Scaling Up Productivity with Technology

Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants. Scaling Up Productivity with Technology A Peer-Reviewed Publication Written by Charles Blair, DDS PennWell is an ADA CERP recognized provider ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns PennWell of complaints is about an ADA a CE provider CERP may Recognized be directed to Provider the provider or to ADA CERP at www.ada.org/goto/cerp. Go Green, Go Online to take your course This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives Upon completion of this course, the clinician will be able to do the following: 1. Know the clinical and business objectives for the dental office and have a clear understanding of how production and productivity influence costs and profitability 2. Be able to determine the financial contribution technology offers through delegation, increased production and increased productivity 3. Understand the factors that should be considered when evaluating the return on investment for new technology and how to measure productivity gains 4. Understand the practice-building implications of technologies offering patient and productivity benefits, including flexibility of scheduling Abstract Dental offices clinical objectives are to provide patients with the best possible treatment that is effective and safe, and to deliver this in a patient-friendly manner. Business objectives are to maintain and increase production and productivity and to limit expenses, thereby ensuring the financial health of the office and increasing profitability. Technologies such as locally-applied noninjectable anesthetic gel and endodontic rotary nickel titanium (NiTi) files increase productivity. Both reduce chairside time and the potential number of visits, while the locally-applied noninjectable anesthetic gel also offers the opportunity to completely delegate a procedure. Technology plays a key role in the modern dental office in improving the standard of care and practice-building, improving convenience and flexibility for clinicians and patients alike. I. Introduction/Overview New value-add technology introductions continue to be available that meet both clinical and business objectives for the dental team providing patients with the highest standard of care that is delivered in a patient-friendly manner, while increasing profitability and improving the financial health of the office by improving productivity and/or increasing production. Examples of productivity enhancing technologies include endodontic NiTi files, ultrasonic scalers, LED composite curing lights and locallyapplied noninjectable anesthetic gel. Productivity is determined by the time taken to perform given procedures as the clinician s productivity increases, less time is taken to perform individual procedures. Increased productivity holds collections at the same level as before, but decreases the clinician s chairside time (and therefore expenses directly associated with the procedure) thereby increasing profit. Production can be defined as the sum of the clinical procedures multiplied by the associated fees increased production increases both collections and certain variable expenses associated with the additional procedures, including chairside time. Procedure Productivity Time taken per procedure Production Number of procedures Production + Productivity = # Procedures + Time per procedure Actual profit depends upon realized income (the collections for services rendered to patients that are collected and deposited), less the actual expenses incurred in conducting business. While reducing overall costs is usually beneficial, increased variable costs directly related to increased production or productivity such as materials or laboratory bills may be positive. Greater productivity also frees up clinician time, enabling increases in production without parallel increases in the expense of the clinician s chairside time, and benefits the patient by reducing the time he or she must sit in the dental chair. II. Procedures and Production In total an estimated 1.2 billion dental procedures were performed in 1999, 82.5% of these in general dental offices. 1 Key procedures performed on a regular basis include evaluations, periodontal procedures, prophylaxis, restorations, extractions, and minor surgery. Periodontal procedures include scaling and root planing, gross debridement and periodontal maintenance procedures that can be performed by dental hygienists. Table 1. Frequency of Dental Procedures* Estimated number (in millions) All oral evaluations 263 All radiographs 231 Prophylaxis 226 Direct and indirect restorations 210 Extractions 40 Periodontal procedures 28 Endodontic therapies 20 All other surgery (exc. implants) 4 *Partial listing of procedures Source: ADA survey. The 1999 survey of dental services rendered. A few States permit dental hygienists to work in hygiene-only practices limited to hygiene procedures (without any involvement or ownership by a dentist), while in some States hygienists work under general supervision in dental offices without a dentist always being directly present. Seventy-five percent of general dentists were estimated to employ dental hygienists in 2003. 2 Building a successful hygiene department and using productivity-enhancing technology both help to improve the overall productivity and profitability of the office. 2 www.ineedce.com

III. Productivity-Enhancing Technology Technology can be productivity-enhancing by three mechanisms reducing clinician chairside time, enabling delegation of a step or procedure, reducing the number of visits required, or any combination of these. Understanding the mechanism(s) by which a specific technology enhances productivity has important implications for practice building and profitability. Technology Mechanisms for Productivity Enhancement Reducing the clinician s chairside time Enabling delegation of a step or procedure Reducing the number of treatment visits Increasing productivity: Reducing the clinician s chairside time and delegation Locally-applied noninjectable anesthetic gel intended for use during periodontal procedures and rotary NiTi files used during endodontic treatments are both productivity enhancing. The anesthetic gel reduces clinician chairside time and has the added benefit of enabling full delegation of administration of anesthesia. Rotary NiTi files reduce clinician chairside time but do not enable delegation of a step or procedure. A. Anesthetic Over 12 million scaling and root planing procedures are estimated to have been performed in the U.S. during 1999, with approximately 85.5% of these performed in general dental practices and 13.7% in periodontal offices. 3 Including debridement and ongoing periodontal maintenance, the total number of procedures was around 28 million. Within the hygiene department, the periodontal care continuum ranges from routine prophylaxis to advanced periodontal disease treatment. The accepted standard treatment for appropriate periodontal patients is non-surgical therapy consisting of thorough debridement and the removal of supragingival and subgingival deposits. Routine prophylaxis and periodontal maintenance may or may not result in discomfort. If they do, and the discomfort is transient or mild, the patient may not receive anesthesia after weighing the benefit (relief from mild discomfort) versus the onset time and lingering numbness associated with injectable local anesthetics. Once subgingival scaling or root planing is involved particularly where deeper periodontal pockets instrumentation can be extensive and painful. Dental hygienists perform the majority of these procedures, and many require use of anesthetics. Unique innovative technology has produced an anesthetic gel containing 2.5 percent lidocaine and 2.5 percent prilocaine that is locally-applied, noninjectable, effective 4,5,6 and has a rapid onset of 30 seconds, 7 and 20 minutes duration (Oraqix, Dentsply).The rapid onset results in productivity gains during scaling and root planing procedures. Table 2. Considerations for Selection of Anesthesia Patient s perception of pain Patient s fear of needles Potential side effects Onset time Type and length of procedure Quadrant scaling and root planing Profundity of anesthesia Convenience Patient acceptance Overall cost net of time savings While injectable local anesthetics can provide profound and reliable anesthesia, they typically have an onset time of 2 6 minutes. Topical anesthetics (benzocaine) may be used on soft tissue during scaling and root planing procedures as an alternative to injectable local anesthetic, and prior to injections to alleviate needle discomfort. They have an onset time of around a minute, however they provide variable anesthesia. Factors playing a role in the choice of anesthesia also include potential side effects, time involved, type and length of procedure, and amount of anesthetic required (Table 2). The patient s perception of pain and fear of injections play a role as to whether or not injectable local anesthetic is given for procedures such as scaling and root planing. 8,9 In the absence of reliable pain relief, the patient will be less cooperative and more anxious potentially increasing the chairside time required for the procedure. As a general rule of thumb, a dental hygienist s and dentist s chairside production costs average $90 per hour and $250 per hour respectively. 10 If a dental hygienist performs a given procedure rather than a dentist the cost of chairside time is reduced. The actual increase in productivity as a dollar value resulting from the use of locally-applied noninjectable anesthesia will therefore depend upon whether the dental hygienist or dentist would perform the procedure. Table 3 shows the increase in productivity comparing use by the dental hygienist of locally-applied noninjectable anesthetic gel versus injectable local anesthetic. This results in a productivity gain of $6.75 per quadrant. Table 3. Type of Anesthetic Used Locally-applied, noninjectable anesthetic gel Local anesthetic Instrumentation time 45 minutes 45 minutes Onset time for applied anesthetic 30 seconds 5 minutes* Cost of RDH chairside time production/hour $90.00 $90.00 Average collection (fee) charged** $223.90 $223.90 Total cost chairside time $68.25 $75.00 Net after cost of chairside time $155.65 $148.90 and before other expenses * Onset time includes one minute of topical anesthetic application and on average four minutes onset time for the drug. **Source: Limoli, T, Limoli, Jr.,T. 2006 Fee Survey. Dent Econ October 2006:2 10. www.ineedce.com 3

Table 4. Delegating Administration of Anesthetic Quadrant scaling Locally-applied, Local anesthetic Local anesthetic and root planing noninjectable anesthetic gel administered administered administered by RDH by RDH by DDS Instrumentation time 45 minutes 45 minutes 45 minutes Actual cost RDH chairside time for srp $67.50 $67.50 $67.50 Onset time for applied anesthetic 30 seconds 5 minutes* 5 minutes* Actual cost RDH chairside time $0.75 $7.50 $7.50 Actual cost DDS chairside time $0 $0 $20.83 Average collection (fee) charged** $223.90 $223.90 $223.90 Net after cost of chairside time $155.65 $148.90 $128.07 and before other expenses * Onset time includes one minute of topical anesthetic application and on average four minutes onset time for the drug. **Source: Limoli, T, Limoli, Jr.,T. 2006 Fee Survey. Dent Econ October 2006:2 10. If the dentist can completely delegate the administration of anesthetic, productivity will be greater. The vast majority of States permit dental hygienists to administer both infiltration and block local anesthesia provided the dental hygienist has met the State requirements to administer local anesthetic. 11 Enabling the hygienist to give an alternative and reliable anesthetic without the dentist having to stop a procedure to administer anesthetic can save dentist s chairside time that can be used for other procedures as well as saving the dental hygienist s chairside time. Eliminating the dentist s time from the equation greatly enhances productivity (Table 4). The dental hygienist s and dentist s productivity increase if the dental hygienist uses locally-applied noninjectable anesthetic gel, with an incremental gain of $27.58. Delegation also enables the dentist to perform other higher-level procedures. If the dentist performs another procedure of equal or greater value during the chairside time he or she would have spent on a procedure now being performed by the dental hygienist, this will increase both productivity and production for the office. The increased productivity and production generate more profit by increasing collections more than the associated expenses. B. Endodontic Treatment Rotary Files A second example of productivity enhancement through reduced chairside time is endodontic rotary NiTi files. Endodontic treatment occurs an estimated 20 million times each year, 12 and has evolved from the use of hand reamers and files to the use of modern rotary NiTi files, shapers and obturators that have reduced the time taken for the procedure increasing productivity. Since the root canals can be routinely debrided, shaped and obturated all in one visit it is possible to schedule one block of time for a one-visit endodontic treatment further reducing the time involved and reducing the expense of room turnaround including the infection control procedures required between patients and the extra assistant time required. In our example, the dentist s productivity as a result of reduced chairside time increases gross profit by $125.00 (Table 5). Modern rotary files and the use of endodontic handpieces and obturators have also increased the predictability of positive treatment outcomes. In contrast to the scaling and root planing example, there is no potential for productivity-enhancement through delegation. It is important to remember that this does not yet consider the incremental cost of using NiTi files. Table 5. Increased Productivity: Endodontic Therapy Rotary Files Hand Instruments Number of treatment visits 1 2 Total DDS chairside time 1 hour, 1 hour, 15 minutes 45 minutes Total cost of DDS chairside time $312.50 $437.50 Average collection (fee), bicuspid endo* $827.40 $827.40 Gross profit before all other costs $514.90 $389.90 *Source: Limoli, T, Limoli, Jr.,T. 2006 Fee Survey. Dent Econ October 2006:2 10. IV. Adoption of Technology: Considerations and Associated Costs Awareness of new technology and a willingness to endorse it varies depending upon an individual clinician s philosophy and knowledge of the benefits of the technology. If the individual interested in adopting a new technology is not responsible for decision-making then buy-in must be obtained from the decision-maker who must have a clear understanding of the benefits and costs associated with the technology. Considerations in the adoption of technology are: Cost of acquisition Potential frequency of use Clinical advantages Improved patient care Standard-of-care Incremental production 4 www.ineedce.com

Increased productivity Learning curve Keeping up with the profession Documentation requirements Ideally, the new technology will improve treatment outcomes, reduce treatment time, have a low acquisition cost that enables increased profitability, and importantly offer a better patient experience. In both of our examples, the cost of acquisition is low, with potential gains in productivity and production as a result of their use. Cost of Anesthetic In the case of the locally-applied noninjectable anesthetic cartridge, the incremental cost of the anesthetic is $4.60 compared to the $0.40 cost of a local anesthetic cartridge. 13 After taking this into consideration, there are still productivity and production gains as well as the ability to offer patients more flexibility, comfort and a needle-free experience. The net gain would be $22.98 per quadrant, with the dental hygienist administering the more expensive cartridge of noninjectable anesthetic gel instead of the dentist administering the less expensive injectable anesthetic. Compared to the dental hygienist giving local anesthetic, the net gain would be $2.15 (Table 6). These net gains are before consideration of the number of visits. Table 6. Cost of Anesthetic and Net Productivity Gain Quadrant Scaling Locally-applied, Local Local noninjectable anesthetic anesthetic anesthetic administered administered administered by RDH by RDH by DDS Cost of cartridge $5.00 $0.40 $0.40 Onset time 30 seconds 5 minutes* 5 minutes* Cost of RDH time $0.75 $7.50 $7.50 Cost of DDS time $0.00 $0.00 $20.83 Total cost of use $5.75 $7.90 $28.73 Net productivity gain $22.98 2.15 * Onset time includes one minute of topical anesthetic application and on average four minutes onset time for the drug. V. Implications for Practice Building: The Hygiene Department The hygiene department drives around 35% 40% of the dentist s production in the dental office. Particularly effective hygiene departments can internally refer as much as 50% of the treatment performed by the dentist. 14 A specific goal for office production is the hygienist s recommendation and referral of patients within the office back to the dentist for elective procedures that the patient may be willing to have carried out following scaling and root planing and discussion with the hygienist. Increasing productivity for the hygienist frees up time to perform additional procedures as well as to talk to patients and recommend elective treatment. Increasing productivity by reducing the number of visits Locally-applied noninjectable anesthetic gel and endodontic rotary NiTi files both offer the opportunity to complete treatment in fewer visits. Time is saved and convenience improves for the patient, without compromising the standard of care. Due to the site-specific application of noninjectable anesthetic gel and lack of lingering numbing side effects, patients can be treated in fewer visits full mouth scaling and root planing can be completed in one or two visits rather than the customary four visits for separate quadrants. One visit full-mouth scaling and root planing has been found to be clinically as effective as 4 one-quadrant visits, 15 and to take significantly less time. 16 Koshy et al found that the total time required for full-mouth ultrasonic debridement was 2 hours and 7 minutes. 17 If a conservative 5 minutes per appointment were assumed for room turnaround, disinfection and sterilization procedures between patients (during which the hygienist is not performing a procedure), one-visit full-mouth treatment would save approximately 15 minutes in room turnaround time per scaling and root planing patient excluding treatment time saved (Table 7). Table 7. Monthly time saved with 5 minutes room turnaround time 2 visits, 1 visit, half-mouth srp whole-mouth srp 1 RDH, 10 srp patients per month 100 minutes 150 minutes Group practice, 2 RDH, 10 srp patients each per month 200 minutes 300 minutes Perio practice, 1 RDH, 30 srp patients per month 300 minutes 600 minutes In reality, many offices book 1 hour for quadrant scaling and root planing visits, anticipating 45 minutes of actual instrumentation within this hour. 18 Based upon the findings of Koshy et al, in this case the time savings would be 45 minutes of saved room turnaround time (including ancillary tasks) plus 53 minutes saved in actual treatment time. The increased productivity gain on a per patient basis would be $147.00 for one full-mouth scaling and root-planing visit. Extrapolating the data from Koshy et al for half-mouth visits and with two room turnarounds would give a productivity gain per patient of $85.50 (Table 8). The timesavings on a monthly basis would depend upon the number of dental hygienists and hours in the office, as well the type of office. In a periodontal office seeing 30 quadrant scaling and root planing patient visits per week equivalent to 30 patients receiving their treatment per month (4 quad- www.ineedce.com 5

Table 8. Increased Productivity: Scaling and Root Planing Visits/Patient Single Quadrant Half Mouth Whole Mouth Number of visits 4 2 1 RDH total chairside time 4 hours 3 hours, 3 minutes* 2 hours, 22 minutes** Average collections (fee)*** $895.60 $895.60 $895.60 Cost of RDH total chairside time $360.00 $274.50 $213.00 Gross profit before any costs $535.60 $621.10 $682.60 Incremental gross profit before all other costs $85.50 $147.00 *2 hours, 33 minutes for scaling and root planing plus 30 minutes room turnaround time. **2 hours, 7 minutes for scaling and root planing plus 15 minutes room turnaround time. ***Source: Limoli, T, Limoli, Jr.,T. 2006 Fee Survey. Dent Econ October 2006:2 10. rants each patient), the monthly time savings would amount to 2,700 minutes (Table 9). This assumes that the time taken would be rounded up to the nearest 10 minutes, in line with scheduling (i.e. 3 hours 10 minutes and 2 hours 30 minutes for half-mouth and full-mouth respectively) prior to calculating monthly timesavings. Table 9. Monthly time saved, 4 quadrant scaling and root planing visits 2 visits, 1 visit, half-mouth srp whole-mouth srp 1 RDH, 10 srp patients per month 500 minutes 900 minutes Group practice, 2 RDH, 10 srp patients each per month 1,000 minutes 1,800 minutes Perio practice, 1 RDH, 30 srp patients per month 1,500 minutes 2,700 minutes The use of modern ergonomically designed ultrasonic scalers compliments the potential productivity gains enabled by the use of locally-applied noninjectable anesthetic gel. Scaling procedures are fatiguing and wearing for the clinician. 19,20 Hand scaling has been shown to reduce tactile sensitivity. 21 These factors become more important in relation to long visits for whole-mouth or half-mouth scaling. Ultrasonic scaling helps to preserve tactile sensitivity, 22 and ergonomic design features also help protect the clinician from work-related injuries. The use of ultrasonic debridement has been estimated to reduce the time required by 36.6% compared to manual debridement, 23 and design features such as wireless foot controls and rapidly interchangeable inserts reduce the need for the operator to stop during the procedure resulting in more efficiency. Table 10. Annualized increase in number of procedures $200,000 $150,000 2 visits, 1 visit, half-mouth srp whole-mouth srp 1 RDH, 10 srp patients per month 28 66 Group practice, 2 RDH, 10 srp patients each per month Perio practice, 1 RDH, 30 srp patients per month Practice with 1 RDH, 2 srp per day Group Practice, 2 RDH, 2 srp each per day Perio practice, 30 srp per week 57 132 86 198 incremental procedures based upon the time savings in Table 9, rounded down to the nearest whole treatment and assuming 11 months are worked in a year. Using this example, a hygiene chair seeing ten quadrant scaling and root planing patients per week would complete incremental procedures based upon half-mouth or whole-mouth treatments equivalent to incremental revenue of approximately $25,000 and $59,000 respectively. The productivity gains in a periodontal office would be greater given the typically higher rate of scaling and root planing procedures within the specialist office. With scheduling of half-mouth visits, and the use of locally-applied noninjectable anesthetic gel and ultrasonic scalers assumed for all patients, annual incremental production could approach $77,000 (Table 11). Table 11. Annualized Potential Incremental Revenue Increasing hygiene production and profitability through increased productivity Productivity gains with use of locally-applied noninjectable anesthetic gel result in time savings that can be used for additional procedures. The incremental production increases revenue and profit. Table 10 shows the annualized number of $100,000 50,000 $0 Half-mouth srp visits Whole-mouth srp visits 6 www.ineedce.com

Appointment Scheduling Scheduling blocks of time for specific types of procedures and ensuring that these blocks are protected, as well as scheduling longer appointments for individual patients, optimizes the available time. Patients that need scaling and root planing procedures are more likely to both schedule their appointment and to keep their appointment if they can have this completed within a week to 10 days after their evaluation. If blocks of time have not been held open for bookings this will not be possible. New patients also prefer to be seen quickly and are more likely to attend after making an appointment if the scheduled time is within a week to 10 days. Improving the convenience of treatment is a great practice building mechanism that will ultimately lead to more case acceptance and completion of treatment and therefore to improved oral health as well as more production. Smart scheduling can enable visits of increased length, and reduce the possibility of a broken appointment at a subsequent visit. Short-term appointments are also available by protecting time within the schedule for specific types of procedures that will be needed, which increases the flexibility of scheduling for the patient. Case Acceptance and Completion of Treatment Lack of time and scheduling issues negatively influence a patient s decision to receive treatment, even when he or she accepts that treatment is required. Block scheduling and/or a reduced number of visits therefore help the patient accept and receive needed treatment, and help the office achieve both its clinical and business objectives. Full-mouth treatment also offers convenience for the patient reducing the time taken to treat a less anxious and more cooperative patient. The risk of future failed appointments and nontreatment for the remaining quadrants is also avoided under this scenario. Pain relief during treatment results in a comfortable patient, the ability to effectively treat the patient, and a greater likelihood that the patient will return for future treatments. Without anesthesia many patients would not return. Up to 21 percent of respondents in an ADA study cited fear of pain as a reason they avoided dental care. 24 In comparing methods of pain relief one study found that 45% of patients were more willing to return if they received noninjectable anesthetic gel rather than local anesthetic. 25 Noninjectable anesthetic gel is convenient and offers flexibility for dental professionals and patients alike. Patients who do not return do not receive needed treatment, and either do not make further appointments or make appointments and either cancel them or simply do not turn up. If one-fifth of patients do not return in an office performing only quadrant scalings at the first visit and of this 20 percent one-third do not turn up then there are production implications as well. Each patient who does not return after the first visit forgoes 3 quadrant treatments, totaling $671.70 of lost production. While some appointments are not made or are cancelled in sufficient time for the appointments to be given to other patients, if one third do not cancel then lost production for that visit amounts to $223.90 based upon average fees for scaling and root planing. Half-mouth and whole-mouth visits in conjunction with locally-applied noninjectable anesthetic gel reduce patient fear, relieve pain, require fewer visits and would result in fewer no-shows and less lost production (Table 12). Table 12. Convenience and Flexibility Convenience and flexibility Rapid onset time Complete delegation of anesthetic is possible Multiple areas of the mouth can be worked on in one visit Enables sufficient, reliable anesthetia without an injection Enables convenient scheduling for the patient and office Patient is not exposed to pain or fear of an injection Patient has no lingering numbness If the office itemizes treatment procedures there is an opportunity to charge patients for the noninjectable anesthesia gel as an added service particularly if no anesthetic would otherwise be used, and will compensate for the incremental expense of administering the anesthetic. In this case, there is a gain due to an additional fee. Studies have found that patients preferred the use of the locally-applied noninjectable anesthetic to local anesthetic, 26 which may increase their acceptance of a fee associated with this. Patients preferred it and found it to be a direct benefit that they were willing to pay an additional fee for. On average this additional fee was estimated at $17.50 in one study. 27 Nonetheless, most offices currently build local or noninjectable anesthesia into the global fee for procedures. While intended for scaling and root planing procedures, other potential uses for rapid onset, noninjectable anesthetic gel may include the removal of a primary tooth that is hanging by a small tag of gingival tissue, prior to removal of impacted debris subgingivally and interdentally in painful areas, and placement of retraction cord around non-vital prepped teeth prior to impression taking. Use during retraction cord placement may not save time since local anesthesia could be given and other steps completed during the onset time, however, it would nonetheless improve patient comfort and the patient s experience. In the case of the primary tooth which may have been an unplanned appointment given the nature of the procedure, it would reduce the time the dentist must wait from 5 minutes to about 30 seconds, offer more convenience and flexibility and likely result in a child that is more comfortable and less fearful. VI. Summary Maintaining and increasing production and productivity in the dental office, while continuing to provide patients www.ineedce.com 7

with standard-of-care treatment and a comfortable experience, are key objectives. In recent decades, new technology has increasingly enabled new and superior treatments that reduce chairside time or enable treatment completion in fewer visits. This in turn enables greater production within the same number of chairside hours as before. Ideally, new technology will improve treatment outcomes, reduce treatment time, have a low acquisition cost that enables increased profitability, and importantly, offer a better patient experience. Recent innovations that have enabled this include endodontic NiTi rotary files and novel locally-applied noninjectable anesthetic. The use of locally-applied noninjectable anesthetic gel by the hygienist leverages the dentist s chairside time for other procedures and can be a valuable practice and profit builder. Dental professionals can look forward to technological innovations in the future that will further improve patient treatment and outcomes, as well as offering economic advantages for the dental office. Endnotes 1 American Dental Association. The 1999 Survey of Dental Services. 2002. 2 American Dental Association. Accessed May 2006. 3 American Dental Association. The 1999 Survey of Dental Services Rendered. 2002. 4 Van Steenberghe, D, et al. Patient Evaluation of a Novel Non-Injectable Anesthetic Gel: A Multicenter Crossover Study Comparing the Gel to Infiltration Anesthesia During Scaling and Root Planing. J Periodontol 2004;75(11):1471 1478. 5 Donaldson, D, et al. A placebo-controlled multi-centred evaluation of an anaesthetic gel (Oraqix) for periodontal therapy. J Clin Periodontol 2003;30:171 175. 6 Magnusson, I, et al. Intrapocket anesthesia for scaling and root planing in pain-sensitive patients. J Periodontol 2003;74(5):597 602. 7 Friskopp, J, et al. The anesthetic onset and duration of a new lidocaine/ prilocaine gel intra-pocket anesthetic (Oraqix) for periodontal scaling/ root planing. J Clin Periodontol 2001;28(5):453 458. 8 Crawford, S, et al. Quantification of patient fears regarding dental injections and patient perceptions of a local noninjectable anesthetic gel. Compendium 2005;26(2) Suppl 1:11 14. 9 Milgrom, P, et al. Four dimensions of fear of dental injections. J Am Dent Assoc 1997;128:756 762. 10 Dr. Charles Blair and Associates, Inc. 11 www.adha.org. Accessed Oct 2006. 12 American Dental Association. The 1999 Survey of Dental Services Rendered. 2002. 13 Sullivan Schein. November 2006. 14 Levin, RP. Increasing hygiene productivity. Compend Contin Educ Dent 2003;24(3):170 172. 15 Jervoe-Storm, PM, et al. Clinical outcomes of quadrant root planing versus full-mouth root planing. J Clin Periodontol 2006;33(3): 209 215. 16 Koshy, G, et al. Effects of single-visit full-mouth ultrasonic debridement versus quadrant-wise ultrasonic debridement. J Clin Periodontol 2005;32(7):734 743. 17 Ibid. 18 Atlanta Dental Services. October 2006. 19 Dong H, et al. The effects of finger rest positions on hand muscle load and pinch force in simulated dental hygiene work. J Dent Educ. 2005;69(4):453 460. 20 Dong H, et al. The effects of periodontal instrument handle design on hand muscle load and pinch force. J Am Dent Assoc. 2006;137(8): 1123 1130. 21 Ryan DL, Darby M, et al. Effects of ultrasonic scaling and handactivated scaling on tactile sensitivity in dental hygiene students. J Dent Hyg. 2005;79(1):9. Epub 2005 Jan 1. 22 Ibid. 23 Tunkel J, Heinecke A, Flemmig TF. A systematic review of efficacy of machine-driven and manual subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol 2002;29 [Suppl 3]:72 81. 24 American Dental Association News Release, 2003. 25 Van Steenberghe, D, et al. Patient evaluation of a novel non-injectable anesthetic gel: a multicenter crossover study comparing the gel to infiltration anesthesia during scaling and root planing. J Periodontol 2004;75(11):1471 1478. 26 Van Steenberghe, D, et al. Patient evaluation of a novel non-injectable anesthetic gel: a multicenter crossover study comparing the gel to infiltration anesthesia during scaling and root planing. J Periodontol 2004;75(11):1471 1478. 27 Matthews, D, et al. Putting your money where your mouth is: willingness to pay for dental gel. Pharmacoeconomics 2002;20(4):245 255. Author Profile Charles Blair, DDS Dr. Charles Blair is a contributing editor for Dental Economics magazine, and a former practicing dentist who now provides consulting services to the dental industry on a full-time basis through Dr. Charles Blair & Associates, near Charlotte, North Carolina. A graduate of Erskine College, he earned his Doctorate at the University of North Carolina at Chapel Hill. Dr. Blair also holds degrees in Accounting, Business Administration, Mathematics and Dental Surgery. He has individually consulted with thousands of practices. Also a widely-read and highly-respected author, he has written the E-Z Tax Cookbook and co-authored Marketing for the Dental Practice and Employing Family Members in Your Practice: A Tax Bonanza! In addition, he has published numerous articles in various dental magazines. Dr. Blair is a nationally recognized speaker for national, state and local dental groups, study clubs and other organizations. He offers leading-edge presentations in the business/finance/insurance coding arena of dentistry. Dr. Blair s extensive background and expertise make him uniquely qualified to share his wealth of knowledge with the dental profession. Disclaimer The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. Reader Feedback We encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com. 8 www.ineedce.com

1. Business objectives for the dental office are to. a. Increase production and decrease productivity b. Decrease production and increase productivity c. Increase production and increase productivity 2. If both productivity and production increase there will always be a proportionate increase in costs. a. True b. False 3. Actual profit in the dental office depends upon realized income. a. Less the actual expenses incurred b. Less only the clinician s time c. Less the fees collected d. b and c 4. Productivity is determined by. a. The sum of all procedures b. The time taken to perform given procedures c. The overall expenses of the office 5. Greater productivity. a. Frees up clinician time b. Enables increases in production without requiring increases in chairside time c. Reduces collections d. a and b 6. As a general rule of thumb, a dentist s chairside production costs per hour. a. $150 b. $175 c. $250 d. $400 7. of all dental procedures were estimated to be performed in general dental offices in 1999. a. 65 percent b. 73.5 percent c. 82.5 percent d. 90 percent 8. of general dentists were estimated to employ dental hygienists in 2003. a. 55 percent b. 73 percent c. 75 percent d. 80 percent 9. If a dental hygienist performs a procedure instead of a dentist and the dentist instead performs a procedure with a higher fee that takes a similar length of time, this will. a. Decrease productivity b. Decrease profit c. Increase gross profit 10. Considerations in adopting new technology include. a. Cost of acquisition b. Improved patient care c. Increased productivity d. All of the above 11. Most States permit dental hygienists to administer local anesthetics. a. True b. False 12. Production-enhancing technology can increase production by. a. Satisfying a patient need b. Offering a new treatment c. a and b Questions 13. A willingness to adopt new technology depends upon. a. An individual clinician s philosophy b. Knowledge of the specific benefits of the technology c. The technology being proven over several decades d. a and b 14. Particularly effective hygiene departments can internally refer as much as of the treatment the dentist performs. a. 20 percent b. 35 percent c. 50 percent d. 100 percent 15. While the cost of locally-applied noninjectable anesthetic gel is higher than the cost of injectable local anesthetic, productivity gains (in $) resulting from the use of the noninjectable anesthetic gel would be higher than the incremental cost. a. True b. False 16. Endodontic NiTi files are productivity-enhancing because they. a. Have increased the efficiency of endodontic treatments b. Help treatment be completed in one visit c. Different sizes don t need to be used during the procedure d. a and b 17. Disinfection and sterilization costs can be reduced by. a. Reducing the number of visits required to complete treatment b. Increasing the number of visits required to complete treatment c. Increasing the number of instruments used during a procedure 18. Factors playing a role in the type of anesthetic used include. a. The patient s perception of pain b. Fear of injections c. The onset time and time involved for the procedure d. All of the above 19. Using a locally-applied noninjectable anesthetic gel instead of an injectable local anesthetic can reduce. a. Onset time b. Chairside time c. a and b 20. In 1999, approximately of scaling and root planing procedures were performed in general dental offices. a. 50.3 percent b. 65.7 percent c. 85.5 percent d. Over 90 percent 21. The use of ultrasonic debridement has been estimated to reduce the time taken by up to compared to manual debridement. a. 24.5 percent b. 36.6 percent c. 40.2 percent d. 50.5 percent 22. A single visit full-mouth scaling and root planing, based upon the findings of Koshy et al, and allowing 15 minutes per room turnaround, would mean the total time required would be compared to 4 hours for single visit quadrant scaling. a. 3 hours 10 minutes b. 2 hours 45 minutes c. 2 hours 22 minutes d. 1 hour 30 minutes 23. The number of visits required to complete full-mouth scaling and root planing can be reduced without compromising clinical effectiveness and patient care by. a. Scaling and root planing only a few of the teeth requiring treatment per quadrant b. Increasing the number of clinicians working on the patient c. Using an anesthetic technique that enables anesthesia to be safely and effectively applied for one-visit full mouth scaling and root planing d. Reducing the time per appointment 24. With respect to locally-applied noninjectable anesthetic gel, studies have found that patients. a. Preferred this to injectable local anesthetic b. Were willing to pay an additional fee for it c. Would rather their mouths were numb when they went home d. a and b 25. Koshy et al found that a onevisit full-mouth scaling and root planing saved of actual instrumentation time. a. 15 minutes b. 25 minutes c. 53 minutes d. 70 minutes 26. Minimizing patient discomfort leads to. a. More case acceptance b. More production c. More completion of treatment d. All of the above 27. Compared to scaling all four quadrants in separate visits, full mouth scaling has been found to. a. Be as effective b. Be less efficient c. Take less time d. a and c 28. Reducing room turnover rates will. a. Reduce disinfection and sterilization costs b. Help increase efficiency c. a and b 29. In offices with over-booked hygiene departments, scheduling blocks of time and protecting these blocks will. a. Make everyone s life miserable b. Expand the time available for additional scaling and root planing procedures c. Mean an extra workday is needed 30. Innovative locally-applied noninjectable anesthesia gel and endodontic rotary NiTi files have both enabled. a. Fewer visits for completion of treatment b. Block scheduling c. Patient convenience d. All of the above www.ineedce.com 9

ANSWER SHEET Scaling-Up Productivity with Technology Name: Title: Specialty: Address: E-mail: City: State: ZIP: Telephone: Home ( ) Office ( ) Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. Educational Objectives 1. Know the clinical and business objectives for the dental office and have a clear understanding of how production and productivity influence costs and profitability 2. Be able to determine the financial contribution technology offers through delegation, increased production and increased productivity 3. Understand the factors that should be considered when evaluating the return on investment for new technology and how to measure productivity gains 4. Understand the practice-building implications of technologies offering patient and productivity benefits, including flexibility of scheduling Course Evaluation Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Objective #2: Yes No Objective #4: Yes No Mail completed answer sheet to Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 For immediate results, go to www.ineedce.com and click on the button Take Tests Online. Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: Exp. Date: Charges on your statement will show up as PennWell 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author s grasp of the topic? 5 4 3 2 1 0 6. Please rate the instructor s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Do you feel that the references were adequate? Yes No 9. Would you participate in a similar program on a different topic? Yes No 10. If any of the continuing education questions were unclear or ambiguous, please list them. 11. Was there any subject matter you found confusing? Please describe. 12. What additional continuing dental education topics would you like to see? AGD Code 550 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. AUTHOR DISCLAIMER The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB s Recertification Department at 1-800-FOR-DANB, ext. 445. RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell 10 www.ineedce.com