Town & Country, Reader's Digest, and GQ. He began his career as a denture technician. After more than 35 years of listening to patients, he retired to start Dr. B Dental Solutions with a full line of products specifically designed to treat the common yet serious issues affecting the daily lives of people with oral appliances—Oral Infections and Dry Mouth—which are not addressed by major brands.

I come from a long line of denture wearers, so denture patients have always been important to me. That is why I started as a denture tech before becoming a dentist.

Dentures are more than just replacing teeth. It’s life-changing dentistry. But while so much has improved in home care for people with teeth, not much has improved for denture wearers. That is why I spent the last 20 years developing Dr. B Dental Solutions—to take proper care of dental prosthetics and appliances, as well as the people who wear them.

But most dentists were skeptical about the future of dentures. They said future generations will have no need for dentures. Fluoridation, better home care, and more dentists will make the edentulous and terminally edentulous extinct. Boy, were they wrong! Now, many of those same dentists are advertising “cosmetic dentures!”

Why? There are many reasons. We live in an aging society. It has been estimated that there are more than 40 million Americans wearing dentures. Ten thousand Americans turn 65 every day. Twenty five percent of Americans 65 & older do not have any natural teeth. There will be over 48 million Americans over 65 by 2050.

Accidents and trauma, systemic health problems, diseases, bad habits, diet, drug abuse, and medications all contribute to tooth loss. And some unfortunate people simply inherit bad teeth.

Not only is the number of denture wearers growing, but first-time denture wearers are getting younger. Why? Because even with our masks on, social media is driving the demand for cosmetic dentistry. While some people may not be able to afford veneers, fixed bridgework, or implants, they absolutely cannot afford missing teeth or a jacked-up smile. They can't get a job, let alone get a date! Let’s not forget, dentures were the original cosmetic dentistry. And what's old is new again.

Further, as much as we hate to admit it, people are afraid of the dentist. And during these turbulent times, patients may choose to avoid dentistry until it’s too late. In the future, even more teeth may need to be removed. In some cultures, dentures are considered a normal part of aging. Coupled with an uncertain economy, partial and full dentures will become even more popular.

To prove my point, recently there has been a proliferation of Facebook groups devoted to denture wearers—Dating With Dentures, Dentures at a Young Age, 

 Denture Support: We Are Here to Help-Before & After, are just some examples. And these sites, already followed by tens of thousands of followers, are growing exponentially.

If there's one thing I've learned in my over 40 years in dentistry, it's that denture-wearers come from all walks of life. You just don't know about it because they don't talk about it. And why should they?

Since I started Dr. B Dental Solutions 2 years ago, probably because we are the only denture care company created/developed by a dentist, we have been besieged with questions from customers regarding their dental treatment. They want to know how to take care of their health as well as their new teeth. They want to know all about their different treatment options—specifically dentures, partial dentures, overdentures, and fixed hybrids. And most of all, they want to know where they can find a dentist they can trust. That is why I created 

Dentistry has made significant advances in bone grafting, implants, and fixed hybrids. But so has removable prosthetics. Due to advances in technology and skyrocketing patient demand, we are entering the “Renaissance of Removable Dental Prosthetics”.

Even though dentistry has seen drastic changes due to the coronavirus disease 2019 (COVID-19) pandemic, the future of dentistry is brighter than ever. The demand for dentures, partial dentures, implants, overdentures, and fixed hybrids is expected to grow. Thankfully, digital dentistry and subsequent stronger materials are transforming full arch prosthodontics. In addition, we now have the ability to store data, reproduce, duplicate, and even improve on our restorations.

Below is a list of the benefits of digital dentures for both dentists and the denture wearing public.

The teeth can be completely customized. Unlike conventional denture teeth, which are prefabricated in pre-existing sizes and shapes, digital denture teeth are designed on a computer. This enables the dental professional to personalize every new smile.

The data for identical dentures are always kept on file, making duplicate dentures a reality. No more emergencies and patients left with no teeth.

Digital dentures are stronger and less porous than conventional dentures. This reduces the possibility of lost teeth and/or fractured dentures.

Facial Digital Integration is now possible to achieve enhanced esthetics and acceptance.

Digital Dentures can be incorporated onto implants for improved overdentures and fixed hybrids.

The color and shape of the teeth can be modified without affecting the fit, and without starting over.

CAD/CAM computing technology is extremely precise, resulting in a tighter fit.

Digital dentures have a much faster turn-around time.

As a dentist, I know there is a tremendous lack of non-biased factual information available for people to learn about all the options regarding replacing missing teeth. Unfortunately, there is a lot of misinformation on the internet. I wanted to change all that. That is why I developed DentureWearers.com. It is a resource designed to create an educational, informative, interactive, and helpful website for both the public and the dental community.

Removable prosthetics can be either final restorations or long-term transitionals. It is up to the patient. Now, more than ever, dentists need to listen to their patients. Different circumstances demand different treatment. And these are unprecedented times. The key to success is adaptation. Dentists who understand this will succeed. And there is so much satisfaction in restoring a person’s smile, confidence and dignity.

Dr. B Dental Solutions designed to care for dental prosthetics and appliances, as well as the people who wear them.

Dental Industry Veteran Shifts Focus to Denture Wearers

Clinician’s Choice has introduced 2 new products to their restorative line. A.S.A.P.® Dailies and the True™ Dental Dam are designed to offer clinicians an effective tool to increase efficiency and clinical outcomes.

A.S.A.P. Dailies is a polishing system that is designed for multiple uses in a single day and is said to deliver consistent performance after a minimum of 3 sterilization cycles. It’s designed to give clinicians fast, efficient, and effective polishing. A.S.A.P. Dailies is designed with diamond, which creates a high luster on almost any restorative materials, including composite, zirconia, and lithium disilicate. This is meant to remove the need for an inventory of multiple polishing systems for different substrates and eliminates the need for polishing paste.

Clinician’s Choice has also released True Dental Dam for the clinical infection control protocols. True Dental Dam is a medium gauge dental dam that is designed to fit, seal, and isolate for better clinical outcomes. Available in latex or latex-free, this dental dam is designed for exceptional durability and tear-resistance. The damn can reportedly be stretched, punched, and placed, and is designed to easily glide through contacts. True Dental Dam is available in dark blue and purple colors that are said to provide greater color contrast with dentition.

“We believe our knowledge of dentistry, dental procedures, leading education, and development of innovative product solutions will consistently help our clients achieve clinical excellence for their patients,” said Peter Jordan, CEO of Clinician’s Choice. “These new products help dentists overcome daily clinical challenges.”

For more information about A.S.A.P. Dailies and True Dental Dam, visit 

The True Dental Dam and A.S.A.P. Dailies are said to offer dentists efficiency and improved clinical outcomes.

Clinican's Choice adds polishing system, dental dam to restorative line

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.

When the coronavirus 2019 (COVID-19) pandemic first broke out last spring, practices scrambled to find adequate personal protective equipment (PPE). The Occupational Health and Safety Administration (OSHA) eased some of its PPE requirements to alleviate the burden on the strained supply chain.

However, OSHA still had to strictly enforce its PPE guidelines for the safety of medical professionals and patients across the country. In fact, in September 2020 the administration 

cited Georgetown Dental, LLC in Georgetown, Massachusetts

 for violating respiratory protection—with 6 serious and 1 other-than-serious violation.

But even 1 year into the pandemic, PPE problems still persist. How much PPE is needed? Is anything new necessary? What’s in short supply and where can you go to get it?

As important as PPE is, it’s easy to forget that it is not meant to be the sole source of protection for dental healthcare personnel (DHCP). The National Institute for Occupational Safety and Health (NIOSH), the research arm of the Centers for Disease Control and Protection (CDC), advises a series of risk mitigation levels, with PPE being the last line of defense. NIOSH’s Hierarchy of Controls are:

“Even before COVID, the Hierarchy of Controls is something that you can implement, no matter what the occupational threat,” says Karen Daw, “The OSHA Lady”, speaker and consultant. “It moves you through a series of controls. You would have applied that to bloodborne pathogens. Now, you’d apply it to bloodborne pathogens and COVID, and for the next virus that might make it to us.”

PPE is at the bottom of the Hierarchy of Controls, not because it’s ineffective, but because it’s the least effective safety measure against bloodborne threats, Daw explains, since the Hierarchy was compiled pre-COVID when bloodborne pathogens were a greater focus. Employers should start with a hazard assessment, which is a method of identifying which hazards exist in the workplace, Daw says. Then, the Hierarchy of Controls should be implemented to determine the best method of removing that hazard. 

Prior to the COVID-19 pandemic, facemasks, scrub jackets, and eye protection were common elements of PPE, Daw says. But the coronavirus has changed not only the type of protection used, but the quantity practices must have on-hand.

“As far as quantity before the pandemic, it wasn’t uncommon for practices to have a couple of week’s worth in the closet, because it can take up a lot of precious real estate, depending on the size of the practice,” she says.

There’s no doubt that the pandemic has forced the healthcare industry to overhaul its infection control methods. For the dental industry, no infection control issue has been bigger than aerosols. The SARS-CoV-2 virus is transmitted in aerosols, and maybe even lighter, less moist airborne particles, says Jackie Dorst, RDH, BS, an infection prevention consultant and speaker.

“That’s where airborne contamination has become a greater concern for PPE than pre-pandemic patient contact,” she says. “With aerosol/airborne disease transmission, we looked at, how much filtration do we get from the different levels of masks and how can we provide greater protection from those aerosols that are created with aerosol-generating procedures, such as when the doctor uses a high-speed handpiece with water; the dental hygienist uses an ultrasonic scaler with water going through it to cool and to flush the debris away. Water flowing through the device magnifies and increases the number of aerosols that the team could be exposed to during direct patient care.”

A year ago, there was so much unknown about this novel virus and how it is passed person-to-person, how contagious it is, and how to mitigate its transmission. Dental practices and other healthcare facilities had to rely on the CDC’s evolving guidelines. 

“Dental professionals have to consider CDC interim guidance during the pandemic,” Dorst says. “And OSHA’s interim guidance during this airborne disease pandemic requires dental professionals to look closely at the different levels of masks. For a surgical, also called a procedural mask, which doesn’t seal tightly around the nose and the mouth, the filtration, and the fluid resistance determines whether if the mask is a level one, a level two, or – the highest level – level three that is going to give the greatest filtration.”

To help determine how much PPE a practice needs, CDC offers its 

. It is a spreadsheet-based model that will help healthcare facilities plan and optimize the use of PPE for a response to COVID-19.

Because SARS-CoV-2 is spread through aerosols, more focus has been placed on masks and respirators.

“The difference between a mask and a respirator is that the respirator seals completely around the nose and mouth,” Dorst says. “Inhaled and exhaled air must come through the filtering membrane. A procedure mask has gaps around the nose and on the sides where the pleated folds may gap. If you breathe out, air escapes all around that mask. If you breathe in, air enters all around that mask. All air is filtered when wearing an N95 respirator, because of the seal. Air must come through the filtering membrane and, therefore, provides greater protection to the wearer for preventing disease transmission. The big PPE difference, prior to the pandemic, was that very few dental professionals had ever worn an N95 respirator.”

It isn’t as simple as stocking a supply of N95 masks. They must be fit tested to ensure that DHCP is adequately protected.

“When an employee is required to wear an N95 respirator, they must pass a medical evaluation. Medical evaluations can be done online in a confidential manner. It should also be completed before the fittest,” Canham adds. “Passing a medical evaluation and fit testing is mandatory. OSHA requires this before an employee is given an N95 respirator to wear.

“The common mistake that I see with people who are wearing an N95,” she continues, “is that they’re not performing the seal check each and every time they don their N95 respirators.”

Seal checks aren’t hard to perform, they just necessitate proper training.

“Another OSHA requirement is that employees must be trained properly on the donning, seal check, and doffing protocols. Canham says. “And there are some fabulous 2- and 3-minute videos on YouTube or the CDCs website.”

Fit testing isn’t something that practices need to hire a consultant to perform in-person. One of Canham’s services is a respirator fit testing tool kit for practices. It is available on her 

“You don’t have to spend, hundreds of dollars on fit testing,” Canham says. “Anybody can do fit testing, as long as they learn how to do it.”

Because of the pandemic, practices may run into shortages. Last year, masks and respirators seemed to be in high demand. This year, gloves are hard to come by.

“For PPE, the supply chain for gowns and masks has been replenished, and those are pretty readily available,” Dorst says. “Respirators in the supply chain was getting refilled. And toward the end of December in 2020, we were seeing that they were still expensive, but they were available. Surgical masks are available. Disposable gowns are available.”

“It’s interesting to see where the shortages occur,” Daw observes. “Initially, it was gowns, and that’s because nobody ever really considered isolation gowns in the dental setting. And now we’re able to find disposable and reusable gowns. That’s not an issue. Then we saw a shortage of disinfecting wipes. Now, people are saying that they’re unable to get their preferred brand of gloves.”

So where can practices turn if they find themselves in short supply of PPE?

“I don’t have a magic cure for that,” Canham says. “I do recommend that dental practices continue to work with their dental supply dealers and document their efforts. Documentation shows the attempt they made to get their PPE, who they called, what date they called, and the result of the call. It is my experience that when OSHA comes knocking, they want to see the documentation of the practice’s effort to obtain PPE.”

In some cases, dental health care workers may have to extend use or use limited reuse strategies for N95s. The CDC website has recommendations on how to do this.

Daw recommends opening accounts with several different companies, reaching out to professional organizations, or even posting on a Facebook Group like her “Dental OSHA and Infection Control” page.

“Sometimes a professional organization can help not only with obtaining, but also distributing PPE. Posting questions related to what you’re experiencing, and then see how other people are managing it, too, will help multiple practices” Daw says. “We’ll get through this. It’s just nice to know that you can turn to your team or even people from all over the country that are part of your tribe. These are the people who you can count on to help you resolve whatever challenges you are facing.”

The National Institute for Occupational Safety ad Health's Hierarchy of Controls offers good guidance on how to remove safety hazards from the practice and how to handle hazards should they appear.

How Much PPE is Enough?

Videos

Dental practice coach Mike Massotto joins Editorial Director Noah Levine to discuss challenges faced in the dental practice and how to solve them. In this episode, Mike provides advice on keeping the team in sync when presenting treatment to patients.

30 Minutes of Therapy – Episode 3

Post-operative sensitivity from composite restorations is a complication most clinicians would like to avoid. Unfortunately, it happens a lot more often than most dentists and patients would like. Common causes exist for post-operative in composite restorations. Here are a few of them and how you can avoid them in your restorations.

, post-operative sensitivity is more likely in complex restorative procedures, like those that require etching of enamel and dentine or that need acidic adhesive monomers. Moreover, the pain patients feel is caused by dentinal fluid movement stimulating the nerves in the tubules, which causes the mechanoreceptors near the dental pulp's outer surface to react. The authors of the 2018 review article suggest that the remaining dentine thickness, the tubule diameters and the sealing of them, and the tooth's overall pulp status may cause the sensitivity. They also categorize the technique factors that contribute to post-operative sensitivity in the general areas of:

Cavity preparation that damages dental tissues

The type of adhesive system you use, self-etch vs. total-etch

Not utilizing a desensitizer on the dentine surface

Incomplete polymerization of the material because of curing

The use of improper technique when placing materials into the cavity

Post-operative sensitivity occurs in up to 50% of composite restorations, per some studies, and is especially prevalent in posterior teeth and Class II restorations, but not limited to them. Post-operative sensitivity could have various causes. 

Per The International Research Journal of Dentistry

, post-operative sensitivity results from the interaction between:

Dentists can't do anything about the tooth's health (at this point, anyway) or the restorative materials' makeup. However, clinicians can refine their technique, and this is where the most significant opportunity to prevent post-operative sensitivity lies.

Some of the Most Common Causes of Post -Operative Sensitivity

Tim Bizga, DDS, FAGD, a private practice dentist outside of Cleveland, Ohio, and lecturer for the dental industry, says that dental material science has reached a point where most post-operative sensitivity comes from operator error and things that clinicians overlook. The updates to the materials and the advances in science have resulted in excellent materials that address the potential for post-operative sensitivity. However, if a doctor rushes the process or doesn't understand what the materials can do, it can lead to problems after restoration.

"There are knowledge gaps regarding materials and which ones to choose," Dr. Bizga says.

White fillings with bonding involved have the most sensitivity post-operatively, Dr. Bizga says. In his experience, Dr. Bizga resolved the issues by reviewing his technique and comparing it to thought leaders in the industry, particularly Mark Latta, DMD, MS, and associate dean of Research at Creighton University School of Dentistry, who lectures on bonding. Dr. Bizga identifies the following causes of post-operative sensitivity and how he solves it in his technique.

 Over-etching is a cause of sensitivity. When you leave the etching agent on the tooth too long, Dr. Bizga explains that the bonding agent physically can't penetrate the depth dentists etched the tooth and creates a demineralization zone.

 "We have changed our opinion on how we etch," Dr. Bizga says. "People need to pay attention to what the current thoughts are on etch time."

For example, you can etch on enamel for 10-20 seconds, Dr. Bizga says. However, living tissue has different needs than enamel. When etching living tissue, like the dentin, he thinks it would be best not to etch it for longer than five to eight seconds.

 Dr. Bizga identified another common problem as not removing the solvents in the drying step. If they are still present upon curing, solvents can cause sensitivity.

 Dr. Bizga says to ensure the solvent is completely evaporated before curing.

Dr. Bizga says that one of the leading causes of post-operative sensitivity is under curing. Under curing can happen for several reasons, including not knowing the length of time to cure the materials with the curing light or the distance you should hold it from the material when curing, or not curing to the depth of the preparation, among others.

 Dr. Bizga thinks paying closer attention to the details when curing is essential to avoiding post-operative sensitivity. In everything from maintaining the curing light regularly to re-reading the manufacturer's instructions, you should be vigilant about the details in curing materials.

"And if it's a deeper prep, you should cure the material longer than is even on the manufacturer's instructions because they do those in ideal conditions, and the mouth is anything but," Dr. Bizga says.

If you over-dry the tooth in the etch and rinse step, then the bonding agent cannot work correctly, Dr. Bizga says.

To avoid drying the dentin too much, review the instructions on the materials, Dr. Bizga says.
"If you read the instructions, many of them call for or recommend a moist-bonding technique," Dr. Bizga says.

These are the four most common clinician-technique-based mistakes that can cause post-operative sensitivity in bonded restorations that everyone who is doing bonding needs to be continuously aware of, Dr. Bizga says. However, there is one more that is less commonly thought of but may cause sensitivity too.

When bonding, Dr. Bizga says, everything must be as close to ideal conditions as you can manage. Your working field needs to be free of saliva, blood, and crevicular fluids, if possible.

Dr. Bizga recommends using a rubber dam or an isolation device, like a Zyris product (Isolite®, Isodry®, or Isovac®) or DryShield®.

Many other areas contribute to post-operative sensitivity, which includes pathology. Secondary caries, cracks from bruxism or other forces, and gum recession can cause sensitivity after restorative work. Also, if you aren't using a composite or glass ionomer for restorative work, there can be sensitivity with metal restorations, like gold. In those cases, Dr. Bizga likes to use desensitizing agents underneath the restoration.

"There are some unbelievable desensitizers you can put down before you do your cementation protocol that can really mitigate it," Dr. Bizga says.

How to Improve Technique to Avoid Post-Operative Sensitivity

If Dr. Bizga had one piece of advice in terms of avoiding post-operative sensitivity for bonded restorations, it would be to re-read the manufacturers' instructions for your particular bonding agent. It's a simple action, but one that could make a significant difference in your restoration outcomes.

"Just read them," Dr. Bizga says. "It's amazing how you think you are using the material the way they ask you to, but you aren't. Understanding the nuances of the bonding agent/system that you are using is important."

Following a review of the materials' particular instructions, Dr. Bizga would also advise reviewing your process and protocols mentally before you do it. Dr. Bizga visualizes going through each step before placing a restoration.

"I like to presume before I ever do a procedure that I've already done it in my head," Dr. Bizga says of his mental run-through. "It's good to revisit those steps."

Sensitivity is the sign that there is a problem somewhere, Dr. Bizga says. If you are having issues with your restorations and patients complain about sensitivity, it's likely something you are missing in your technique that can be corrected and resolved. Having made these mistakes before and addressing them for himself, Dr. Bizga recommends reviewing the five areas he mentioned to see if there is anything that stands out as an opportunity for adjustments in your technique.

"A lot of the materials are forgiving, so if you still having problems, it's got to be something that you're missing. A lot of times, it is curing or lack thereof. With curing, it is easy to become lackadaisical and cut corners," Dr. Bizga says, adding that when he trained his assistant to cure that he told her to "cure it like it was her mom in the chair."

Trying to do it right the first time and put yourself out of business is a good mindset, Dr. Bizga says. He approaches restorations as if he is building them to last and never revisit them.

"I'm doing it right now, so hopefully I won’t have to do it again," Dr. Bizga says.

Sabbagh J, Fahd JC, Mcconnell. Post-operative sensitivity and posterior composite resin restorations: A review. Dental Update. March 2018. Accessed February 11, 2021. researchgate.net. https://www.researchgate.net/publication/323763472_Post-operative_sensitivity_and_posterior_composite_resin_restorations_A_review

Porto I. Post-operative sensitivity on direct resin composite restorations: Clinical practice guidelines. International Research Journal of Dentistry. 2012. Accessed February 9, 2021. 

Post-operative sensitivity is something all dental professionals want to avoid. We take a closer look at some common causes for post-operative sensitivity—and what you can do to prevent them. 

Causes and Solutions for Post-Operative Sensitivity

Throughout 2020, nothing was more eagerly awaited than the COVID-19 vaccine. The vaccine, it was thought, would be the steppingstone to ending the pandemic and society returning to normal. But now that it is finally here, what does the vaccine’s rollout mean for dental practice infection prevention?

The Advisory Committee on Immunization Practices (ACIP) provides advice and guidance to the Director of the CDC regarding use of vaccines and related agents for control of vaccine-preventable diseases in the civilian population of the United States, recommending the COVID-19 vaccine to healthcare workers in its first rollout phase.

“They warn about the flu virus, measles, mumps, rubella—they have recommendations for them,” 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 OSAP, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists. “The ACIP has the best interest of the providers and the patients in mind. If they are saying that healthcare providers should get the vaccine, then yeah. Healthcare providers should get the vaccine.”


Healthcare professionals have a particular need for the COVID-19 vaccination, especially dental healthcare personnel (DHCP).

“The microbiologist side of me, and everything that I have read on the research and the data that I have seen, tells us that we have to get the vaccination to get ahead of infections, especially these emerging variants,” infection prevention consultant and speaker Jackie Dorst, RDH, BS, says. “It's almost as if we're in a race to get the population vaccinated, and get to that goal of 70 to 80 percent to provide us with herd protection so that we can get ahead of this virus and reopen our society and get back to being able to hug each other.

“Dental healthcare professionals are right there on the forefront of exposure with all of the aerosols that we create,” she continues. “The patient has to be unmasked for us to treat them. You can't treat a patient in the oral cavity without them being unmasked. Unlike going to the dermatologist or going to the general physician, where patients can still wear their mask the entire appointment. Dental patients can't. The patient has to take off their mask for us to care for them. It’s so very important that we get vaccinated. The other important thing is that after you are vaccinated, and you've had both doses of the vaccine, that you continue to wear your PPE, because at this time we don't have enough data on how quickly our immune systems provide that total protection.”

Dr Risk warns, however, that the vaccine is not a magic bullet—proper infection control protocols must still be adhered to.

“It’s not an, ‘I'm going to get the vaccine. Therefore I never have to wash my hands again,’ kind of thing,” Dr Risk says. “It's not reasonable to expect that everything is going to change just because a few people, or the person that is doing the work, gets vaccinated. The entire population that we see also has an ability to carry virus still, whether they're vaccinated or not.”

The National Institute for Occupational Safety and Health (NIOSH) 

 should still be followed to mitigate infection risks.

“We've got this bigger subject of source control, the source of the virus,” Dr Risk observes. “You want to control that. We've got the engineering controls. We've got the administrative controls. We've got the ability to screen. Maybe the tests are going to come out, which are going to be able to catch infectivity. It’s not just, ‘Are you sick?’ but, ‘Are you contagious?’ Those are the things that are really going to be a game-changer, along the vaccine, because the vaccine is going to afford us some protection against getting very sick. It’s probably not going to afford us that much protection if we are definitely exposed to not being just ‘a little bit sick’. So vaccine has a perspective.”

Infection prevention considerations with the COVID vaccine rollout.

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