Journal IDA Spring 2020 : simplebooklet.com

Journal IDA The Journal is owned and published by the Indiana Dental Association a constituent of the American Dental Association 550 W North Street Suite 300 Indianapolis IN 46202 The editor and publisher are not responsible for the views opinions theories and criticisms expressed in these pages except when otherwise decided by resolution of the Indiana Dental Association The Journal is published four times a year and is mailed quarterly Periodicals postage pending at Indianapolis Indiana and additional mailing offices Manuscripts Scientific and research articles editorials communications and news should be addressed to the Editor 550 W North Street Suite 300 Indianapolis IN 46202 or sent via email to kathy indental org Advertising All business matters including requests for rates and classifieds should be addressed to Kathy Walden at kathy indental org or 800 562 5646 A media kit with all deadlines and ad specs is available at the IDA website at www indental org adverts add Copyright 2020 the Indiana Dental Association All rights reserved Personnel Editorial Board Dr Jack Drone Editor Dr William B Risk Peer Review Editor Dr Rebecca De La Rosa Associate Editor Kathy Walden Managing Editor Communications Committee Dr Matthew Kolkman Chair Dr Todd Butwin Dr Caroline Derrow Dr Jack Drone Dr Nels Ewoldsen Dr Brian King Dr Thomas M Murray Dr Joseph Platt Officers of the Indiana Dental Association Dr Steven Ellinwood President Dr David Wolf President Elect Dr Steven Hollar Vice President Dr Thomas R Blake Treasurer Dr Jack Drone Editor Dr Jill M Burns Speaker of the House Dr Rebecca De La Rosa Vice Speaker of the House Dr Daniel Fridh Immediate Past President Mr Douglas M Bush Executive Director Secretary Submissions Review Board Dr Jeffrey A Dean Indianapolis Indiana Dr Roger L Isaacs Indianapolis Indiana Dr Joseph H Lovasko Hammond Indiana Dr Jeffrey A Platt Indianapolis Indiana Dr Christopher R Miller Indianapolis Indiana A publication of the Indiana Dental Association

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Editor s Message JOURNAL IDA Thank You Dr Jack Drone As I write my sixth and final version of my last Editorial from my empty unlit office I am overwhelmed with my thoughts emotions and memories I am very appreciative for the vote of confidence from the IDA to fulfill four terms as Editor S ometime around 2003 our receptionist told me that Terry Schechner was at our front desk He asked me if I would join him at a Northwest Indiana Dental Society Board Meeting He also challenged me to get more involved in organized dentistry I did As I write my sixth and final version of my last Editorial from my empty unlit office I am overwhelmed with my thoughts emotions and memories I am very appreciative for the vote of confidence from the IDA to fulfill four terms as Editor Now the thank you Our Central Office is outstanding Doug has talked me through many instances He is available and always willing to help I can say that I have worked with almost everyone in the office at a committee or council level and I have always felt supported Laurie and Jody have always been incredible on the phone and in person Thank you all very much I will miss calling and catching up with all of you daily if not weekly I have worked with some exceptional Managing Editors Laura Barnard and Kelly Jones Sharp were great I was really fortunate to catch lightning in a bottle with Will Sears and Karen Scharf They are true friends and I still communicate with them regularly I was at my best when I was working in tandem with them Thank you both Kathy Walden has been a great addition and I have enjoyed working with her very much She is great and the next Editor s transition will be easy due to her ABOUT THE AUTHOR Journal Editor Dr Jack Drone is a general dentist practicing in Rensselaer He can be reached at jack hillcrestdental net I have had the pleasure of working closely with two Deans at IUSD Dean Larry Goldblatt is a friend who I can always count on His leadership is and has been unshakable Dean John Williams has always treated me as one of his own His vision and leadership are and were immeasurable Thank you both for your friendship My former Component Society Northwest is the best Lou Sertich Terry Schechner Steve Holm Mark Mihalo and the goat are near and dear to me I am forever grateful for your support and encouragement Thank you all Marty and Patty Szakaly will always hold a special place in my heart as I traveled to many meetings with them Marty was so formative in my early years He is a gem and a fellow Notre Dame man Thank you both 4 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Editor s Message JOURNAL IDA My wife Jana is a rock and I have been selfish with my time on occasion I thank her for the meeting times where I was gone I thank her for proofreading and keeping track of things at home while I am at all things IDA related I outkicked the punt coverage when I married Thank you Jana Dick Jones has become a very good friend of mine I owe him a debt of gratitude for always trying to keep me on a good course He loves dentistry and our great profession I hope his passion for dentistry never subsides Thank you Dick Tom Murray is one of finest ever to be affiliated with the Indiana Dental Association He is tireless and unflappable I miss seeing him at Trustee meetings He and I worked on many projects for the Association and I have very fond memories of all of those moments Thank you Tom Mike Rader was my best friend in dentistry He has been gone over two years now I miss him daily I would have likely not known him if it were not for the Editor position He would often call me and say that he was near Rensselaer No one is really ever near Rensselaer He would stay at the house for four to five hours while never having so much as a glass of water because he was in a hurry In the last years he would bring me gifts A brick from Notre Dame Stadium a picture a ham That was Rader The boys loved him We still read books he purchased for them They still talk of a lunch we had in a carnicera in Benton Harbor Michigan We had to pass through a plastic sheeted refrigeration fruit section to arrive at the self order restaurant They know him as Dr Bulldog his Township School mascot Thank you Mike Thanks to my four boys Tate Graham Beck and Merr They always think that when I have a meeting that it has to do with the Journal They too have benefited from me being Editor They will have a fuller appreciation of that someday Thanks boys I know that I am remiss to mention others but this is it Thank you all very much I do not view this a good bye but a see you later Let me watch some Sectional Championships with the boys Take care of the IDA and please make us essential again That may be our greatest task in the next decade The Golden Dome at Dr Drone s beloved University of Notre Dame Despite my 12 years as Editor my two favorite columns of all time come from the same issue Summer 2018 See pages 6 9 to read a reprint I hope you enjoy them as much as I have The Drone family at Arches National Park March 2019 VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 5

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President s Message JOURNAL IDA Farewell to a Dramatic Year Dr Steve Ellinwood 2020 turned into one crazy unpredictable tumultuous year but I wouldn t trade this experience for anything ABOUT THE AUTHOR Dr Steve Ellinwood is the 20192020 IDA president and practices in Fort Wayne He can be reached at sedds drellinwood com W hen I took office last June I never imagined the year 2020 taking the turn that it did Things that I felt the IDA needed to accomplish this year faded into the COVID 19 pandemic The challenge to all of you has been dramatic and we are still working our way through it The pandemic has taken a toll on your practice your family and your team In my practice we are piecing it together slowly trying to help my team and our patients find their comfort zone I know it was very rough in the beginning because information was coming out and changing so quickly Some of it was confusing and sometimes information changed so fast we did not even have a chance to vet it I know that two or three announcements and emails did not even get published because the information changed as we were preparing them I understand that early on many of you were very angry with the IDA for asking you to close your offices voluntarily in agreement with the ADA s national recommendation I still feel this was the right decision I wish it had not lasted as long but it was the right decision for our patients our team ourselves and our greater community The new normal is a statement I really have grown tired of hearing But I do feel that our practices are going to evolve due to the pandemic I am not sure where we will end up but growing and stretching and changing is good for our patients We all wish to provide the very best in dental care It has been an honor and privilege to serve as your IDA president this past year 2020 turned into one crazy unpredictable tumultuous year but I wouldn t trade this experience for anything Next month I will turn the association over to the capable hands of Dr David Wolf who I m sure will do an even better job guiding the IDA through the remainder of the COVID 19 crisis as well as all the other issues certainly more mundane in comparison that affect the day to day running of our great association 10 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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President s Message JOURNAL IDA I also want to thank the hard working volunteers who are rotating off of the Board of Trustees next month Dr Jack Drone who is hanging up his Editor hat after 12 years of hard work and terrific guidance on our quarterly Journal Dr Jim Shupe who for three years has been the dedicated trustee of my own component Isaac Knapp and Amanda Yacoub our ASDA representative who has provided a youthful and enthusiastic voice on our Board for 2019 2020 Best of luck and a million thanks to the three of you A special thanks to Dr Steve Hollar and the COVID 19 Task Force as well as the IDA team They really stepped up when the association needed them the most None of us knows exactly what the coming months and years will bring but I m sure we will get through it and be stronger than ever Thank you for your support and membership this year Did You Notice Something Different With Your Journal This edition of Journal IDA includes a complimentary continuing education folder that allows members to record and store certificates and other proof of CE for this license renewal period In the past these folders have been extremely well received by members and their team and we are happy to provide them again VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 11

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Executive Director s Message JOURNAL IDA Unprecedented Mr Doug Bush As I pen this article most dental offices are closed or open for emergency care only 97 percent according to the ADA Optimists say efforts to flatten the curve are working and America will reopen soon By the time you read this article hopefully we ll know if they were right ABOUT THE AUTHOR Mr Doug Bush is serving his 25th year as IDA Executive Director He can be reached at doug indental org U nprecedented If you are like me you ve grown weary of that word In the context of COVID 19 it seems to be uttered by reporters and politicians every other sentence In one sense our current health crisis is not unprecedented this is not our first pandemic and won t be our last But it is certainly unlike anything I ve experienced I was an early denier I understand that sensational headlines attract viewers and readers and political opportunists will stoke public fear to advance an agenda So my cynical side prompted me to dismiss early alarmists Then the Big 10 Conference called off its tournament and the NBA canceled its season That got my attention These groups forfeited millions of dollars in ticket sales and television contracts a pretty good indicator they thought the threat was real Within two weeks the president had advocated social distancing the governor had issued a stay at home order and the ADA and CDC had called for dentists to delay all but essential care We watched both infection rates and death rates steadily rise So here we are As I pen this article most dental offices 97 percent according to the ADA are closed or open for emergency care only Businesses are shut down All schoolers are homeschoolers and churches are holding Sunday services online Optimists say efforts to flatten the curve are working and America will reopen soon By the time you read this article hopefully we ll know if they were right But what do we do in the meantime Some of you may have seen a quote that has broadly circulated in recent weeks In 1948 as the atomic age ushered in the Cold War British author C S Lewis was asked to address this newfound threat to society His essay On Living in an Atomic Age was his response to how to live under the threat of mutually assured destruction 12 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Executive Director s Message JOURNAL IDA How are we to live in an atomic age Lewis wrote Why as you would have lived in the sixteenth century when the plague visited London almost every year or as you would have lived in a Viking age when raiders from Scandinavia might land and cut your throat any night or indeed as you are already living in an age of cancer an age of syphilis an age of paralysis an age of air raids an age of railway accidents an age of motor accidents We ll benefit from a healthy dose of humility as we remember how easily society was brought to its knees by a microscopic virus It is perfectly ridiculous to go about whimpering and drawing long faces because the scientists have added one more chance of painful and premature death to a world which already bristled with such chances and in which death itself was not a chance at all but a certainly Lewis alternative The first action to be taken is to pull ourselves together If we are going to be destroyed by an atomic bomb let that bomb when it comes find us doing sensible and human things praying working teaching reading listening to music bathing the children playing tennis chatting to our friends over a pint and a game of darts not huddled together like frightened sheep and thinking about bombs They may break our bodies a microbe can do that but they need not dominate our minds Some have been critical of applying Lewis counsel to COVID They retort How can you suggest gathering with friends for darts when we re supposed to observe social distancing But I think they miss his point Lewis is simply reminding us that we can t allow fear of dying to keep us from living Some folks get it As I jog through my neighborhood carefully observing social distance with others sharing the street I see uplifting sidewalk chalk drawings and messages left by someone I look in the front windows of homes at stuffed animals on display Our neighborhood website encouraged parents to take kids on bear hunts so I dutifully placed a big stuffed bear in our window to play my part in the game I read that someone organized a caravan of cars that parked at the entrance to a local hospital so they could honk and shout thanks to health care workers as they entered and exited the hospital at shift change Families are relearning board games Couples are eating at home together Neighbors are checking on neighbors This unprecedented pandemic will end Sports will resume Toilet paper will again appear on store shelves Dental offices will reopen and patients will return We ll look back and better assess who did or didn t overreact We ll learn more about infection control and how to be better prepared for next time We ll benefit from a healthy dose of humility as we remember how easily society was brought to its knees by a microscopic virus And hopefully we gain a better appreciation for the blessings of friends family and good health VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 13

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Cover Story JOURNAL IDA HIPAA Is 24 Years Old Take a look at a history timeline for the Health Insurance Portability and Accountability Act AUGUST 1996 HIPAA INTRODUCED When Congress passed the Health Insurance Portability and Accountability Act the process of modernizing information exchange in healthcare began in earnest HIPAA also ensured that workers would not lose health insurance coverage when changing jobs looked at national standards with Current Dental Terminology CDT code sets and fraud mitigation MARCH 2002 PRIVACY RULE MODIFIED DHHS mandated changes are designed to clarify the Privacy Rule and ease the administrative burden on healthcare providers 14 AUGUST 1998 SECURITY RULE PROPOSED New legislation to improve security standards to better protect individual health information in the hands of health plans healthcare clearinghouses and healthcare providers FEBRUARY 2003 SECURITY STANDARDS FINAL RULE ISSUED With the issuance of the Final Rule Covered Entities are required to implement appropriate Administrative Physical and Technical safeguards to protect PHI NOVEMBER 1999 PRIVACY RULE PROPOSED Proposed to improve privacy standards and restrict the disclosure of Protected Health Information PHI the Privacy Rule also fostered better health data access for patients It added forms for Notices Acknowledgments and Business Associate Agreements APRIL 2003 DEADLINE FOR PRIVACY RULE COMPLIANCE With the Privacy Rule in place Covered Entities are required to allow patients to access their PHI on request The Rule limits how when and to whom health information is disclosed Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2 DECEMBER 2000 POLICING HIPAA The Office for Civil Rights OCR is assigned responsibility for policing HIPAA APRIL 2005 HIPAA ENFORCEMENT RULE PROPOSED The Enforcement Rule paves the way for OCR investigations and financial penalties for HIPAA violations

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Cover Story JOURNAL IDA APRIL 2005 SECURITY RULE COMPLIANCE All Covered Entities must comply with Security Rule requirements and implement more stringent controls for safeguarding health records The OCR is empowered to issue penalties for violations OCTOBER 2009 HITECH ACT ENFORCEMENT INTERIM RULE ISSUED MARCH FEBRUARY ENFORCEMENT RULE GOES INTO EFFECT HITECH ACT SIGNED INTO LAW 2006 The OCR is expected to start issuing financial penalties for any Covered Entity that fails to implement the requirements of the Privacy and Security Rules JANUARY 2010 FIRST OCR SETTLEMENT FOR HIPAA VIOLATIONS 2009 Health Information Technology for Economic and Clinical Health Act HITECH is introduced Incentives aim to speed the adoption of electronic health record systems FEBRUARY 2010 START OF HITECH ENFORCEMENT CVS Pharmacy Inc is ordered to pay 2 25 million for improperly dumping patient records New financial penalties for HIPAA violations now apply the healthcare industry is warned that compliance will be robustly enforced MARCH JANUARY MARCH OMNIBUS FINAL RULE OMNIBUS FINAL RULE ISSUED The Interim Rule introduces a tiered structure of penalties for violations with four categories of liability Fines are increased to 1 5 million 2012 Omnibus modifies HIPAA Privacy Security Enforcement and Breach Notification Rules Changes include changes to a number of HITECH provisions and major updates 2013 Incorporating changes to HIPAA required by HITECH four years earlier Omnibus aims to improve data security further restrict PHI access and prevent use of PHI for marketing 2013 OMNIBUS RULE IN FORCE The healthcare industry is given six months to comply before Omnibus is enforced Breach notification rules are updated and Business Associates can be held liable for breaches AUGUST 2009 BREACH NOTIFICATION INTERIM REGULATIONS ISSUED DHHS introduces regulations promulgated by HITECH covering data breaches Covered Entities are required to report breaches to OCR and notify potential victims NOVEMBER 2011 OCR BEGINS HIPAA COMPLIANCE AUDITS The OCR begins a pilot round of just 115 audits of Covered Entities to gauge the state of HIPAA compliance Only 11 percent pass APRIL 2016 OCR BEGINS SECOND ROUND OF HIPAA COMPLIANCE AUDITS The second round of HIPAA compliance audits were originally scheduled for late 2014 delayed until 2015 and finally begun in April 2016 VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 15

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Cover Story JOURNAL IDA HIPAA Deconstructed Breaking Down the Parts of HIPAA Jay Dziwlik MBA CAE T he acronym of the whole body of federal law has its official name as Health Insurance Portability and Accountability Act It was established in 1996 by bipartisan effort of Senators Kassebaum and Kennedy but its roots stem from promised efficiencies of electronic health records and the need for standards in electronic health records for patient and health care provider protections Below you ll find a breakdown of the different aspects of HIPAA Current Dental Terminology CDT ABOUT THE AUTHOR Jay Dziwlik is the IDA s assistant executive director and resident HIPAA expert He can be reached at jay indental org 16 These are the dental code sets published annually by the American Dental Association The CDT 2020 are the most up to date sets on Dental Procedure Codes and the only HIPAA recognized code set for dentistry Prior to HIPAA every third party payer had their own unique codes which resulted in the dental staff referring to multiple code sets Privacy The HIPAA Privacy Rule as it s officially known establishes national standards to protect individuals medical records and other personal health information and applies to health plans health care clearinghouses and those health care providers including dentists that conduct certain health care transactions electronically The Rule requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization The Rule also gives patients rights over their health information including rights to examine and obtain a copy of their health records and to request corrections In 2002 this was the first big introduction of HIPAA to dentistry Indiana dentists were a little better prepared than other states due to current Indiana laws previously established in statutes Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Cover Story JOURNAL IDA Security Breach and Breach Notification This is a summary of key elements of the Security Rule including who is covered what information is protected and what safeguards must be in place to ensure appropriate protection of electronic protected health information Because it is an overview of the Security Rule it does not address every detail of each provision Breach in the simplest terms is when protected health information goes where it should not Breach Notification according to rule 45 CFR 164 400414 requires HIPAA covered entities and their business associates to provide notification following a breach of unsecured protected health information National Provider Identifier NPI HIPAA requires that health care providers have standard national numbers that identify them on standard transactions The National Provider Identifier NPI is a unique identification number for covered health care providers Covered health care providers and all health plans and health care clearinghouses use the NPIs in the administrative transactions adopted under HIPAA The NPI is a 10 position intelligence free numeric identifier 10 digit number This means that the numbers do not carry other information about healthcare providers such as the state in which they live or their medical specialty HITECH HITECH is an acronym for Health Information Technology for Economic and Clinical Health Act a part of the American Recovery and Reinvestment Act of the 2009 The laws were a part of the omnibus HIPAA rulemaking process of the U S Department of Health and Human Services Office of Civil rights and they implemented a number of provisions to strengthen privacy and security protections for health information established under the original HIPAA legislation A breach is generally an impermissible use or disclosure of the protected health information An impermissible use or disclosure of protected health information is presumed to be a breach unless the covered entity or business associate as applicable demonstrates that there is a low probability that the protected health information has been compromised based on a risk assessment Enforcement HHS Office for Civil Rights is responsible for enforcing the Privacy and Security Rules Enforcement is primarily complaint driven but the Office of Civil Rights also has instituted an audit process The compliance issues most often alleged in complaints are the following in order of frequency 1 Impermissible uses and disclosures of protected health information 2 Lack of safeguards of protected health information 3 Lack of patient access to their protected health information 4 Lack of administrative safeguards of electronic protected health information 5 Use or disclosure of more than the minimum necessary protected health information VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 17

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Cover Story JOURNAL IDA Business Associate and Business Associate Agreements A business associate is a person or organization other than a member of a covered entity s workforce that performs certain functions or activities on behalf of or provides certain services to a covered entity that involve the use or disclosure of individually identifiable health information Business associate functions or activities on behalf of a covered entity include claims processing data analysis utilization review and billing Business associate services to a covered entity are limited to legal actuarial accounting consulting data aggregation management administrative accreditation or financial services Business Associate Agreements should exist between any business associate and the covered entity and outline the responsibility of the business associate to maintain HIPAA standards in handling protected health information It is like a chain of custody and responsibility for your patient information If a business associate fails in their duty they would be subject to HIPAA enforcement rules Information sourced from the U S Department of Health and Human Services www hhs gov hipaa index html Conclusion No one ever accused HIPAA of being simple or completely easy to understand However understanding the basic components of HIPAA will help you to better comprehend your rights and responsibilities as a health care provider in the protection of your patients privacy and health records 18 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Cover Story JOURNAL IDA Are Your Systems Secure Cybersecurity Training is a Critical Aspect of Adhering to HIPAA Guidelines Laura M Cascella I n recent years cybersecurity has become a top buzzword in business and public sectors including dentistry The need to protect proprietary and sensitive information is increasingly challenging as technology expands and evolves Complex networks and data exchanges cloud based services social media online portals the Internet of Things and other technologies have introduced opportunities and efficiencies but also potential threats The Importance of Cybersecurity Training ABOUT THE AUTHOR Laura Cascella MA is a medical writer editor at MedPro Staff members are a frontline resource in preventing cyberattacks but they also can represent a significant vulnerability for practices Verizon s 2018 Data Breach Investigations Report notes that Healthcare is the only industry where the threat from inside is greater than that from outside Human error is a major contributor to those stats 1 A Medscape article echoes this concern stating that Many physicians providers and employees unknowingly engage in risky behavior on their home and work computers 2 A survey of more than 600 healthcare professionals conducted by Merlin International and the Ponemon Institute revealed that about half of the participants felt that lack of employee awareness and training affects their ability to achieve a strong security posture almost three fourths of participants cited insufficient staffing as the biggest obstacle to maintaining a fully effective security posture 3 Staff awareness of best practices related to cybersecurity and data protection as well as a thorough understanding of organizational security protocols are the basis of a solid training program and crucial to each practice s cybersecurity plan 20 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Cover Story JOURNAL IDA Developing a Robust Training Program Dental practices vary in size location patient population clinical staff systems and so on Because each practice is unique a one size fits all training approach for cybersecurity is unrealistic however it is likely that many practices face similar threats and will want to educate staff on similar topics When devising educational outreach related to cybersecurity consider the following topics for inclusion Common ways that breaches occur such as lost or stolen laptops data sharing over unsecured networks inappropriate access to systems and careless security practices Common cyber threats such as ransomware phishing spyware distributed denial of service attacks Trojan horses worms and pretexting and how they are executed Best practices for preventing data breaches and cyberattacks including Implementing technical safeguards such as data encryption two factor or multi factor authentication strong passwords or passphrases and system lockouts Sharing confidential or sensitive information via approved secure communication channels Avoiding accessing confidential or sensitive information on public computers or over public or unsecure wireless connections Knowing red flags for cyberattacks such as suspicious URLs or domain names unsolicited emails requesting personal information offers that seem too good to be true emails containing odd messaging or typos grammatical issues requests for money and messages containing threats Avoiding risky online behaviors such as bypassing virus protection alerts clicking on pop up ads visiting sites with security issues using the same password for multiple sites opening email attachments from unknown sources and failing to sign out of shared computers Being aware of how cybercriminals might access social media to glean key information that will allow them to crack passwords and breach accounts VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 21

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Cover Story JOURNAL IDA Taking physical precautions to prevent inadvertently disclosing protected information such as using privacy screens avoiding writing down or sharing passwords logging out of systems after use and following policies related to taking mobile devices or hard copy data outside organizational premises Possible consequences of cybersecurity lapses including loss of systems interruptions to patient care and processes possible patient harm financial losses and impact to the practice s reputation Practice policies and protocols that support a culture of security including Compliance with state and federal privacy and security laws Procedures for conducting risk assessments and gap analyses Rules related to social media and use of personal electronic devices 22 Strategies for securely storing and disposing of protected information hard copy and electronic Strategies for managing loss of systems or access to electronic health records Resources for continued learning about cybersecurity best practices and breach prevention protocols such as The Office of the National Coordinator for Health Information Technology the Federal Bureau of Investigation and the U S Department of Health and Human Services RESOURCES 10 WAYS TO ESTABLISH A SECURITY CULTURE AT YOUR HEALTHCARE ORGANIZATION www medpro com security culture PASSWORDS A NEW APPROACH TO AN OLD SCHOOL SECURITY STRATEGY www medpro com password security RISK RESOURCES CYBERSECURITY www medpro com documents 10502 2824311 Risk Resources_Cybersecurity pdf RISK TIPS USING PHYSICAL SAFEGUARDS TO PREVENT SECURITY BREACHES www medpro com documents 10502 2824311 Risk Resources_Cybersecurity pdf VIDEO ONLINE VULNERABILITIES FOR HEALTHCARE ORGANIZATIONS vimeo com 282356874 Procedures for reporting behaviors and actions that violate the practice s privacy and security policies as well as continued assurance of a nonpunitive environment for raising concerns Disciplinary actions for deviating from established policies and protocols Procedures for responding to suspected or known breaches or cyberattacks including incident reporting protocols and staff roles and responsibilities Conducting a security risk assessment as required by HIPAA for covered entities and business associates can help define the specific needs of each practice so that training can be focused or customized as needed Other Training Considerations Individuals in charge of developing and organizing staff education should consider various training formats and activities to keep individuals engaged and aware For example using simulated phishing emails can help staff learn to identify cybersecurity red flags Reviewing actual scenarios of healthcare breaches and cyberattacks including discussing what occurred how it occurred and ways to prevent similar incidents also might be beneficial Other options include periodic email reminders interactive modules posters team discussions and role playing Educators also should be mindful that staff members will have varying levels of technical knowledge and aptitude Training sessions and materials should be clear and understandable to all participants Focusing on need to know information and avoiding technical jargon can support participant understanding and retention of information Summary Cultivating a knowledgeable and well educated staff is one of the preeminent ways that dental practices can protect against security breaches and cyberattacks By developing a comprehensive staff education program on cybersecurity best practices policies and protocols practices can help ensure that staff members are an asset rather than a vulnerability Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Cover Story JOURNAL IDA References 1 Verizon 2018 2018 data breach investigations report Executive summary Retrieved from https enterprise verizon com resources reports dbir 2 Hood G A 2017 April 25 How to prevent costly and dangerous cyberattacks Medscape Retrieved from https www medscape com viewarticle 878592_3 3 Merlin International 2018 March 12 Merlin International Ponemon Institute cybersecurity study signals dangerous diagnosis for healthcare industry BusinessWire Retrieved from www businesswire com news home 20180312005302 en Merlin International Ponemon InstituteCybersecurity Study Signals 4 Hood How to prevent costly and dangerous cyberattacks Shryock T 2017 February 10 Top tips for protecting a practice from hackers Medical Economics Retrieved from www medicaleconomics com medical economics blog top tips protecting practice hackers Weil S 2017 February 10 How 4 key practices can prevent ransomware incidents Health Data Management Retrieved from www healthdatamanagement com opinion how 4key practices can prevent ransomware incidents Downing K 2017 AHIMA guidelines The cybersecurity plan Retrieved from http journal ahima org ahima guidelines cybersecurity plan 5 Snell E Ed 2017 Training employees to avoid healthcare data security threats HealthIT Security Retrieved from https healthitsecurity com features training employees to avoid healthcare data security threats VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 23

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Cover Cover Story StoryJOURNAL JOURNAL IDA IDA HIPAA FAQs Test Your HIPAA IQ With These Common Questions and Answers Jay Dziwlik MBA CAE L et s face it Sometimes HIPAA is really complicated A lot of what the dental association does for you as a member is to help translate the many regulations on dentistry so you can understand and apply them to your practice HIPAA regulations often bring more questions than answers so the IDA has collected some frequently asked questions from dental offices and provided some helpful guidance Some of those questions can be very practicespecific so these answers are general guidelines Any specific questions related to your practice should be thoroughly researched for your situation Is there a mandate to go chartless or a requirement for electronic charting ABOUT THE AUTHOR Jay Dziwlik is the IDA s assistant executive director and resident HIPAA expert He can be reached at jay indental org HIPAA legislation has roots in the concept of paperless society and the potential cost savings of medical and dental offices to go from physical paper charting to electronic charting But there is no current mandate for any dental practice to go completely to electronic charting This is a dentist owner decision A lot of this transition also raises concerns about retaining health records for the seven years and five years for radiographs required by Indiana statutes All records management including disposal should ensure all records are private and secured Can our practice use postcard appointment reminders for patients even with HIPAA You can as long as you have permission from the patient Most patients appreciate the reminders Some dentists include this in new patient information or add it to the Notice of Privacy Practices Some have the patients fill out their own postcard reminders and then the practice mails them at the appropriate time Patient information is their own and giving you permission to use it is totally appropriate 24 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Cover Story JOURNAL IDA Are dental offices required to use encryption Encryption can be a tricky question because there is a difference between what is required and what is recommended HIPAA security rules outline that security standards in the technical physical and administrative realm should be reasonable and appropriate This standard is moving and similar to standard of practice It is easier to understand when you think about security standards of 1995 and how they re not the same security standards in 2020 So back to the question at hand Encryption is currently not required by HIPAA but often recommended I do foresee a day when that will be the expectation and standard but we re not there yet Google has a free encryption feature Regular email is not encrypted and it is good to add language to your notice of privacy practices that tells patients you communicate in a non encrypted email What does an office do if a patient refuses to sign the acknowledgment of Notice of Privacy Practices form What do I do if a patient changes the language on the forms Remember that all the forms in your office related to HIPAA are to remind you and the patients that they have rights related to privacy and security related to their personal health information PHI and in order to provide treatment payment and normal healthcare operations the patient needs to give the dentists and practice permission to use PHI If a patient does not sign an acknowledgment then they have not given you permission to use their PHI for treatment payment and normal healthcare operations So that means something different in your practice One obvious relates to payment If you cannot share PHI with a third party payer or financing group to help the patient pay then the patient would need to pay in full prior to treatment If you need to refer you would not be able to send information to that specialist There may be many more impacts you will need to determine for yourself as you think about where PHI goes in the course of a patient visit What HIPAA concerns should I have about responding to social media comments online Social media and HIPAA do not mix well Privacy rules limit your ability as a dentist and practice to respond to any public posting of comments or information It may seem like a double standard and a big frustration for a patient to be able to post their own information on a social media site and you are limited Any social media comments by patients should be handled very carefully so as not to create more problems especially with a HIPAA violation All responses should be aimed at taking the conversation offline for example Thank you for contacting us We value and aim for the highest oral health standard and patient satisfaction We invite you to contact us directly to discuss your situation Avoid acknowledging specifics on patients and their treatment to avoid sharing any PHI Why is updating our computer software important to HIPAA security The security rules ask for technical standards to avoid breaches of protected health information Security updates that come regularly through your software providers are often updates to plug the holes in security hacks and data breaches If you do not update your software regularly you may be leaving your computers susceptible to future breach Software that is no longer supported e g Microsoft Windows 7 means software patches are no longer maintained and updated Without this support those softwares no longer comply with HIPAA security rules How should our practice interact with minors as it relates to HIPAA paperwork Our practice has parents who are paying for the dental care of their adult child and want to see the health record What should we be doing to comply with HIPAA Interaction with children under 18 years old is to also interact with that child s custodial adult With HIPAA those adults would sign paperwork to allow the use of an underage child s PHI for treatment payment and normal healthcare operations This would continue until the child VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 25

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Cover Story JOURNAL IDA turns 18 when they must sign their own paperwork According to HIPAA there is no stipulation for who is making payment on healthcare Any patient who is 18 or older must give permission for the practice to share any information with someone other than the patient Realistically a parent might want to have a conversation with their own adult child to have communication as a condition of continue payment assistance Can I share patient information with another dentist for example a referring specialist What about payment information Again you can use protected health information with the permission of a patient In the case of consulting and referring to a specialist researcher or physician it is often the best to share You want to make sure you have signed Acknowledgment of Notice of Privacy Practices on file Referrals directly to a specialist are included in 26 that initial paperwork The specialist should then have the patient complete separate HIPAA paperwork so that the specialist will be able to share information back with you as the referring dentist Payment information usually is not included in that paperwork because HIPAA allows you to get permission to facilitate payment for the work and treatment you do not for treatment done in another office The best practice would be to allow each office to get payment information for themselves IDA knows that there are many other questions related to HIPAA If you have a specific question that you would like addressed please email Jay Dziwlik at jay indental org Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Clinical Focus JOURNAL IDA Evaluation of a Dental Diagnostic Terminology Subset Heather L Taylor MPH LDH Zasim Siddiqui BDS MS S NODENT a dental diagnostic terminology or any of its subsets should be evaluated for content coverage and completeness The objective of this study was to determine how well a subset of SNODENT designed for general dentistry met the needs of dental practitioners Participants were asked to locate their written diagnosis for tooth conditions among a subset of SNODENT terms uploaded into an electronic dental record Investigators found that 65 percent of providers original written diagnoses were in agreement with their selected SNODENT dental diagnostic subset concept s highlighting the effectiveness of using terminology subsets at the point of care Additional education and training for dental providers on appropriate selection and use of SNODENT terms to document patient care is needed Results provide valuable insights on useful revisions updates and expansions to the SNODENT terminology Keywords Electronic Health Record terminology SNODENT Electronic Dental Record SNOMED CT Dental Informatics Kendall Frazier DDS Thankam Thyvalikakath DMD PhD 28 Introduction For over a century medicine has benefited from systematized documentation of clinical diagnostic and procedures through the use of controlled terminologies 1 Clinicians use diagnostic terminologies for disease surveillance monitoring quality of care and research 2 Examples include the International Classification of Diseases Tenth Edition Clinical Modification ICD 10 CM and the Systematized Nomenclature of Medicine Clinical Terms SNOMED CT ICD 10 CM is a wellestablished classification system used to record diagnoses for billing purposes and collection of mortality data and SNOMED CT is a controlled terminology that facilitates the expansion of concepts with cross mapping to associated body structures devices pharmaceuticals events and laboratory data 3 6 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Clinical Focus JOURNAL IDA Unlike medicine no standardized diagnostic terminology is mandated for use within the profession of dentistry 7 Both ICD 10 CM and SNOMED CT contain some dental diagnostic concepts but overall they lack comprehensive descriptions and relationships representing all aspects of oral diseases and conditions 8 As a result dental providers tend to classify or describe patients according to their treatment rather than disease diagnosis 1 9 Given that reimbursement from payors only requires dental providers to use the Code on Dental Procedures and Nomenclature CDT procedure codes not many dental clinicians consistently record diagnoses for each tooth or oral condition 2 9 10 opinion and consensus for use in the dental clinics of the School of Dentistry University of Detroit Mercy They developed the subset to facilitate efficient documentation of common dental conditions seen in a general dentistry setting Although this subset precedes the current SNO DDS General Dentistry subset which also remains to be thoroughly evaluated this study highlights the importance of using terminology subsets to record diagnoses effectively and efficiently Findings from this study are of interest to dental practitioners who wish to carefully track disease diagnoses study oral health outcomes and monitor quality Methods Since existing controlled terminologies lacked comprehensive This study was approved by the The objective of this descriptions of oral conditions Indiana University Institutional Review various stakeholders educators and study was to Board Study 1503902699 and interest groups began developing conducted at the Indiana University determine how well more representative terminologies for School of Dentistry IUSD A subset dentistry Notable contributions of the SNODENT terminology 410 a SNODENT subset include Leake codes 9 Dental unique concepts designed for use Diagnostic System DDS codes designed for by general dentists was uploaded formerly EZ Codes 11 and the into the training module of axiUm 6 x general dentistry Systematized Nomenclature of Exan corporation Vancouver BC Dentistry SNODENT terminology 12 meets the needs of Canada the school s electronic dental Recently SNODENT a subset of record EDR The training module of dental practitioners SNOMED CT since 2013 and DDS the EDR allows study participants to an interface dental terminology directly interact with the SNODENT were harmonized 1 3 7 The terminology in a familiar clinical EDR combination of these two environment terminologies led to the 2017 accreditation of SNODENT a dental diagnostic terminology as the standard by the We recruited a convenience sample of 20 participants American National Standard Institute ANSI and the consisting of six faculty and fourteen third and fourthAmerican Dental Association ADA and the creation of year dental students Participants were either full time two subsets SNO DDS and SNO DDS General clinical faculty or third or fourth year dental students We Dentistry 3 7 While having an accredited standard required the participant to be a full time faculty member terminology brings dentistry closer to systematically or an advanced dental student to ensure the participant tracking diagnoses it does not guarantee clinician 3 was familiar and comfortable with documenting patient acceptance and use In fact SNODENT a dental care in the EDR system diagnostic terminology or any of its subsets have yet to be thoroughly evaluated for content coverage and completeness The objective of this study was to determine how well a SNODENT subset designed for general dentistry meets the needs of dental practitioners The ADA Practice Institute developed this particular subset through expert Investigators selected a record of a dental case patient herein referred to as case patient previously described in a another study 13 The record included the case patient s health history information and oral findings related to periodontal disease and caries Specifically the case patient had poor oral hygiene generalized gingival VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 29

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Clinical Focus JOURNAL IDA inflammation mesial and distal primary caries on anterior teeth cracked teeth secondary caries extensive decay with pulp exposure and a periapical radiolucency Upon enrollment into the study participants were asked to review the case patient s record and to think aloud as they examined the case patient s medical history dental findings clinical photographs and radiographs The think aloud method includes the participant verbalizing their thoughts and actions as they carry out tasks 14 16 The entire session was audio and video recorded to capture participants interactions and thoughts Each participant thought aloud while reviewing the case patient record and while writing dental diagnoses for eight teeth and the overall gingival health of the case patient on a paper form While continuing to think aloud participants next worked within the treatment planning module of the EDR to locate and select the best SNODENT diagnostic term s for each of their written diagnoses Afterwards participants rated their satisfaction as to whether each selected SNODENT concept represented their original written diagnosis Specifically each participant was asked if they were completely partially or not at all satisfied with each SNODENT concept selected within the EDR We recorded participants interactions with the EDR using Camtasia screen and voice capturing software TechSmith Corporation Okemos MI At the end of the study session each participant completed a questionnaire consisting of four Likert scale questions as well as two open ended questions The questionnaire was designed to assess the participants opinions on the use and clinical value of the subset presented to them in the EDR Data Analysis Two investigators HT ZS independently compared each participants written diagnoses and the corresponding SNODENT concept selected from the subset of SNODENT concepts uploaded into the EDR Written diagnoses and selected SNODENT concepts were considered in agreement if they represented analogous clinical meanings Conversely if the written diagnosis and the selected SNODENT concept were different in meaning or intent the match was labeled as non agreement by investigators Differences between the two investigators classification of agreement and non agreement cases were resolved through discussion with a third investigator TT Inter rater reliability between the two investigators was calculated using Cohen s Kappa coefficient 17 The percentage of SNODENT concept selections deemed in agreement with the participant s written diagnoses was calculated In addition the percentage of agreement among subgroups students versus faculty was compared using a Table 1 Examples of Agreement Between the Participants Written Diagnosis and Selected SNODENT Subset Concept s Participants and Tooth Written Diagnosis SNODENT Subset Concept s Student Tooth 8 Caries M L Caries involving multiple surfaces of the tooth Student Tooth 15 Gross caries Extensive cavitated lesion with exposed dentin Faculty Tooth 13 Recurrent decay Secondary caries Student Tooth 13 Irreversible pulpitis Irreversible pulpitis FIG 4b 30 FIG 5b Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Clinical Focus JOURNAL IDA generalized estimating equation GEE model for logistic regression We calculated the overall percentage of participant satisfaction with selected SNODENT concepts Students satisfaction with their selections was compared to faculty satisfaction using a GEE model for ordinal logistic regression Regressions were performed with a 95 percent confidence interval at a p value of 0 05 The software IBM SPSS Statistics Version 23 SPSS Inc Chicago IL was used to perform statistical analysis Descriptive statistics were utilized to evaluate the Likert scale questions of the end questionnaire Qualitative content analysis was used to determine any recurring themes in the open ended responses of the end questionnaire Video Analysis Two study investigators HT KF reviewed each recorded video of the participants interaction with the EDR and SNODENT terminology The recordings were evaluated to determine what barriers if any limited the participant s experience using the subset of SNODENT concepts within the EDR Specifically investigators wanted to determine if participants were able to locate a concept within the SNODENT subset that matched their written diagnosis Participants were considered to be experiencing difficulty if they had multiple failed search term queries attempted synonyms to their original written diagnosis expressed frustration or gave up searching In addition investigators noted whether the participant used the interface search box tool or browsed a categorical list of concepts presented in the interface We also documented whether the participant selected one or multiple diagnostic concepts to represent the findings and conditions of a single tooth Results Twenty participants selected a total of 251 SNODENT concepts 42 unique codes to diagnose the specified dental conditions of the case patient Study investigators compared participants written diagnosis and the selected SNODENT subset concept s for similarity in conceptual representation Inter rater reliability between the two investigators was 89 percent Investigators found that 162 64 5 percent of the written diagnostic concepts were in agreement and 89 concepts 35 5 percent were in non agreement with the participants corresponding selected SNODENT concept s The subgroup analysis revealed that students selected a total of 169 diagnostic concepts and had 75 percent agreement between their written diagnoses and their selected SNODENT subset concepts whereas faculty selected a total of 82 diagnostic concepts and had 44 percent agreement The percentage of concept agreement among students was significantly higher than faculty p 0 0270 Tables 1 and 2 provide examples of agreement and non agreement matches between the participants written diagnoses and their selected SNODENT concept s from the subset presented in the EDR Participants were asked to subjectively report their satisfaction with the SNODENT concept s and its representation of their original diagnosis Participants reported being completely satisfied with 155 62 percent of their selected SNODENT subset concepts partially satisfied with 82 32 5 percent and not at all satisfied with 14 5 5 percent of their selections No significant differences were observed in satisfaction levels between students and faculty p 0 54 Our end study questionnaire revealed that participants perceived value in this particular subset of the SNODENT terminology Table 3 displays participants questionnaire responses Analysis of the participants open ended responses to the end questionnaire revealed issues with the subset of SNODENT concepts and the EDR interface Participants who were frustrated with the terminology reported that there were too many concepts to search through too many options with similar meanings and missing concepts Regarding the EDR interface participants noted their frustration with the categorization of certain concepts the necessity to search for the exact concept with correct spelling the EDR search tool box offered no suggestions for misspelled words and the time required to locate concepts Video analyses revealed that 75 percent 15 of participants experienced difficulty finding all of their written diagnoses within the subset of SNODENT concepts To compensate participants found substitute diagnostic concepts for the majority of their original diagnoses See Table 4 For 11 VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 31

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Clinical Focus JOURNAL IDA Table 2 Examples of Non Agreement Between the Participants Written Diagnosis and Selected SNODENT Concept s Participants and Tooth Written diagnosis SNODENT Subset Concept s Student Tooth 29 DO Amalgam Secondary dental caries Faculty Tooth 15 Extract non restorable a Retained dental root and b Extensive cavitated lesion with exposed dentin Faculty Tooth 30 Extract non restorable Abscess Student Tooth 1 Fracture with secondary caries Irreversible pulpitis Faculty Tooth 13 Restorable direct restoration Secondary dental caries Faculty Tooth 29 Restorable a Caries involving multiple surfaces of the tooth and b Dental caries extending into dentin and c Leaking dental restoration Student Tooth 15 Extraction Carious exposure of pulp Student Tooth 30 Extraction Periodontal and endodontic lesion searches participants were not able to locate a substitute Both students and faculty had difficulty in determining which SNODENT concept within the subset was the best selection especially among concepts with similar meaning One participant could not determine an ideal SNODENT concept to describe secondary caries on an anterior tooth Unsure of which concept to choose the individual selected four concepts to describe one tooth condition i e 161648D Caries involving multiple surfaces of the tooth 132634D Secondary caries 161653D Dental caries extending into dentin and 105102D Leaking dental restoration Two participants reported confusion as to the difference between SNODENT concepts 178311D Leaking dental filling and 105102D Leaking dental restoration They felt these concepts were identical and were perplexed as to why both options existed in the subset 32 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Clinical Focus JOURNAL IDA Table 3 Participants Responses to End Questionnaire Regarding Their Experience Using a Subset of SNODENT Concepts Questions Strongly Mildly Agree Agree Mildly Disagree Strongly Disagree Q1 This terminology worked well at identifying appropriate diagnoses for this patient s unique case 6 3 13 65 0 0 1 5 Q2 I believe using this terminology will add value to patient care and treatment planning 9 45 10 50 1 5 0 0 Q3 I found this terminology 6 30 9 45 easy to navigate and understand 3 15 2 10 Q4 I believe this terminology would be easy to implement in daily clinical care activities 6 30 2 10 6 30 6 30 Discussion This study investigated the extent to which a subset of the SNODENT terminology supported documentation of findings commonly seen during a typical dental examination Overall we found agreement between 65 percent of study participants written diagnosis and the SNODENT terminology they selected They were also completely or partially satisfied with 94 percent of the SNODENT concepts they selected which highlights the value of having smaller subsets of the SNODENT terminology for practical clinical use Created by expert opinion the subset used in this study was designed to be a reduced list of concepts for use by general dentists who primarily manage caries and periodontal disease In total this subset contained 410 unique concepts Despite a limited subset of concepts our results revealed that this subset still contained an overwhelming number of diagnoses for the provider to choose from These results are consistent with an early study on EZ Codes that found granularity and specificity of concepts to be suboptimal for users 7 In the sections below we describe recommendations to improve adoption of SNODENT to document diagnosis in dental settings based on the results VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 33

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ClinicalFocus Focus JOURNAL JOURNALIDA IDA Clinical Table 4 Examples of Written Diagnostic Concepts Participants Could Not Locate in the Subset of SNODENT Terminology and the Substitute SNODENT Subset Concept They Selected 34 Written Diagnostic Concepts Searched but Not Located by the Participant Substitute SNODENT Subset Concept Selected Poor oral hygiene Dental plaque 109682D Generalized moderate gingivitis Localized adult periodontitis 130428D Generalized chronic gingivitis Periodontitis 107582D Local severe chronic periodontitis Chronic gingivitis 131320D Generalized mild periodontitis Chronic gingivitis 131320D Generalized chronic periodontitis Periodontitis 107582D Primary caries Dental caries extending into dentin 161653D Interproximal caries No substitute found Gross caries Carious exposure of pulp 177244D Non restorable 177198D Extensive cavitated lesion with exposed dentin Extensive cavitated lesion with fracture Carious exposure of pulp 177244D Periapical radiolucency Periapical abscess 120676D Pulp polyp No substitute found Extract 177198D Extensive cavitated lesion with exposed dentin Bony defect Localized adult periodontitis 130428D Bruxism Cracked crown 107065D Altered active eruption No substitute found Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Clinical Focus JOURNAL IDA Ongoing Calibration and Training of Providers on Appropriate Selection and Use of SNODENT Concepts As indicated by the study results at times participants chose more than one concept to describe a tooth s condition For example to describe secondary caries on an anterior tooth one participant chose four concepts that included secondary caries caries involving multiple surfaces of the tooth leaking dental restoration and dental caries extending into the dentin These findings indicate the need to invest in training and calibrating dental providers on choosing the most appropriate diagnosis from the many concepts available in SNODENT We found significantly higher agreement among students written diagnoses and their selected SNODENT concepts when compared to faculty Interestingly when study investigators analyzed faculty s original written diagnoses faculty were more likely to write down treatment concepts as opposed to diagnostic concepts Example written diagnoses DO Amalgam Faculty s tendency to consider the case patient with regards to dental treatment rather than diagnoses is noteworthy and common in seasoned dental clinicians Our results emphasize the need to train experienced and licensed dentists in diagnostic concepts and their meaning Now that ANSI and ADA have accredited SNODENT a dental diagnostic terminology as standard it is time to research how this terminology can be used in a meaningful way to benefit patient care It is important to understand how professionals and stakeholders may use the terminology to support clinical decisions Appropriate education on the use of dental diagnostic terminologies will be necessary for successful adoption and implementation in the future Improve User Interface and Navigation to Improve Accurate Documentation of Diagnosis and Findings Gross Caries into the box Several of the concepts that participants were unable to locate did exist in the subset but because of the interface s search features many users remained oblivious as they struggled to find a SNODENT term that best represented their written diagnoses In most cases the participant did not search for their diagnoses under the right category list nor did they think to change their query slightly by using an analogous term In very few cases the queried concept did not exist within the subset Example pulp polyp Our study did not set out to evaluate the user interface However these findings demonstrate that the interface design of an electronic dental record plays a significant role in the providers ability to select an appropriate diagnosis from a dental diagnostic terminology The ease of navigation through the concepts is a major concern and illustrates the need to fit the technology to the end user s thought processes and workflow 18 Therefore to promote widespread adoption and use of the SNODENT terminology it is important to consider how the terminology is presented to the user taking care to make the searching and selection of concepts intuitive Map Concepts to Commonly Used Terms and Synonyms to Improve Accuracy and Eliminate Redundant Analogous Concepts Our study analysis revealed that dental providers have a typical vernacular language for dental diagnoses that lacks granularity e g Gross Caries Primary Caries etc The subset of SNODENT concepts however had a high level of specificity for dental conditions e g Dental caries extending into dentin 161653D Therefore future work must determine if it would be more advantageous to 1 create a system that maps commonly used diagnostic concepts to highly specific options in the terminology or 2 educate and train clinicians to describe dental findings with more granular detail A large majority of participants could not locate a diagnostic concept in the subset that represented one of their original diagnoses At first glance this may appear to be a deficiency of the subset of SNODENT terms presented to the user However our video analysis revealed additional challenges that were related to the interface For instance the search toolbox did not correct spelling errors or suggest alternatives when users typed common but unspecific concepts such as VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 35

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Clinical Focus JOURNAL IDA Limitations The generalizability of our study is constrained by our convenience sample of 20 participants from one dental school setting We also did not evaluate the full SNODENT terminology which may have contained representation for all of the study participant s written diagnoses Rather we evaluated a subset of the SNODENT terminology that was created from the most common dental conditions treated Our case patient was not representative of all potential dental conditions but did have multiple findings related to caries and periodontal disease the two most commonly treated diseases in dentistry Overall our study is one of the first to evaluate concepts from the SNODENT terminology and we identified gaps in a subset of SNODENT designed for general dentists that should be studied further Continuous revision and modifications to the SNODENT terminology are needed to increase its adoption and utilization by dental practitioners Conclusions The majority of participants in this study agreed that a subset of SNODENT concepts within the EDR could add value to patient care and treatment planning Investigators found that 65 percent of providers original written diagnoses were in agreement with their selected SNODENT dental diagnostic subset concept s Our findings illuminate the need for continual improvement of dental diagnostic terminologies through revisions and updates We recommend training on the use of dental diagnostic terminologies for documentation of dental diagnoses and conditions for all dental providers In addition an intuitive user interface is needed to support accurate and complete documentation of diagnosis and findings using controlled terminologies Acknowledgments We acknowledge Mr Craig Eberhart at the Indiana University School of Dentistry for his assistance with the EDR interface and Mr George Eckert at the Indiana University School of Medicine for his assistance with statistical methods 36 This research was supported by the National Library of Medicine of the National Institutes of Health under award number T15LM012502 Content in this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the National Library of Medicine Conflicts of Interest The authors declare no conflict of interest Address for Correspondence Thankam Thyvalikakath DMD PhD Indiana University School of Dentistry Department of Cariology Operative Dentistry Dental Public Health Associate Professor Director of Dental Informatics Core 1050 Wishard Boulevard R2206 Indianapolis IN 46202 Email tpt2 iu edu Future work must determine if it would be more advantageous to create a system that maps commonly used diagnostic concepts to highly specific options in the terminology or educate and train clinicians to describe dental findings with more granular detail Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Clinical Focus JOURNAL IDA About the Authors Heather Taylor is a PhD student at the Richard M Fairbanks School of Public Health at IUPUI in the Department of Health Policy and Management and a licensed dental hygienist She can be contacted at hhavens iu edu Zasim Siddiqui is a graduate student at West Virginia University School of Pharmacy He can be contacted at siddiqui zasim gmail com Kendall Frazier is a general dentist in Jacksonville FL and is a member of the ADA Florida Dental Association Academy of General Dentistry American Academy of Cosmetic Dentistry and American Academy of Implant Dentistry He can be contacted at frazier2 alumni iu edu Thankam Thyvalikakath DMD PhD is a dentist and associate professor at the Indiana University School of Dentistry a research scientist at the Center for Biomedical Informatics Regenstrief Institute Inc and director of the Joint Dental Informatics program at IUSD and Regenstrief Dr Thyvalikakath can be contacted at tpt2 iu edu References 1 Obadan Udoh E Simon L Etolue J et al Dental Providers Perspectives on Diagnosis Driven Dentistry Strategies to Enhance Adoption of Dental Diagnostic Terminology Int J Environ Res Public Health 2017 14 7 2 Miller CS Where are the diagnostic codes in dentistry Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011 111 2 131 132 3 Ramoni RB Etolue J Tokede O et al Adoption of dental innovations The case of a standardized dental diagnostic terminology J Am Dent Assoc 2017 148 5 319 327 4 Topaz M Shafran Topaz L Bowles KH ICD 9 to ICD 10 evolution revolution and current debates in the United States Perspect Health Inf Manag 2013 10 1d 5 Outland B Newman MM William MJ Health Policy Basics Implementation of the International Classification of Disease 10th Revision Ann Intern Med 2015 163 7 554 556 6 Elkin PL Brown SH Husser CS et al Evaluation of the content coverage of SNOMED CT ability of SNOMED clinical terms to represent clinical problem lists Mayo Clin Proc 2006 81 6 741 748 7 Shimpi N Ye Z Koralkar R Glurich I Acharya A Need for diagnostic centric care in dentistry A case study from the Marshfield Clinic Health System J Am Dent Assoc 2018 149 2 122 131 8 Walji MF Kalenderian E Tran D et al Detection and characterization of usability problems in structured data entry interfaces in dentistry Int J Med Inform 2013 82 2 128 138 9 Leake JL Main PA Sabbah W A system of diagnostic codes for dental health care J Public Health Dent 1999 59 3 162 170 10 Voinea Griffin A Fellows JL Rindal DB Barasch A Gilbert GH Safford MM Pay for performance will dentistry follow BMC Oral Health 2010 10 9 11 Kalenderian E Ramoni RL White JM et al The development of a dental diagnostic terminology J Dent Educ 2011 75 1 68 76 12 Goldberg LJ Ceusters W Eisner J Smith B The Significance of SNODENT Stud Health Technol Inform 2005 116 737 742 13 Thyvalikakath TP Dziabiak MP Johnson R et al Advancing cognitive engineering methods to support user interface design for electronic health records Int J Med Inform 2014 83 4 292 302 14 Kushniruk AW Patel VL Cognitive and usability engineering methods for the evaluation of clinical information systems J Biomed Inform 2004 37 1 56 76 15 Joe J Chaudhuri S Le T Thompson H Demiris G The use of think aloud and instant data analysis in evaluation research Exemplar and lessons learned J Biomed Inform 2015 56 284 291 16 Thyvalikakath TP Monaco V Thambuganipalle H Schleyer T Comparative study of heuristic evaluation and usability testing methods Stud Health Technol Inform 2009 143 322 327 17 Cohen J A Coefficient of Agreement for Nominal Scales Educ Psychol Meas 1960 20 1 37 46 18 Tokede O White J Stark PC et al Assessing use of a standardized dental diagnostic terminology in an electronic health record J Dent Educ 2013 77 1 24 36 VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 37

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Special Report JOURNAL IDA A Year No One Expected COVID 19 Sends the World and Dentistry Into Chaos 2020 was just around the corner when news began to surface about a virus in Wuhan China that had flu like symptoms but a higher death rate and faster rate of infection As January progressed so did concerns about the virus and by February panic began to grip the U S On March 16 the ADA recommended that dental offices around the country postpone routine procedures for three weeks but the recommendation eventually became moot as nearly every governor in the country began to issue varying degrees of public health emergencies and stay at home orders that forced office employees to work from home closed businesses deemed non essential and prohibited routine medical and dental care A lmost overnight dental offices were closed completely or open only for emergencies and dentists found themselves in a situation they never imagined Unemployed unsure of the future and facing the difficult decision to fire or lay off staff The education of Indiana s children and young adults was also put into jeopardy as schools and universities around the state closed first temporarily then for the remainder of the semester K 12 schools shifted to e learning platforms that made Indiana parents instant homeschoolers and as of press time colleges and professional schools including IUSD are still grappling with how to help students make up for the lost months in the practical education required to complete their degrees Indiana Governor Eric Holcomb initially announced the state s stay at home order on March 16 and extended it multiple times but then unexpectedly announced on April 20 that routine medical and dental procedures would be allowed to resume on April 27 Though the 38 announcement was welcome news to many dentists even the prospect of re opening dental offices was fraught with uncertainty Will my patients be unemployed and unable to afford dental care Will I have enough PPE Will the CDC issue new and expensive protective and disinfecting guidelines that add extra burdens to dental offices What if my staff are too afraid to treat patients and refuse to come back to work It s almost impossible to overestimate the impact of COVID 19 on the economy or our daily lives So much changed in a short period of time and no one is quite sure how it will end On May 1 Governor Holcomb unveiled a staged plan to re opening businesses and large events in Indiana but some experts predict that quarantines and closures will need to continue for as long as two years until the development of a reliable coronavirus vaccine Throughout the crisis IDA did its best to keep members informed and inspired while doing its part to help slow the spread of the virus See page 40 for more on how IDA responded to this crisis Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Special Report JOURNAL IDA IDA Donates PPE to State Health Facilities As the COVID 19 crisis unfolded throughout the country concerns grew over a lack of PPE for hospitals and health care providers On March 23 IDA staff and volunteers responded to the shortage by emptying gloves masks face shields gowns and canisters of disinfecting wipes from a storage facility and donating them to a nursing home the Suburban Health Organization and the Indiana Primary Health Care Association A Month Without Dentists Beginning with the ADA s recommendation and following most governors directives most dental offices in Indiana and around the country shuttered their doors partially or completely throughout March and April What is was the status of your office during the COVID 19 crisis Results as of April 20 Fully open INDIANA Completely closed 14 U S Completely closed 18 3 Open for urgent emergency cases only Open for urgent emergency cases only 86 79 VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 39

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Special Report JOURNAL IDA 1 300 000 PREMIUM SAVINGS ON THE IDA INSURANCE TRUST The IDA Insurance Trust Board voted to give every plan participant 50 percent off of their May and June premiums The decision saved Trust participants over 1 million 26 1 007 POLICYHOLDERS ON THE IDA INSURANCE TRUST WHO WERE HELPED BY THE PREMIUM SAVINGS More than 1 000 dentists and staff and their spouses and dependents benefited from the 50 percent reduction in May and June premiums MEMBER COVID 19 EMAILS Emails to members between March 12 and May 1 helped keep everyone updated on state directives federal assistance upcoming events and CE opportunities and positive messages from our president Dr Steve Ellinwood Visit the IDA website for continuing updates on COVID 19 state regulations and more www indental org category COVID 19 VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 41

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Member Zone JOURNAL IDA Have You Installed Your Amalgam Separator Dr Tom Murray ABOUT THE AUTHOR Dr Tom Murray practices in Princeton and is the current chair of the Indiana Dental Enterprises Association IDEA which selected Solmetex as the IDA vendor partner for amalgam separators F or most of us dentists the regulation deadline for installation of an amalgam separator is July 14 2020 For new Source Generators Transfer Generators and those that do not place or remove amalgams refer to details listed in Regulation 40 CFR Part 441 In addition to installing this apparatus you will be required to properly handle and dispose of waste amalgam as well There are also provisions within this new law that stipulate cleansing of vacuum lines using an approved vacuum line cleaner with a pH between 6 and 8 Safe handling and disposal of these wastes need to be properly documented as to when where and how they are disposed of as well Lastly all dental dischargers must submit a One Time Compliance Report to a Control Authority by October 12 2020 or within 90 days after transfer of ownership of a dental practice Please refer to Form OMB No 2040 0287 for details of this requirement a listing of Control Authorities and further details can be located at www epa gov eg dentaleffluent guidelines Regarding installation of your amalgam separator First of all make certain it is compliant with the stipulations of the law and secondly don t wait until the last minute to install it It took me about a month to find a person to install my particular amalgam separator I chose the Solmetex NXT Hg5 Amalgam Separator because it complied with all the standards of the law it was easy to install and maintain and it didn t cost me an arm 42 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2 and a leg to purchase and install Your IDEA negotiated a very reasonable price for this apparatus and Solmetex was very helpful in assisting me and meeting compliance standards Regarding installation I have very limited space in my utility closet where my vacuum system is located As a result I chose a plumber rather than a dental supplier technician He installed the unit in about an hour and charged me about 200 All in all choosing and installing the AS went relatively easy and the Solmetex compliance paperwork is going to make my life easier in dealing with and tracking these regulation standards One could argue that these regulations are a bit of a hassle but thanks to the IDEA and its parent association the IDA much of the legwork was minimal comparatively speaking I don t think anyone is necessarily in favor of more regulations but they seem to be a fact of life At least we have an organization to help us get over these hurdles when they occur Good luck with your installation just remember not to wait until the last minute July will be here all too soon Solmetex is helping IDA members through several different special offers Visit the Solmetex website for details www solmetex com promotions

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Member Zone JOURNAL IDA Viral Dr Bill Risk R ecently there have been a great many changes made in the way dentists have been able to practice Not only have they been told to only treat emergency patients they have also been asked to not treat hygiene patients nor are they to undertake any elective procedures in their practices So much for preventive and interceptive dentistry This must mean that reconstructive dentistry is out the window also COVID 19 has forced dentists to make quite a number of changes in the effort to control this malady ABOUT THE AUTHOR Dr Bill Risk is a general dentist practicing in Lafayette He can be reached at wriskdds gmail com In the 1980s the HIV epidemic caused a number of changes in the way dentistry was practiced At that time the great majority of practicing dentists did not wear gloves or masks when they were treating patients in their offices Not only that the dental instruments were only cold sterilized between patients AIDS made a great difference in the way we practice dentistry Presently there are about 14 states that have requirements for dental offices and their infection control procedures including required continuing education Additionally there are four states that allow dentists to administer flu and papilloma virus vaccines in their offices Could that give the dental profession some inkling of what might be coming its way Our legislators rightly so consider dentists health care professionals Their concerns are about looking after Hoosiers and the public health issues that citizens of Indiana present to them With the healthcare problems this coronavirus raises these policy makers are working already to find solutions and these solutions are going to include all health care providers With the healthcare problems this coronavirus raises policymakers are working already to find solutions and these solutions are going to include all health care providers This past winter the legislature had a short session One of the bills HB 1008 would have given licensure to any health professional that had a license in another state without allowing the professional board a chance to evaluate the applicant on his or her own merits This was an attempt to allow greater freedom for practitioners to come to Indiana This bill was introduced before COVID 19 was thought to even be a problem HB 1008 died but it is an example of the solutions our lawmakers are seeking When legislators seek to improve public health in Indiana they often look to other states What could some of these solutions be Dentists vaccinating patients in their offices Changes or increases in CE requirements New infection control regulations including personal protective equipment requirements Other solutions not even thought of yet Our state senators and representatives can be very creative COVID 19 demonstrates just how important it is to be in touch with the legislative process and have contact with our policymakers No matter what the profession does there are some changes in the practice of dentistry coming down the road It could be said these changes are going viral There are those who might say these changes are overdue and it is about time they were addressed That being said it is very important for dentists to be sitting at the table when these issues are being discussed Dentists must become acquainted with their legislators Sign up for their newsletters and if there is some reluctance in meeting them get in touch with the lawmaker s contact dentist and work through him her Remember this is not a partisan matter it is a public health one Change is coming and at viral speed VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 45

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Member Zone JOURNAL IDA Component News Indianapolis District Dental Society Deadlines For IDDS Dateline Friday July 10 Friday October 9 Dr Tyler Thomas wants your ideas and content Contact Dr Thomas at his office at drtylerjthomas gmail com or call 317 884 4155 IDDS Foundation Golf Tournament Wednesday July 15 Hillcrest Country Club Indianapolis First Merchants Bank will be giving away a 1 000 prize for dentists only Dentists registered by May 29 will be entered twice There will be another 250 from First Merchants Bank to the dentist who wins the PLINKO game that will be on the course that day play for free and maybe win some cash All of this is in addition to the 10 000 Hole In One Prize underwritten by Horizons Bank also available to all players Register by contacting IDDS at info indydentalsociety org or 317 471 8131 OSHA BLS Friday July 17 Friday October 9 Hillcrest Country Club Indianapolis Please register yourself and your staff at www indental org oc or call 317 634 2610 Lunch will be served to those attending both OSHA and BLS OSHA is from 9 11 a m and BLS is 11 30 a m 3 00 p m Space is limited IDDS Membership Committee Tuesday August 11 6 30 p m All are welcome 46 New Dentists Social Thursday September 17 New Dentists Social at Big Woods Brewery All dentists in practice 10 years and under are invited Contact IDDS at info indydentalsociety org to register IDDS President s Fall Workshop Thursday September 24 The Garrison Indianapolis CE seminar on the topic of Vaping Contact IDDS at info indydentalsociety org to register General Membership Meeting Wednesday October 7 IDDS Fall General Membership Meeting and recognition of our 5 and 10 year members Contact IDDS at info indydentalsociety org or 317 471 8131 to register IDDS Member Featured on ADA Blog Site Dr Elizabeth Simpson was a featured blogger on the ADA s New Dentist blog site Her April 3 post Doing our part in the COVID 19 crisis described her role working as a dentist at a Federally Qualified Health Center and the stress of her experience treating urgent cases during the COVID 19 crisis To read her full post visit the ADA New Dentist blog site newdentistblog ada org doing our part in the covid 19crisis Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

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Member Zone JOURNAL IDA Isaac Knapp District Dental Society Young Dentists Committee Thursday July 9 7 05 p m Join us for baseball fun as the Fort Wayne TinCaps battle the Dayton Dragons The evening is also Thirsty Thursday with fireworks after the game This event is tentative pending the lifting of COVID 19 restrictions Check www ikdds org for updates IKDDS Members Donate PPE IKDDS members responded to the hospital PPE shortage by generously donating their own supplies Dr Ronald Hammond donated six boxes of masks and 10 boxes of gloves after a request from Adams Memorial Hospital Dr Caroline Derrow donated five packs of gowns two cases of gloves and four boxes of masks to local health facilities IKDDS Hosts Successful All Day Meeting National speakers Dr Michael Greger along with Dr Vinodhi Bhoopathi and Dr Robin Steely led the IKDDS March 6 All Day Meeting with a nutrition and a healthier lifestyle focus We had 340 attendees and 45 vendor booths Dr Catherine Periolat formally transitioned her duties to President Elect Dr Geoffrey Glogas who will begin his term as president June 1 Thank you to everyone who attended We look forward to growing and making our All Day Meeting even better in the future VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 47

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Member Zone JOURNAL IDA New Members EAST CENTRAL DISTRICT DENTAL SOCIETY Dr Jessica Barry IU 2001 Dr Jack Summerlin IU 2008 FIRST DISTRICT DENTAL SOCIETY Dr Joshua Welborn Southern IL 2018 Dr Barbara Wells Univ of Louisville 1995 Dr Peter Wulff Univ of Louisville 2015 NORTH CENTRAL DENTAL SOCIETY Dr Jenna Oberley IU 2014 Dr Jennifer Roig IU 1997 Dr Andrew Zaremba Midwestern Univ IL 2016 NORTHWEST INDIANA DENTAL SOCIETY Dr Calara Hardin Univ IL Chicago 1998 Dr Nunya Irvine Southern IL 2007 Dr Anthony Pulver Midwestern Univ IL 2015 INDIANAPOLIS DISTRICT DENTAL SOCIETY Dr Aatif Ansari IU 2015 Dr Nomin Aomin Univ of WA 2019 Dr Millie Chang IU 2001 Dr Ashok Das Univ of Detroit 1991 Dr Emily Dauenhauer IU 2015 Dr Anthony Dee Southern IL 2011 Dr Harold Ervin IU 1977 Dr Jeffrey Grasser Univ of TN 1986 Dr Richard Low Midwestern Univ 2015 Dr Iris McNicholl IU 1994 Dr Amy Montefalco Loyola Univ Chicago 1992 Dr Jaren Shelton Univ of KY 2011 Dr Kevin Toole IU 2007 ISAAC KNAPP DISTRICT DENTAL SOCIETY Dr Todd Kleinrichert IU 1997 Dr Elisa Salazar IU 2017 48 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2 SOUTHEASTERN INDIANA DENTAL SOCIETY Dr An Hamman Univ of Louisville 2013 WEST CENTRAL DENTAL SOCIETY Dr Aaron Braithwaite IU 2013 Dr Glendale Lim Univ of MI 2016

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Member Zone JOURNAL IDA IN MEMORIAM DR JOHN R BEAN of Lebanon and member of the Ben Hur Dental Society passed away February 17 2020 Dr Bean graduated from Indiana University School of Dentistry in 1982 DR CECIL E BROWN JR of Carmel and member of the Indianapolis District Dental Society passed away February 20 2020 Dr Brown graduated from University of Tennessee School of Dentistry in 1959 DR BARBARA MCELHINEY of Indianapolis and member of the Indianapolis District Dental Society passed away February 8 2020 Dr McElhiney graduated from Indiana University School of Dentistry in 1989 DR CARL MCKEE of Terre Haute and member of the Western Indiana Dental Society passed away May 1 2020 Dr McKee graduated from Indiana University School of Dentistry in 1956 DR DAVID C VANDERSALL of Indianapolis and member of the Indianapolis District Dental Society passed away April 1 2020 Dr Vandersall graduated from Case Western Reserve University in 1961 Midwest Dental Assembly Canceled Virtual House of Delegates Planned for June The IDA s Annual Meeting Subcommittee unanimously agreed to cancel the 2020 Midwest Dental Assembly in the interest of allowing members and their dental teams to focus on their practice and rescheduling patients during the week of the conference IDA is planning a one day House of Delegates on Saturday June 13 Because of a continuation of state law prohibiting large gatherings until July 4 the IDA Board of Directors agreed that the House of Delegates should be scheduled as a virtual meeting More details will be coming to members throughout May VOLUME 99 2020 ISSUE 2 Journal of the Indiana Dental Association 49

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Member Zone JOURNAL IDA Classifieds EQUIPMENT REPAIR PRACTICES AVAILABLE INTRAORAL X RAY SENSOR REPAIR SALES We repair broken sensors Save thousands in replacement costs Specializing in Kodak Carestream major brands We buy sell sensors American SensorTech 919 229 0483 www repairsensor com PRACTICE FOR SALE WARSAW A very successful practice is for sale in Warsaw We currently run 3 full time hygienists 2 front desk and 2 assistants One is expanded There are 9 operatories with plenty of room for adding additional associates If desired and storage Our office is located on a lake with seven operatories facing the water on the busiest street in town The community has a very strong economic base with a lot of entertainment and recreation Call 574 265 3175 POSITIONS AVAILABLE PART TIME GP OR PEDIATRIC DENTIST West 10th Dental Group a doctor owned multi specialty group practice is looking for an associate doctor to help provide care to our growing pediatric patient base Currently we need a doctor on Mondays to see patients while our pediatric dentist is scheduled in the hospital Email bbarta west10thdentalgroup com COMPLETE OFFICE FOR SALE Complete dental office for sale Building plus equipment 2 hygiene rooms 2 treatment ops digital x ray digital charts laser intraoral camera North central Indiana Only 1 dentist in county of 12 000 Will help finance Ready to go 175 000 huttondds whsi tv LOUISVILLE KY PRACTICE FOR SALE The practice is located in an office building along the Ohio River with ample parking for patients The current doctor has practiced in the community for nearly four decades and is open to staying on to ensure a smooth transition for the incoming doctor Additionally the current lease expires in May of 2021 3 fully equipped operatories Collections of 660 000 adjusted EBITDA of 200 000 located in a medical office building minutes from downtown Contact Kaile Vierstra with Professional Transition Strategies via email kaile professionaltransition com or by phone 719 694 8320 MULTIPLE OPPORTUNITIES Legacy Practice Transitions has multiple opportunities for ownership throughout Indiana We have general and specialty practices available General practices ranging from 300K to 2M To see our complete list of opportunities visit LegacyPracticeTransitions com Contact Blake Ring directly at Blake LegacyPracticeTransitions com or 317 4647857 MISCELLANEOUS BUYER FOR DENTAL SCRAP METAL I pay CASH on the SPOT for dental scrap for EcoSolutions I sort the scrap very thoroughly into 4 categories and price them separately then total them up No obligation whatsoever You will find that I am trustworthy loyal and honest and will do my best to pay you the highest price possible My company is unique in the fact that we give back to America s Tooth Fairy Foundation For more information call Meg at 317 431 5932 50 Journal of the Indiana Dental Association VOLUME 99 2020 ISSUE 2

Journal IDA Spring 2020

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