Beruflich Dokumente
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C A L I F O R N I A
D E N TA L
August 2015
Seattle Care Pathway
Root Caries
Aging Periodontium
Apple Tree Dental
A S S O C I AT I O N
DENTISTRY
FOR THE AGES:
Part II
Aug. 2015
C D A J O U R N A L , V O L 4 3 , N 8
D E PA R T M E N T S
419 Impressions
461 RM Matters/Accounting Controls Can Prevent
Dishonest Behavior
471 Periscope
419
429 The Seattle Care Pathway: Defining Dental Care for Older Adults
This article describes the evidence for, and the details of, the Seattle Care Pathway
to ensure older adults receive optimum dental care.
Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED)
A U G U S T 2 015 415
C D A J O U R N A L , V O L 4 3 , N 8
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416A U G U S T
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Journal of the California Dental Association (ISSN 1043-2256) is published monthly by the
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Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal
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Editor
Editor
C D A J O U R N A L , V O L 4 3 , N 8
A U G . 2 0 15
GUEST EDITOR
C D A J O U R N A L , V O L 4 3 , N 8
Our archives
are your archives.
Our archive is online for your research. Access every issue
of the Journal from the past 16 years at cda.org/journal.
418A U G U S T
2 015
Impressions
C D A J O U R N A L , V O L 4 3 , N 8
The nub:
1. Respect for autonomy is
nice, but a bit paternalistic
because either party alone
can make that determination.
2. Dentists and adult patients
and nonpatients are agents,
with the capacity to aect
each other.
3. Morality requires that the
same moral status as agents
be accorded all concerned.
Practice Support
Employment Practices
A U G . 2 0 15
IMPRESSIONS
C D A J O U R N A L , V O L 4 3 , N 8
2 015
In 2011, there were more than 8,500 deaths in the U.S. from cancers
of the oral cavity and pharynx. A recent study, published in JAMA Internal
Medicine, estimated the number of deaths attributable to cigarette smoking
for 12 smoking-related cancers and found that, among U.S. adults 35 years
and older in 2011, almost half (47 percent) of the deaths caused by cancers
of the oral cavity and pharynx were attributable to cigarette smoking.
Additionally, in the multi-institution research letter, the authors report that
the overall number of deaths from 12 smoking-related cancers was nearly
346,000. Of those, 48.5 percent were attributable to cigarette smoking.
Specically, the researchers linked smoking with 80.2 percent of lung,
bronchus and trachea cancer deaths, as well as 76.6 percent of deaths from
cancer of the larynx. Secondhand smoke exposure, which was estimated by
the 2014 U.S. Surgeon Generals report to cause an additional 5 percent
of lung cancer deaths, was not included in the analysis.
In the research letter, the authors stated that 44.8
percent of bladder cancer deaths, 19.6 percent of
stomach cancer deaths and 22.2 percent of cervical
cancer deaths were linked to smoking.
For more details and specic
breakdowns within each category, see
the full report published online ahead
of print in the journal JAMA Internal
Medicine, June 15, 2015.
C D A J O U R N A L , V O L 4 3 , N 8
A U G . 2 0 15
IMPRESSIONS
C D A J O U R N A L , V O L 4 3 , N 8
2 015
With age, postmenopausal women with osteoporosis are at greater risk of losing
their teeth. In a new study, researchers from Case Western Reserve University School
of Dental Medicine suggest dental implants may provide postmenopausal women
with osteoporosis with the highest degree of satisfaction in their work and social lives.
This investigation was initiated to incorporate oral health into womens health
promotion and to examine psychosocial outcomes associated with dental implant
supported rehabilitation, the authors wrote.
In the study, researchers surveyed 237 osteoporotic women with one or more
adjacent teeth missing. The survey consisted of 23 questions rating their satisfaction
with replacement teeth and how it improved their lives at work and in social
situations specically in regards to the work, health, emotional and sexual
aspects of their lives. Of the 237 participants, 64 had implant retained prosthetic
restorations, 60 had traditional xed partial dentures, 47 had removable partial
denture and 66 had no restoration to restore missing teeth. No signicant
dierence in age exists between groups, according to the study.
The authors found that women with dental implants reported a higher overall
satisfaction with their lives, according to lead researcher Christine DeBaz, who
personally interviewed each participant. Fixed dentures scored next highest in
satisfaction, followed by false teeth and then women with no restoration work.
In order to make decisions about the most
appropriate treatment option in rehabilitation a dentist
must understand not only the prosthetic therapeutic
specics such as chewing function and orofacial esthetics
but also the patient-centered specics of psychosocial
and overall well-being, the authors wrote.
For more, see the study in the International Journal
of Dentistry, vol. 2015, article ID 451923, 6 pages.
C D A J O U R N A L , V O L 4 3 , N 8
introduction
C D A J O U R N A L , V O L 4 3 , N 8
GUEST EDITORS
Susan Hyde, DDS,
MPH, PhD, FACD,
chairs the division of
oral epidemiology and
dental public health at the
University of California,
San Francisco, School
of Dentistry. She is the
dental director of UCSFs
multidisciplinary fellowship
in geriatrics and faculty
lead for interprofessional
education for the School of
Dentistry. Dr. Hyde received
her dental degree from
UCSF, Master of Public
Health and doctorate of
philosophy (epidemiology)
from the University of
California, Berkeley, and
certicates in dental public
health and geriatrics from
UCSF.
Conict of Interest
Disclosure: None reported.
You are the reason people stand tall in front of the class,
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result in a larger proportion of older adults and those adults will live longer than ever
before. There is, therefore, a need to ensure dental services recognize this transition
and plan for the management of older adults in primary care dental practices. This
article describes the evidence for, and the details of, the Seattle Care Pathway to
ensure older adults receive optimum dental care.
AUTHOR
ACKNOWLEDGEMENT
The Shift
There is no doubt Western countries
are all experiencing a demographic shift
a change in the population profile
that will see a greater proportion of older
adults who will be living longer than
ever before.2,3 Such a shift has a profound
impact on many aspects of society, not
least the financial considerations, but
perhaps, one of the biggest concerns
is maintaining the health and wellbeing of an aging population in an
economically viable manner that does
not destabilize health care systems.4
Many could argue the shift is a perfect
storm older individuals with greater
and more complex health care needs
but no workplace medical insurance
will strain health care systems while
at the same time the proportion of
working-age, tax-contributing individuals
reduces. The obvious solution to these
issues would seem to be that prevention
A U G U S T 2 015 429
End of life
Start of life
Services
Well-dened and integrated within
national schemes, such as health
visiting, HeadStart, childrens centers,
nurseries and schools. Clear and
consistent oral health promotion and
prevention messages linked with eective
interventions, therapies and treatments.
Good access to care generally.
Research
Strong, evidence-based, with wide range
of clinical trials and numerous systematic
reviews to provide guidance to health
care systems. Evidence embodied within
national recommendations and endorsed
by governments and organized dentistry.
Vulnerable
Population 1
Population 2
Population 3
Line of vulnerability
Services
Poorly dened, often highly variable, even
within health care systems. Poor access to
services and service specications based
on the treatment aspirations of younger
adults rather than directed by the oral
health needs of the elder patients.
Research
Evidence base is poorer, fewer
recommendations based on clinical trial
evidence, often focused on settings rather
than delivery.
2 015
C D A J O U R N A L , V O L 4 3 , N 8
TABLE 1
While now far less common, incremental loss of teeth leading to the decision to render an individual edentulous is still a major challenge for
many older adults. The provision of complete prostheses is becoming more complex as patients typically lose their teeth at an older age and
have a reduced ability to cope with the challenges of managing a prosthesis.
Dental caries
Perhaps the most common challenge, in community-dwelling older adults, caries rates are similar to those in young children at about one
surface per year. While root caries are often considered the major issue in this age group, this appears to be largely a disease of adults
in residential and nursing homes, with coronal caries remaining the site of increment for older adults. Those in nursing homes will typically
experience a caries increment rate double that of their community-dwelling peers.
Periodontitis
A highly prevalent condition in this cohort of patients but with most attachment loss being in the form of gingival recession rather than
increases in probing depth. The concept of health survivors is apropos here with teeth that remain into old age likely resilient to
periodontal disease. The changes in the immune system also contribute to the altered progression of the disease in this group, although this
must be set against the reduced ability to undertake some oral hygiene procedures that require ne motor skills.
Dry mouth
Both xerostomia and salivary gland hypofunction are seen in older patients, either together or alone, and can have a devastating impact.
Caries risk is increased either due to loss of the protective saliva or due to measures taken to stimulate salivary ow (often sucking candies),
and dry mouth is associated with a decrease in quality of life, diculty eating and wearing a prosthesis. Dry mouth is often associated with
polypharmacy.
Oral cancer/
Precancer
Epidemiological data are scarce, but oral cancer and its precursors are generally seen in older populations and rates vary across developed
and developing nations. Given its devastating impact, however, clinicians should be vigilant for oral lesions in all patients, especially those
with recognized risk factors.
Access
Many older adults nd it increasingly dicult to access care. This may be due to transport, cognitive ability or their own general health and
mobility. Dental oces may not cater well to wheelchair users or may not be located close to public transport links. In patient surveys, the
need to maintain access to dental care is often raised as older adults No. 1 concern with respect to their oral health.
Setting
Older adults living in nursing and residential care may be especially dicult to treat, especially if they cannot be easily transported to a
regular clinical setting. The need for mobile dental units and sta is clear but the provision of these is often sporadic.
Resources
For many adults, dental insurance ceases or is reduced at retirement and, combined with a lower overall income level, resources become
scarce. This is confounded by the fact that many of these patients will have received complex dental treatments that may require additional
resource to maintain and protect.
TABLE 2
2 015
No dependency
Fit, robust people who exercise regularly and are in the most t group for
their age.
Predependency
People with chronic systemic conditions, which could impact on oral health
that, at point of the presentation, are not currently impacting on oral health.
A comorbidity whose symptoms are well-controlled.
Low dependency
People with identied chronic conditions that are aecting oral health but
who currently receive or do not require help to access dental services or
maintain oral health. These patients are not frankly dependent, but their
disease symptoms are aecting them.
Medium
dependency
High dependency
People with complex medical problems preventing them from going to receive
dental care at a dental clinic. They dier from patients categorized in medium
dependency because they cannot be moved and must be seen at home.
C D A J O U R N A L , V O L 4 3 , N 8
No Dependency
These are older individuals who are fit
and exercise regularly. An example of this
type of patient might be the following:
Arnold is a 75-year-old who lives
at home with his wife and three dogs.
He exercises regularly and is actively
involved in dog training for new dog
owners in his community. He attends
six-month recalls at your practice
and three-month cleanings with your
hygienist. When you review his chart,
the last treatment you provided was
a replacement restoration two years
ago. He is on a statin for cholesterol
but otherwise is on no medication.
Predependency
These patients present with a
chronic systemic condition with
potential impact on oral health,
which at point of presentation, is well
controlled. An example of this type
of patient might be the following:
Sarah is 66 years old and is a
widow living alone. She is active in
her community and attends church
regularly where she has an extensive
social network. She sometimes uses a
walking stick when she feels a little dizzy,
and is taking medications for diabetes
and high blood pressure but both are
well controlled. She recently had an
CONTINUES ON 436
A U G U S T 2 015 433
TABLE 3
Assessment
Prevention
No Dependency
High Dependency
20
2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2014; 31 (Suppl. 1): 7787.1 Reproduced with permission.
* Consideration of the long-term success, impact and maintenance of current restorative condition, oral health and prevention.
** Development or modication of this plan.
Contact is dened as an activity involving contact between patient and the wider dental team.
434A U G U S T
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C D A J O U R N A L , V O L 4 3 , N 8
Treatment
Communication
Speak to patient about long-term oral health issues especially when considering
complex treatment modalities that require replacement and/or maintenance.
Identication of the condition and its likely future impact on oral care
education of patient.
Link in with wider health care team around medication management (sugar
in medicines).
Establish link with source of support to ensure that daily oral health plan can
be delivered and that prevention modalities are appropriately implemented.
Ensure that the patient is at the center of discussions to ensure that what is being
delivered is what is needed.
A U G U S T 2 015 435
Medium Dependency
These are patients with an identified
chronic systemic condition that is
currently impacting oral health and who
receive or require support in managing
access to dental services or maintaining
oral health. This category would include
patients who demand to be seen at home
or who cannot get transportation to a
dental clinic. An example of this type
of patient might be the following:
John is living in residential care in
the same town as your dental practice.
436A U G U S T
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Cultural/Generalizability
Care pathways, such as the Seattle
Pathway, are designed to be generalizable
to a range of populations, health service
organizations and cultures. They should
be consistent with, or enable the
incorporation of, local, regional and
national guidance and regulations. They
should be operable in insurance and
state-funded systems. It is therefore a
requirement of practitioners to assess the
guidance and consider its implementation
within their practice population.
The impact of culture should not
be ignored when considering the needs
of patients in this group. Lo described
C D A J O U R N A L , V O L 4 3 , N 8
Summary
The purpose of this article has been
to present and describe the rationale
behind the Seattle Care Pathway. The
authors recognize the pathway may be
a first step to providing an evidencebased approach to the management
of this increasingly complex group of
patients who are destined to become an
ever-greater proportion of our practice
populations. The overarching advice
is that prevention, both self care and
professional, is key for these patients
and the practitioners should be vigilant
about changes in the health and social
circumstances of their older adult patients.
While products and therapies exist for
this cohort of patients, there is a need for
robust clinical trials in this population,
as well as further consideration of how
dental service funding, either public or
private, can be leveraged to support the
implementation of effective prevention.
REFERENCES
A U G U S T 2 015 437
root caries
C D A J O U R N A L , V O L 4 3 , N 8
nearly half of all individuals aged 75 and older have experienced root caries. Root
caries is a major cause of tooth loss in older adults, and tooth loss is the most significant
negative impact on oral health-related quality of life for the elderly. The need for
improved preventive efforts and treatment strategies for this population is acute.
GUEST EDITORS
Dick Gregory, DDS, is the
San Mateo Center director
for Apple Tree Dental. He
completed his dental
degree at the University of
California, Los Angeles,
School of Dentistry in 1980
and a two-year postgraduate multidisciplinary
geriatric fellowship at the
University of California, San
Francisco in 2014. During
the intervening three
decades, he cared for his
patients while in private
general dental practice
in Northern California.
Conict of Interest
Disclosure: None reported.
root caries
C D A J O U R N A L , V O L 4 3 , N 8
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C D A J O U R N A L , V O L 4 3 , N 8
Genetic Susceptibility
There appears to be variation in
individual susceptibility to caries. Intrinsic
host factors related to the structure
of enamel, immunologic response to
cariogenic bacteria and the composition
of saliva play key roles in modulating the
initiation and progression of the disease.
Genetic variation of the host factors
may contribute to an increased risk for
dental caries. However, the evidence
supporting an inherited susceptibility
Saliva
Saliva contains many important cariesprotective components, such as calcium,
phosphate and fluoride, which are essential
to tooth surface remineralization. Salivary
proteins and lipids form a protective
pellicle on the tooth surface, while other
proteins bind calcium, maintaining saliva
as a supersaturated mineral solution.
Bicarbonate, phosphate and peptides
in saliva provide a critical pH-buffering
function. With age, the amount of saliva
remains stable, however, saliva becomes
thicker due to a reduction in serous
flow relative to the mucous component,
resulting in decreased lubrication or
perceived decreased moistness.
Fluoride
Other than the pre-eruptive
mineralization of the developing
dentition, systemic benefits of fluoride
are minimal. The anticaries effects of
fluoride are primarily topical in adults.
The topical effect is described as a
constant supply of low levels of fluoride
at the biofilm/saliva/dental interface
being the most beneficial in preventing
dental caries. Therapeutic levels of
fluoride can be achieved from drinking
fluoridated water and the use of fluoride
products (toothpaste, rinse, gel, varnish).
Fluoride can inhibit plaque bacterial
growth, but more significantly, fluoride
inhibits demineralization and enhances
remineralization of the tooth surface.1
The most widely used forms of fluoride
delivery have been the subject of several
systematic reviews, providing strong
evidence supporting the use of dentifrices,
gels, varnishes and mouth rinses for the
A U G U S T 2 015 441
root caries
C D A J O U R N A L , V O L 4 3 , N 8
Chlorhexidine
The use of chlorhexidine for caries
prevention has been a controversial topic
among dental educators and clinicians.
Chlorhexidine rinses, gels and varnishes or
combinations of these items with fluoride
have variable effects in caries prevention,
and the evidence is regarded as suggestive
but incomplete. The most persistent
reductions of mutans streptococci have
been achieved, in order of more effective
to less effective, by chlorhexidine varnish
followed by gels and, lastly, mouth rinses.
While chlorhexidine had been widely used
in Europe before gaining FDA approval,
the only chlorhexidine-containing
products currently marketed in the
United States are 0.12% chlorhexidine
mouth rinses. The preferred dosage
regimen for rinsing is once a day with 5
cc of a 0.12% chlorhexidine gluconate
solution for one week every month for
a year.1 Patients should be informed
442A U G U S T
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C D A J O U R N A L , V O L 4 3 , N 8
Caries Removal
Partial caries removal has been
found to greatly reduce the risk of pulp
exposure.22 For asymptomatic teeth, partial
caries removal generally results in no
detriment to the patient from increased
pulpal symptoms, decay progression
under restorations or premature loss of
root caries
C D A J O U R N A L , V O L 4 3 , N 8
FIGURE 3A .
FIGURE 3B .
FIGURE 3C .
FIGU R E S 3AC . Root caries are clinically detectable on most remaining teeth. The clinical crown on tooth No. 11 is completely missing due to caries. The arrow points to
Clinical Scenario
FIGURE 4 . Radiographs taken to determine the extent of the carious lesions (see clinical scenario for details).
2 015
C D A J O U R N A L , V O L 4 3 , N 8
Future Directions
ART is expected to play a significant
part in essential caries management for
the frail elderly, especially as additional
scopes of practice are more widely
included in an expanded clinical care
team. One of the indications for the
appropriate use of the ART approach
is for the elderly who are homebound
or living in institutions. More studies
are needed to investigate the potential
of ART in providing essential caries
management in this population. However,
field trials report two-year survival
CDA Presents
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periodontics
C D A J O U R N A L , V O L 4 3 , N 8
health in the elderly patient. While age-related alterations in periodontal tissues and
the immune system may make an elderly patient more susceptible to periodontal
breakdown, age itself is not a major risk factor for periodontal diseases. Rather,
individual age-associated factors such as systemic diseases, medications and changes
in behavior, motor function and cognitive function should be considered for each
elderly patient when making treatment decisions.
AUTHOR
Mark Ryder, DMD, is
the chair of the division of
periodontology and director
of the postgraduate program
in periodontology at the
University of California,
San Francisco, School of
Dentistry.
Conict of Interest
Disclosure: None reported.
periodontics
C D A J O U R N A L , V O L 4 3 , N 8
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C D A J O U R N A L , V O L 4 3 , N 8
periodontics
C D A J O U R N A L , V O L 4 3 , N 8
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C D A J O U R N A L , V O L 4 3 , N 8
RE FERENCES
Office of
CONTINUING EDUCATION
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Napa Valley, CA
Presented at the
Were on
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A U G U S T 2 015 451
Be a part
of the story.
Its a tale of healing, resiliency,
strength and empowerment. Through
the CDA Foundation, thousands of
Californians who need it most gain
access to dental care. Participate
in Foundation events and put your
compassion into action.
Help create the condence, dignity
and joy that come with healthy smiles
and lead to brighter opportunities.
Join us at cdafoundation.org/events.
September 36
September 17
September 12
CDA Cares
Fresno, CA
October 23
health solutions
C D A J O U R N A L , V O L 4 3 , N 8
the silent epidemic of dental disease. Older adults and other vulnerable people
continue to suffer disproportionately from dental disease and inadequate access to
care. As a society and as dental professionals, we face multiple challenges to care
for our aging patients, parents and grandparents. Apple Tree Dentals community
collaborative practice model illustrates a sustainable, patient-centered approach
to overcoming barriers to care across the lifespan.
AUTHORS
Deborah Jacobi, RDH,
MA, is the policy director
for Apple Tree Dental. She
holds degrees in sociology
and public policy and
health administration from
the University of Wisconsin,
Madison.
Conict of Interest
Disclosure: None reported.
Michael J. Helgeson,
DDS, is the CEO and
co-founder of Apple Tree
Dental. He completed
his dental degree and a
two-year postgraduate
fellowship in geriatric
dentistry at the University
of Minnesota.
Conict of Interest
Disclosure: None reported.
health solutions
C D A J O U R N A L , V O L 4 3 , N 8
TABLE
Link
nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/nationalcalltoaction.htm
b.3cdn.net/teeth/1a112ba122b6192a9d_1dm6bks67.pdf
sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.pdf
hrsa.gov/publichealth/clinical/oralhealth/improvingaccess.pdf
networkforphl.org/_asset/92jtkp/Access-to-Oral-Health-Care-Science-and-Law-Brief.pdf
2 015
FIGURE 1. Apple
Trees Centers for Dental
Health also serve as
regional hubs for onsite services and care
coordination.
C D A J O U R N A L , V O L 4 3 , N 8
12,000
10,000
10,132
8,000
7,471
6,000
5,059
4,000
3,135
2,526
2,000
78
>100
0
< 21
2144
4564
6584
8599
Age
FIGURE 2 . 2014 Patients age distribution. Originally founded to serve nursing facility residents, Apple Tree now
$25M
Dollars in millions
$20M
$15M
$10M
$5M
0
86
88
90
92
94
96
98
00
02
04
06
08
10
12
14
Year
FIGURE 3 . Dental care value: 1986 to 2014. Sustained growth demonstrates the viability of Apple Trees
health solutions
C D A J O U R N A L , V O L 4 3 , N 8
2 015
C D A J O U R N A L , V O L 4 3 , N 8
FIGURE 6A .
FIGURE 6B .
FIGURE 6C .
FIGURES 6A6C . Apple Trees Centers for Dental Health are equipped to serve people with special needs. Shown here is a ceiling lift used to transfer nonambulatory
A Sustainable Solution
High levels of uncompensated care
associated with Medicaid and uninsured
populations make it difficult or impossible
for most private practices to accept
significant numbers of public program
and low-income patients. In order to
A U G U S T 2 015 457
health solutions
C D A J O U R N A L , V O L 4 3 , N 8
Veterans
0.7%
Insurance
10%
Fundraising
$108,821
.8%
Management
$924,523
6.5%
Insurance
12.4%
Private pay
9%
Veterans
0.8%
Private
12.5%
Medicaid
80.3%
Medicaid
63.6%
FIGURES 7A and 7B . Comparison of gross and net revenue sources reveals the low reimbursement levels paid
by public insurance programs.
2 015
Program
$13,218,827
92.7%
REFERENCES
resources
C D A J O U R N A L , V O L 4 3 , N 8
Resource
Link
FOR CLINICIANS
ada.org/en/education-careers/continuing-education/long-term-care-course
geriatricoralhealth.org/topics/default.aspx
dentalcare.com/media/en-US/education/ce8/ce8.pdf
www.uky.edu/NursingHomeOralHealth
ahprc.dal.ca/projects/oral-care/default.asp
healthinaging.org/medications-older-adults
toothwisdom.org/resources/entry/cognitive-status-legal-implications-andinformed-consent
ada.org/en/member-center/member-benets/practice-resources/payingfor-dental-care-a-how-to-guide-incurred-med
smilesforlifeoralhealth.com
aptrweb.org/?PHLM_15
pogoe.org
FOR PATIENTS
toothwisdom.org/resources/category/importance-of-oral-health
A U G U S T 2 015 459
ORANGE COUNTY
LOS ANGELES 65 years of goodwill Grossed approximately $350K in 2013. Buyers net of $71K.
Please contact your CPS Agent for more details.
Property ID #5008.
FULLERTON Leasehold Improvement and Equipment! On one the busiest intersec ons of Fullerton.
3 equipped operatories. Some pa ent charts included. Property ID #5028.
MISSION HILLS - Leasehold Improvements & Equipment Only! 8 equipped Property ID #5014.
MONTEREY PARK (GP) Leasehold Improvements
& Equipment Only! 3 equipped operatories.
Property ID #4449.
PASADENA (GP) - 3 equipped ops. Grossed approximately $335K for 2014. Property ID #5035.
RANCHO SANTA MARGARITA Leasehold Improvement Only!! 4 plumbed not equipped operatories.
Property ID #4483.
TORRANCE 5 equipped ops. Grossed approximately $493K for 2014. Property ID #5036.
LAGUNA HILLS 2 equipped ops. Approximately 2025 new pa ents/mo. Ins/Cash/Cap (~$500/mo).
Grossed approximately $319,024 in 2014. Property
ID #5033.
RESEDA 3 equipped operatories (stand up den stry). Projec ng approximately $292,796 for 2014
with monthly revenues of $24K. Property ID#5017.
youtube.com/mycpsteam
faceboook.com/mycpsteam
WWW.CALPRACTICESALES.COM
CA DRE #00491323
RM Matters
C D A J O U R N A L , V O L 4 3 , N 8
mbezzlement is typically
defined as the theft of money
or property by a person trusted
with those assets. It usually
occurs in employment settings,
and small businesses suffer more losses
from fraud than larger organizations,
according to the Association of
Certified Fraud Examiners.
Analysts with The Dentists
Insurance Company say dentists may
inadvertently put their practices at risk
for fraud by trusting a single employee
with sole financial responsibility or
by not reviewing accounts payable
and receivable. However, this
vulnerability can be reduced through
awareness of red flag behaviors and
a few key accounting protections.
Fraudulent activity can happen
in a number of ways, and TDIC case
studies show instances of employees
deleting appointment and ledger entries,
endorsing patient checks to personal
accounts, forging payroll checks,
modifying payroll, misappropriating
a credit card and using a signature
stamp without authorization.
Jennifer Duggan, a Northern
California attorney specializing in
business and employment law, says
there are also more sophisticated
schemes in which employees fabricate
fictitious vendors, create nonexistent
employees, receive kickbacks from
patients or from vendors for awarding
company contracts or actually coerce
subordinate employees to carry out theft.
Sometimes employees forge
signatures on checks and sometimes
the employees are authorized
signatories, said Duggan.
Duggan notes that the thief is more
often than not a highly trusted employee.
Protecting dentists.
Its all we do.
thedentists.com
A U G U S T 2 015 461
A U G . 2 0 15
RM MAT TERS
C D A J O U R N A L , V O L 4 3 , N 8
462A U G U S T
2 015
1.
2.
3.
4.
5.
6.
7.
2.
3.
4.
5.
LEE SKARIN
& ASSOCIATES INC.
6.
7.
What are the tax consequences for the Buyer when purchasing a practice?
Lee Skarin & Associates have been successfully assisting Sellers and Buyers
of Dental Practices for nearly 30 years in providing the answers to these and other
questions that have been of concern to Dentists.
Call at anytime for a no obligation response to any or all of your questions
Visit our website for current listings: www.LeeSkarinandAssociates.com
2IFHV
805.777.7707
818.991.6552
800.752.7461
CA DRE #00863149
A U G . 2 0 15
RM MAT TERS
C D A J O U R N A L , V O L 4 3 , N 8
Post
Search
Hire
Postings syndicated to
multiple networks
30 day job posting start
at $79!
464A U G U S T
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9LHZFDQGLGDWHVSKRWR
SHUVRQDOLW\WHVWFXOWXUH
YDOXHVVNLOOVDQGPRUH
Search by position, zone,
education, and more
Practices
Wanted
NORTHERN
NORT
RN CALIFORNIA
(415) 899-8580 (800) 422-2818
Raymond and Edna Irving
Ray@PPSsellsDDS.com
www.PPSsellsDDS.com
(
(714)
) 832-0230
832 0230 (800)
(800 695-2732
Thomas Fitterer and Dean George
PPSincnet@aol.com
www.PPSDental.com
6090 SANTA ROSA Entry level opportunity includes 1,200 sq.ft. condo.
On relaxed schedule, PPO practice collected $274,000 in 2014 with Profits
of $154,000 with no rentH[SHQVH. Near Memorial Hospital.
6089 MOUNT SHASTA Small town living renowned for mountain
recreation, lakes & streams, fishing, golfing and abundant culture. Perfect
escape from the Rat Race and corporate intrusion. On 3-day week,
revenues topped $800,000 in 2014.
6088 SANTA CRUZ Well established, lots of patients. Strong Hygiene
Department with 6.5 days of hygiene per week. Collected $600,000 in
2014. 2015 trending $675,000+. Full Price $375,000.
6087 LAKE TAHOE - NEVADA'S STATELINE Located adjacent to
California's South Lake Tahoe. Out-of-Network practice. Collections
last year topped $600,000 with Available Profits of $220,000. 3.5 days of
hygiene per week. Escape California income taxes!
6085 PERIO PRACTICE SAN FRANCISCO BAY AREA 2014 grossed
$2 Million. 7 Doctor days per week. Seller can work back. Beautiful 8-Op office.
6081 SANTA CLARA El Camino Real location. 2014 collected
$687,000. Available Profits of $305,000. 2-days of Hygiene. 5-ops in
1,700 sq.ft. Extend hours and revenues shall increase.
6080 SAN RAMON 8+ days of Hygiene. $450,000 invested in 6-Op
office. Consistent $900,000+ per year performer. Attractive transition
arrangements available.
6079 BERKELEYS ALTA BATES MEDICAL VILLAGE SOLD
Strong performer on Owners 24 hour week. 2014 collected $676,500.
Patient foundation anchored by 4-days of Hygiene. Endo and OS referred.
Renowned Medical Village has regional draw.
6078 FRESNO Strip center practice on West Shaw Avenue. 2014s
Collections totaled $383,000 with Profits of $192,000. Practice will do better
with Successor who devotes full attention here. 4-Ops. Full Price $245,000.
6077 PERIO PRACTICE SAN FRANCISCOS NORTH BAY
Highly regarded and located in desirable family area. On 3.5 day week,
revenues were $1 Million in 2014 with profits of $400,000. Beautiful facility
with 4-Ops.
6075 MONTEREY BAY AREA SOLD Digital, paperless and well
positioned for future. 2014 collected $1.47 Million with Profits of
$690,000. 7+ days of Hygiene. First Quarter of 2015 collected $449,000.
Extremely unique opportunity.
6071 CHICO Strength is 4-day Hygiene schedule. Retiring DDS focuses
on restorative. Endo, OS, Perio & Pedo referred. 2014 collected $450,000.
Beautiful 4-Op office. Full Price $150,000.
6070 VISALIA Strong foundation and well-positioned for ambitious
successor. Strong Hygiene Department, beautiful facility, well equipped.
Digital throughout. Not a Delta Premiere practice.
6067 MONTEREY - ADVANCED RESTORATIVE PRACTICE
Strong foundation for DDS desiring quality restorative practice. $310,000
invested here. Digital and paperless. 2014 collected $400,000. 2XWRI
Network practice. Considerable transition assistance available. Full
Price $185,000.
Dr. Lee
Maddox
LIC #01801165
Dr. Thomas
Wagner
LIC #01418359
Dr. Dennis
Hoover
LIC #0123804
Dr. Russell
Okihara
LIC #01886221
Jim
Engel
LIC #01898522
Kerri
McCullough
LIC #01382259
Mario
Molina
LIC #01423762
Jaci
Hardison
LIC #01927713
Steve
Caudill
LIC #00411157
Thinh
Tran
LIC #01863784
(949) 675-5578
25 Years in Business
(916) 812-3255
40 Years in Business
(209) 605-9039
36 Years in Business
(619) 694-7077
33 Years in Business
(925) 330-2207
42 Years in Business
(949) 566-3056
35 Years in Business
(949) 675-5578
35 Years in Business
(949) 675-5578
26 Years in Business
(951) 314-5542
25 Years in Business
(949) 675-5578
11 Years in Business
D
SOL
CENTRAL CALIFORNIA
CENTRAL COAST: 6 Ops, 8 days of
hygiene/wk. 2013 GR of $2.3M and $804K
in adj. net. Dentrix, Digital, Paperless.
#CA208
FRESNO: General Dentistry Partnership.
2013 Partnership GR $4.7M. Selling Partner
2013 Net Inc $368K. #CA196
SOL
SOUTHERN CALIFORNIA
ANAHEIM: General Practice & Bldg.
6 Ops, 3 Equipped, 3 Plumbed. Near
Disneyland. Est. 39 years. #CA186
ANAHEIM: 4 Ops, 5 addl available,
SoftDent, Digital X-Rays and Digital Pano.
2013 GR 237K. #CA207
BAKERSFIELD: General Practice. 4 Ops.
Pano. Est. 20+ Years. 2013 GR $521K.
#CA193
BALDWIN PARK: General Practice. 5
Ops, 4 Equipped. 2014 GR $276K. #CA176
BANNING: General Practice. 6+ Ops.
Paperless, Digital, EagleSoft. 8 Days Hyg/
Week. 2014 GR $1.4MM+. #CA183
BEVERLY HILLS: Small boutique
practice, 2 Ops, 1 Equipped, Open Dental,
Digital, 2014 GR $120K on 3 days/wk..
#CA215
BEVERLY HILLS: 5 Ops, EagleSoft,
Digital, CEREC. Long-term staff, newer
equipment. 2014 GR 1.07MM, Adj. Net of
$406K. #CA210
1.800.519.3458
NEW
SAN DIEGO
www.henryscheinppt.com
OUT OF CALIFORNIA
HAWAII (MAUI): PRICE REDUCED!
General Practice. 4 Ops, Approx. 1,200 Sq.
Ft. GR $636K #20101
1.888.685.8100
Regulatory Compliance
C D A J O U R N A L , V O L 4 3 , N 8
Linda Brown
30 Years of Experience Serving
the Dental Community Proven
Record of Performance
A U G U S T 2 015 467
AU G . 2 015 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 3 , N 8
Paul Maimone
Broker/Owner
ARCADIA (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare.
Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. NEW
BAKERSFIELD #29 - (4) op comput G.P. (3) ops eqtd, (1) add. plumbed. Located in a free
stand bldg. Cash/Ins/PPO. Digital x-rays. Annual Gross Collect $300K+ p.t. Seller moving.
CULVER CITY (3) op Turnkey Office with included charts. In free standing Bldg. NEW
LOS ANGELES - (3) op computerized G.P. located in a Landmark Medical/Dental Bldg. on a
main thoroughfare. Cash/Ins/PPO pt base. No HMO & No Denti-Cal. Digital X-rays. Annual
Gross Collections $600K+. NEW
MONTEREY PARK (6) op comput G.P. located in a street front suite on a main thoroughfare
w exposure & visibility. Cash/Ins/PPO & small % Denti-Cal. Annual Gross Collect $250K+ p.t.
Seller retiring but will assist with Transition. NEW
PASADENA Nearly New Turnkey Office w some charts. Newer eqt. Gorgeous!
RANCHO CUCAMONGA - (4) op comput. G.P. in a strip ctr. w visibility. (3) ops eqtd (4th) op
plumbed. Annual Gross Collect $185K+ on 2.5 days/wk. Cash/Ins/PPO pts. Seller moving.
SANTA BARBARA COUNTY (3) op comput G.P. & 1,900 sq ft Bldg. Cash/Ins/PPO pts. No
HMO and No Denti-Cal. 2015 Projected Gross Collections $250K on a very relaxed 3
day week. Seller refers all O.S., Perio, Ortho and Endo. Also refers implant placement. Seller is
retiring but will assist with a short transition prior to moving out of state. NEW
SHERMAN OAKS (3) op comput G.P. in a well known, easily accessible Med/Dental bldg.
Cash/Ins/PPO. Annual Gross Collect $180K+ p.t. Great Starter or Satellite. Seller retiring.
So. KERN COUNTY (6) op comput. G.P. located in a Bakersfield suburb in a small strip ctr. w
exposure/visibility. Pano eqtd. Limited competition. Cash/Ins/PPO pts. Annual Gross Collect.
Approx. $350K p.t. Seller is moving and is motivated.
SANTA ANA - absentee owned (6) op fully eqtd G.P. First floor street front location on a main
thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqtd
& Computerized. 2014 Gross Collect. of $549K+ on a (3) to (4) day Associate run week. NEW
SOUTHWEST RIVERSIDE COUNTY - (5) op comput. G.P. (4) ops eqtd/5 th plumbed. 2015
Project Gross Collect $400K+. Cash/PPO. Located in a smaller prof. bldg. in a condo which can
be purchased or leased. Seller giving up private pract. to accept institutional position. NEW
TUSTIN - (4) op comput. G.P. (3) eqtd/4th plumbed. Located in a busy shop ctr. on a main
thoroughfare. Exposure, visibility & signage. Digital x-rays & CEREC. Annual Gross Collect
$460K+ on an easy 4 day week. Cash/Ins/PPO. No Denti-Cal or HMO. Growth potential. NEW
WEST SAN FERNANDO VALLEY - (4) op comput. G.P. w modern equipt. Located in a
smaller prof. bldg. on a main thoroughfare. Cash/Ins/PPO pts. Annual Gross Collect $750K+ on a
(4) day week. Excell. long term lease, outstanding signage, & great off street parking. SOLD
UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Montebello,
Oxnard, Pomona, San Gabriel, SFV, Temecula, Thousand Oaks, Torrance, Visalia & Valencia.
D&M SERVICES:
Q Practice Sales and Appraisals
Q Practice Search & Matching Services
Q Practice and Equipment Financing Q Locate and Negotiate Dental Lease Space
Q Expert Witness Court Testimony
Q Medical/Dental Bldg. Sales & Leasing
Q Pre - Death and Disability Planning Q Pre - Sale Planning
2 015
CARROLL
& C O M P A N Y
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions
Phone:
650.362.7004
Email:
dental@carrollandco.info
Website:
www.carrollandco.info
CA DRE #00777682
AU G . 2 015 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 3 , N 8
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Periscope
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A U G . 2 0 15
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C D A J O U R N A L , V O L 4 3 , N 8
MICROBIOLOGY
PERIODONTICS
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WPS@SUCCEED.NET
WESTERNPRACTICESALES.COM
What separates
us from other
brokerage firms?
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Be er
Fit
Be er
Price
We are a proud member of:
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HN-290 PLACERVILLE: Excellent Merger Op!
Embrace the lifestyle and build your success
story here! FFS. 1,400 sf w/ 4 ops $210k
HG-448 S. LAKE TAHOE: 2 Story, Rustic dcor. Upscale Family Practice. 3400sf w 6 ops
$725k
CENTRAL VALLEY
IG-067 STOCKTON: Fully computerized, paperless, digital. 5,000 sf w/10 ops Steal of
the Century! Now ONLY $240k
IG-367 MERCED: Newly Remodeled, Paperless. 1,550 sf w/4 ops REDUCED! $325k
IN-345 MODESTO: Long-standing tradion of
quality care. 3016 sf w/ 5ops + 1 addl. $495k
IN-358 MODESTO: Pracce nets over 50%!
1,200 sf, 3 ops+1 addl. REDUCED! $275k
IN-397 FRESNO/MADERA: the Perfect
Locaon! 2,000 sf w/5ops. NOW ONLY:
$440k
IN-429 TRACY Facility: Move-in ready
Hesitate and you might miss out! 2,488 sf, 5
ops $245k/RE: $650k
JC-349 FRESNO Facility: Doctor is rering
and is movated! Step right in and make
yours! Call for Details!
SPECIALTY PRACTICES
CG-431 FAIRFIELD Perio: Priced to sell!
1400 sf w/ 3 ops. Plumbed for 2 addl $60k
I-7861 CENTRAL VALLEY Ortho: 2,000 sf,
open bay w/ 8 chairs. Fee-for-Service.
$370k
I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5
chairs/bays & plumbed for 2 addl $180k
DG-264 SAN JOSE Ortho: $300-400k in
build-outs alone! 1800 sf w/ 5 chairs. REDUCED! $195k
CC-346 SO MARIN CO Perio: 1,142 sf w/ 3
ops. Meticulously maintained! REDUCED!
$199k
BN-393 PINOLE Pedo: Streamlined pracce,
where every child counts themselves lucky to
be a paent here! 2,000 sf w/ 5 ops. $1.2m
CG-424 NAPA Prostho: Ready for Experienced, high-end Prosthodonst! One track to
collect just under $1m $725k
CC-405 SOLANO CO. Endo: Endodonc Pracce in a vibrant community! 1,250 sf w/ 4
ops. $485k
What we did not fully comprehend is that Delta has not really sold any new Premier
plans for many years. Each year, the percentage of Delta Premier patients is reduced
compared to the PPO plans. Currently the percentage of Delta Premier patients is
approximately 7%. Todays current Premier Only doctors normally do not realize
that as much as 93% of their Delta Premier patients are really what we refer to as
PPO Plus, meaning that Delta has agreed to pay the Premier fee schedule for the time
being, but any change in the contract will reduce all of these patients to the standard
PPO fee schedule.
We have also witnessed transitions over the years where the practices gross receipts
did suffer after the buyer was forced to take the lower fee schedule. However, since
2011 when we began following this phenomenon, I can say that there is no direct
correlation to declining revenue just because of the Delta fee change issue. We recently
sold a predominately Delta practice that had 1.7 Million in gross receipts. We expected
this practice would suffer as this practice did not need to grow their patient base with
the additional PPO patients. Six months after the sale the monthly collection numbers
were actually greater!
It is imperative that buyers understand this issue and find out how much of the
revenues are generated by a Delta Premier only office. However, it is just one of the
many variables a buyer should understand in making a good decision to purchase a
practice.
Edmond P. Cahill, JD
Tech Trends
C D A J O U R N A L , V O L 4 3 , N 8
Google Photos for iOS provides all users with cloud storage backup
for photos and videos on mobile devices. The application and service
is also available for Mac, PC and Android devices. Once logged
in with a Google account, Google Photos works seamlessly in the
background by continuously backing up all photos and videos on the
iOS device through a Wi-Fi connection. When backups are complete,
users are free to delete photos and videos from their camera rolls
on their iOS devices. All photos and videos are available to view
on the cloud through the Google Photos app. Within the Google
Photos app, users can view their photos sorted by date or collections
based on photo location data. Tapping on any item enlarges it to
full screen, where users can share, edit, view info or delete the item
from cloud storage. Users can apply lters and use simple editing
tools for their photos and videos. Google oers two storage options
for this service: Original and High Quality. The Original storage
option backs up and syncs photos and videos at their full resolution
and quality. This option counts against the standard storage quota
for a Google account, which is 15GB and is shared amongst other
services such as Gmail and Google Drive. The High Quality storage
option provides unlimited storage for photos and videos that are
equal to or less than 16MP or 1080p resolution. For most users, the
High Quality option will more than suce.
2 015
Dr. Bob
C D A J O U R N A L , V O L 4 3 , N 8
Aging Gracefully
(and Other Indignities)
The following Dr. Bob column was originally printed in the March 2010 issue of the Journal.
Robert E.
Horseman,
DDS
ILLUSTRATION
BY VAL B . MINA
A U G . 2 0 15
DR. BOB
C D A J O U R N A L , V O L 4 3 , N 8
2 015
Thurs.Sat.
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