Sunday 13 January 2013

Healthy teeth and gums important during pregnancy


Healthy teeth and gums important during pregnancy


May 6, 2008 -- NEW YORK (Reuters Health), May 6 - The American Dental Association (ADA) is reminding mothers-to-be about the importance of maintaining good oral health during pregnancy.

"There is a lot of research that shows a possible correlation between having untreated gum disease and a higher risk of having a preterm, low birth weight baby," Dr. Sally Cram, ADA consumer advisor noted in a telephone interview with Reuters Health.

In addition, pregnant women with gum disease may be more likely to develop pregnancy-related (i.e., gestational) diabetes. This is a concern, said Cram, a periodontist in Washington, DC, "because women who develop diabetes during pregnancy often have a lot of problems with the birth; the baby is often overweight and the mother may get high blood pressure, which can be very risky for both mother and fetus." Gestational diabetes often leads to preterm birth.

"If you are pregnant or planning a pregnancy, you should schedule a dental checkup to be sure you don't have brewing infection and gum inflammation," Cram advised.

Eating a well-balanced diet, brushing twice a day with fluoride toothpaste and flossing at least once a day is also important, according to Cram. The ADA recommends consumers use dental care products that have earned the ADA Seal of Acceptance. Pregnant women often crave sugary food and beverages, which can lead to cavities.

Don't be surprised if your dentist recommends more frequent cleanings during pregnancy, Cram added. For a woman with a history of gum disease or problems, "your dentist may recommend that you have your teeth cleaned every two or three months during the pregnancy," she noted.

Rising hormone levels that accompany pregnancy can irritate gums already battling gum disease and make it worse. "When the hormones get really high during pregnancy, some women are more susceptible to what we call pregnancy gingivitis, which is real severe inflammation in their gums.

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Top ADA executives leave organization


Top ADA executives leave organization

May 5, 2008 -- The two top executives at the American Dental Association (ADA), executive director James Bramson, D.D.S., and chief operating officer Mary Logan, have left the Chicago society.

The ADA announced on April 18 that Dr. Bramson and Logan had left the organization. Both had served in their positions since 2001, with Logan the second-ranking executive at the society after Dr. Bramson.

The ADA declined to elaborate on the reasons for their departures, leaving some members puzzled, according to an announcement by the organization's president, Mark J. Feldman, D.M.D.

"I have received many calls, e-mails, and questions regarding the departure of the executive director and chief operating officer," Dr. Feldman stated in an e-mail to dental societies. "I know that the first question on everyone's mind is, 'What happened?' And, I am sure you understand that we cannot discuss the details."

Dr. Feldman is serving as interim executive director while the ADA forms a committee for a national search for a new executive director. "I have been meeting with ADA senior management in a supervisory role," Dr. Feldman wrote. "A transition plan is being developed to ensure that the ongoing work of the ADA staff, councils, commissions, and various taskforces continues."


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CDA Show Report: Volunteer your services


CDA Show Report: Volunteer your services

May 3, 2008 -- ANAHEIM, Calif. - Are you eager to help the needy but flummoxed by the hassles? In a heart-warming session at the California Dental Association (CDA) Spring Scientific Session on Saturday, pediatric dentist Gregory Psaltis, D.D.S., and hygienist Dayna Dayton, R.D.H., of Olympia, Wash., offered practical tips for reaching out a helping hand without causing yourself a headache.

First, said Dr. Psaltis, you don't have to get on an airplane to find the needy. "For those of you who don't like to travel on a rutted toad, or eat food that won't settle in your stomach, try helping locally."

One option: Get involved with your local Gospel Rescue Mission. There are 300 Gospel Rescue Missions in the U.S., and in 2006 they provided more than 240,000 medical and dental visits. These missions rely purely on volunteers to provide dental care.

The missions encourage you to bring your own supplies and let you set your own schedule. Also, patents' from the Gospel rescue Missions are not ultimately your responsibility -- and won't get your pager number.

"So you can help those in need without letting it affect your own practice," Dayton said.

You can get even more local by bringing needy patients into your own office. To avoid the legal liability, you can partner with an existing clinic, where the clinic screens patients, takes down their medical history, and then rents your space for treating them.

"I rented my space for a morning for $100 dollars to a hospital. We supplied all the manpower, equipment, but for those few hours the clinic morphed into that hospital," Dr. Psaltis said.

Another easy way to help a lot: Identify families in your practice who are going through a difficult time and write off their dental bills. Ask them for discretion so other people in the practice won't demand the same favour.

You could also get involved with one of the many mobile dental clinics in multiple cities across the U.S. They are backed by colleges, foundations, and insurance providers. Essentially, they are a dental office on wheels. They rely on volunteers and donated dental supplies. Many offer CE credits for dentists who volunteer. They are good for screenings, cleanings, fluoride treatments, and other minor treatments.

Two program with good reputations are Give Kids a Smile and Project Stretch.

For the more adventurous dentist, there are opportunities to volunteer abroad. Dr. Psaltis suggests the Kikuyu Hospital Dental Clinic in Kikuyu, Kenya, which is often manned by volunteers from Europe. This is a flexible program that allows you to provide care or lecture and is a fairly modern facility.

In Honduras, programs seek to fill the spiritual and material needs of the poor. They focus on anything that is needed -- whether it is a dental clinic, medical care, construction of new health facilities, or drilling wells for fresh water.

If teaching is your passion, Health Volunteers Overseas may be the program for you, Dr. Psaltis said. You can teach at universities in Cambodia, Laos, Nicaragua, Tanzania, and Vietnam. Most teaching commitments are for two weeks.

You can affiliate yourself with an existing program or start your own.

If you don't like any of the existing programs, maybe you'd like to set up one of your own. The two speakers offered key tips for the would-be founder:

Find sponsor dentists who will let you use your office so that they will deal with any legal issues.

Arrange health department permits. Some health departments, including the one in Mexico, will require you to get a work permit.

Get a contact person to send you a letter in the local language that explains the purpose of your visit and the material you are bringing. The customs department needs to make sure you are not bringing in material for resale. Try to leave equipment in the host country so you don't have to keep bringing it back and forth.

Document all the work you have done and get signed forms.

Volunteer at a place that tugs at your heart or that you have a special affinity to.

Identify how you want to help -- whether it is building a new clinic or providing dental treatment.

Bring support personnel, such as dental hygienists and assistants.

Hire a translator who is fluent in the local language.

Ask corporate sponsors for donations. You will be surprised how many contributions you will actually receive for volunteering efforts.

You won't remember the teeth or the decay or the long tiring hours, the experts concluded. You will only remember the lives that you touched and the smiles and hugs from the children whom you helped.

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CDA Show Report: More perfect x-rays


CDA Show Report: More perfect x-rays

May 2, 2008 -- ANAHEIM, Calif. - How do you control contrast and density? When do you want a long cone and when a short one? And what's a bisecting angle, anyway? Brad Potter, D.D.S., M.S., a University of Colorado dean and oral and maxillofacial radiology specialist, zoomed in on such confusing x-ray problems at the semiannual meeting of the California Dental Association (CDA) today.

Much about successful x-rays depends on the technique of the operator, Dr. Potter said. He offered helpful tips on contrast and density, distance, angle, bitewings, and patient comfort.

Contrast and density

What can look like an underexposed image may actually be a problem of contrast, Dr. Potter pointed out. For bitewing x-rays, he recommended using darker density films, which work best on hard tissue. They should be combined with short-scale contrast (in other words, set your kVp at the low end of its range).

For periapical x-rays, on the other hand, use lighter density films and long-scale contrast, meaning a higher kVp.

Distance

"In theory, you want to move the film as close as possible to the tooth," Dr. Potter said. "Moving further away you get the tooth blurry." For most exposures, try to achieve a distance between the source and the object (the tooth) of about 16 inches.

That may be hard to achieve with most equipment, because short cones are standard. Look closely at the equipment to find markings that show the distance from the source to the end of the cone. You can special order particularly long cones that will produce sharper images for most exposures. Cones are now called beam indicating devices (BIDs) because most are no longer cone-shaped, Dr. Potter noted.

But for intraoral periapicals and bitewings, a shorter distance between the source and the object works better. That's because the beam spreads out more the farther away it gets from the tooth. For these exposures, you may do better with a short cone.

Angle

"The teeth and the receptor should be parallel to each other," Dr. Potter said. That much is well known. What's not so obvious is how to ensure that they are parallel. One point that's helpful to remember is that teeth are angled differently in different parts of the mouth.

"You must know the long axes of the teeth," he said. The maxillary teeth all tilt facially, which means they splay out a little bit (and the flatter the palatal vault, the greater the tilt). The mandibular anterior teeth are usually facial, while the premolars are straight up and down, and the molars are slightly lingual.

To achieve paralleling, you may have to increase the distance between the film and the tooth. This goes against the standard rule of putting the film as close as possible to the object. "Push the film back as far as possible in the patient's mouth if you are using long-cone paralleling," Dr. Potter said.

Another key is ensuring that the central ray of the x-ray beam is perpendicular to the long axes of the teeth (which means it should also be perpendicular to the plane of the film).

A good film holder can help a lot in maintaining the correct angle.

One instance when the film is not held parallel to the tooth is the bisecting angle technique, in which the plane of the tooth and the plane of the film are bisected by a line that evenly divides them. This line is known as the common side. If the x-ray beam is directed perpendicular to the common side, then it will produce an image of the tooth that is the same size as the tooth, even though the tooth and the image are not parallel.

The concept is difficult to grasp, but a useful one because it is almost the only way to get good images in very small mouths. It's also helpful for shallow palates and during endodontic procedures.

"One problem with the bisecting angle technique is that it's easy to foreshorten," Dr. Potter warned.

If a patient holds the film, he or she should use the thumb for the maxillary arch and the index finger for the mandibular arch.

Bitewings

It's critical that the contacts appear on the x-ray. Don't let patients close their lips because you won't be able to see if they open their teeth. "Always, always the patient should be grinning," Dr. Potter said. Watch out also that the patient doesn't protrude a jaw.

For molars, aim for the maxillary first molar to second molar contact. For premolars, aim for the maxillary second premolar to first molar contact.

Patient comfort

"Just remember we're not in the patient comfort business," Dr. Potter said. Too many x-rays are ruined because the operator let the patient move the film to a more comfortable position.

If the patient seems likely to gag, don't overreact; you may lose the patient's confidence. Do the anterior projections first, because they are less likely to trigger a gag reflex. "Once you set off a gagger," Dr. Potter said, "it's all downhill."

Another key is diverting the patient's attention. It helps to talk a lot -- but don't talk about gagging!

Salt can help too -- "You will be absolutely amazed at how effective this is!" he said. Just sprinkle a few grains on the tongue, then have the patient swallow. As a last resort, try a topical anesthetic, sprayed, not swabbed.

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CDA Show Report: Product breakthroughs enhance patient and practice management


CDA Show Report: Product breakthroughs enhance patient and practice management

May 2, 2008 -- ANAHEIM, CA - The exhibit hall at the 2008 California Dental Association (CDA) meeting opened for business today, and crowds packed three halls at the Anaheim Convention Center, hoping to discover the next new product or service that will keep their businesses booming and their patients smiling. From improving practice management to imaging in multiple dimensions, hundreds of new products were on display to see and test out.

Some of the highlights included:

The new SuniRay digital radiography system from Suni Medical Imaging of San Jose, Calif., uses the latest CMOS technology and Suni imaging software to deliver high-image quality with maximum diagnostic capabilities. According to the company, SuniRay's ergonomic design and rounded corners ensure easy positioning and optimal patient comfort. Functions include calibrated length measurements, image-enhancement tools, digital zoom, colorizing, and archiving. The system is designed to be integrated with the leading practice management software systems.

The Dental Practice Optimizer from Sikka Software of Milpitas, Calif., is now in its fourth iteration, with more than 2800 installed systems across North America. This unique software package works in conjunction with any practice management system (and most financial systems) to take the headache out of tracking productivity ups and downs. It is a digital "dashboard" that resides on top of your practice management system and automatically reads all the data in the system, providing real-time evidence-based ROI analysis of marketing, referrals, patients, providers, supplies, inventory, vital signs, and even embezzlement.

"This is the first business management system for dentistry that starts where your practice management systems stop," said Roger Telegan, Sikka Software's chief information officer.

HealthCare Volunteer of Los Angeles launched a statewide free dental screening program to help low-income families meet the requirements of AB 1433 (the 2007 California kindergarten oral health assessment law). Partially funded by the CDA Foundation, the screening program is managed and operated by HealthCare Volunteer. By logging onto the Web site (www.healthcarevolunteer.org) or calling 310-928-3611, children and families in need are provided with a free screening given by a local volunteer dentist in their area. Dentists interested in volunteering their time can also register online and will be provided with dental screening supply kits by HealthCare Volunteer via mail.

MedX Health's Oralase, which is awaiting FDA cleared for dental applications, brings low-level laser energy to pain management and wound healing. The diode-laser device has long been used for pain management in professional sports, veterinary medicine, and general therapeutic applications such as carpal tunnel syndrome. Now this same technology is being used by dentists to eliminate the need for anesthesia and stimulate the body's lymphatic system to aid in wound healing.

"The Oralase is a biostimulation laser, also referred to as phototherapy," said Dr. Paul Silver, who oversaw the FDA clinical trials. "Phototherapy takes photons of light and places them into the body to create a healing and pain-management effect at the cell level. The laser does not cut or burn, so it is safe enough to use every day on nearly every patient."

MedX Health of Mississauga, Ontario, offers a free 15-day trial of the product, which sells for $3,995.

Dental-Dek, a Minneapolis-based company that markets product-based advertising "value paks" to dental practices across the U.S., is now the exclusive sales and marketing company behind Waiting Room Theater. According to the company, dental patients experience an average of 18 minutes in the waiting room during each visit -- time that can be utilized to provide them with a televised look at various products and services offered by your office. The DVD can be played in both waiting rooms and exam rooms, and features dental "factoids," interviews, and explanations of procedures and other services -- all interspersed with paid advertising. Waiting Room Theater is the brainchild of Jay Grossman, D.D.S., a well-known Los Angeles-based dentist.

LED Dental is launching the next generation of its Visually Enhanced Lesion Scope (VELScope), the VELScope Vantage, which uses fluorescent light to help dentists visualize whether a patient has a developing oral cancer. Changes in the natural fluorescence of healthy tissue generally reflect light-scattering biochemical or structural changes that indicate developing tumor cells, according to the Vancouver, British Columbia-based company. Thus, dentists can use VELScope to shine a light on a suspicious mouth sore, look through an attached eyepiece, and watch directly for color changes. VELScope Vantage features a more powerful lamp technology than earlier models, plus a camera adapter kit for clear, crisp digital photography.


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CDA Show Report: Don't give up on endodontics


CDA Show Report: Don't give up on endodontics

May 1, 2008 -- ANAHEIM, Calif. - Infected tooth? Replace it! With the rapid improvement in implantology, that kind of thinking comes easily, but in many cases, endodontics still offers a better alternative, Jerome H. Stroumza, D.D.S., M.S., D.Sc., told an audience Thursday at the California Dental Association (CDA) Spring Scientific Session.

"The trend now is probably to extract too easily and forget what endodontics can do," said Dr. Stroumza, who has combined the two specialties at his EndoImplantology Institute in San Francisco.

Implants have progressed dramatically in recent years, particularly with the improvement in bone grafting materials and growth factors, Dr. Stroumza said. And in many cases, he places implants where they would not have been possible a decade ago.

But using endodontics, he also saves many teeth that have already been unsuccessfully restored by another dentist.

So how do you know when to give up? The key is to carefully analyze the long-term prognosis, the patient's expectations, and the risk versus the benefit, Dr. Stroumza said.

In some cases, patients are deeply attached to their teeth and will be grateful -- and willing to pay -- for heroic efforts to save them. "In the worst case, you fail, then you go on to the other approach," he said.

In other cases, implants are not likely to succeed because the bone condition is so poor that even bone grafting techniques can't help.

One way to figure out which teeth can be saved is through the use of CT scans, Dr. Stroumza said. He showed examples of cases in which CAD/CAM images produced by a CT scan showed that a canal could not be found, and other cases in which there was insufficient bone to support an implant.

"I used to do a lot of exploratory surgery, but now we have the CT scan -- it's almost like you're right there," he said.

The use of CT scans for endodontology was the biggest revelation in Dr. Stroumza's talk, said Arthur Schultz, D.D.S., a general dentist in Manhattan Beach, Calif. "I had never heard of that before," he said.

But CT scans are not the only technique Dr. Stroumza uses to decide whether to do a root canal or place an implant. In another case, a cast helped him model the occlusion of two posterior molars and decide that both had to be replaced with implants.

What other factors should a clinician consider? The type of lesion shouldn't determine the type of therapy you use, and neither should the mobility of the tooth, Dr. Stroumza said. He gave the example of a tooth so mobile that he "didn't want to put a dam around it because the dam might extract it." After the root canal, however, the bone regenerated enough to support the tooth.

It was one of many cases in which he has found that eliminating endodontic infection encouraged bone growth. "Osteoplastic cells will not migrate if you have toxicity, but if you really remove what's wrong, the bone will grow," he said.

That's why he emphasizes proper cleaning, shaping, and disinfection. "I don't know why people rush to pack," he said. "Packing has no value; cleaning and shaping has the value."

As for sealing the tooth, Dr. Stroumza prefers amalgam to composite resins. "My confidence in plastic is very limited," he said. On the other hand, if he even suspects there is a crack, he uses composite resins because even a little pounding can do damage.

But in addition to making use of such classic endodontic techniques, Dr. Stroumza also wields the latest tools in implantology, and he talked as well about the use of platelets in implant sites.

Ultimately, he said, the two approaches are not in opposition. "In truth, there is no battle between endodontics and implantology," he said. "You can get the best of both."

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CDA Show Report: Simple tips to make your practice more profitable


CDA Show Report: Simple tips to make your practice more profitable

May 1, 2008 -- ANAHEIM, CA - Does a patient walking into your reception area see candy wrappers on the floor? Is your office staff shouting at each other in front of the patients? Is your receptionist unfamiliar with the services you offer?

These may be minor problems, but they could have big implications. Patients encountering scenes such as these will likely not come back to your practice, explained Sandy Pardue, a consultant, lecturer, and published author, today at the California Dental Association (CDA) Spring Scientific Session.

In a seminar on maximizing productivity and practice growth, Pardue offered real-world advice on making dental practices more profitable.

The key to a thriving practice is a courteous, trained staff, Pardue said. A live person should always answer the phone in a friendly, helpful way and never turn away a patient. If someone calls and asks for a special service that your office doesn't provide, the caller doesn't need to know that. Offer an alternative and say, "We found something that works better." It piques interest and brings in new patients. Patients should never be put on hold, and also avoid asking them embarrassing questions, such as "How long has it been since you last went to the dentist?" she said.

Appearances make a difference. The office needs to be clean and welcoming, not just from the inside but also from the outside -- that means no beer bottles in the parking lot. Create a pleasurable ambiance. Try aroma therapy fragrances, and make sure the office does not reek of cigarettes or medicine.

The reception area also should be clean and professional, Pardue said. A tip: Make sure the front-desk staff is wearing a phone headset instead of grappling with the handset, and the technical staff should not be milling around, distracting the staff member from calls and customers.

Customer service is crucial to a profitable practice. Getting a new patient is five times harder than retaining an existing one, according to Pardue. An upset patient will tell 14 people about his or her experience, and a very upset one will tell 20 people, she said. Treat each patient like you would want to be treated yourself.

Making new patients comfortable and offering them convenient treatment plans are also important. "If someone has not been to a dentist their whole life and they have decay and periodontal disease, and you tell them they have to pay $25,000, you will see a back," Pardue said. "Fix their main concern first, win them over, and then do the rest of the treatment."

Pardue quoted a survey that found that 68% of patients leave a service or business when they sense indifference. A few ways to show concern are to make it easy for patients to get emergency care, have a good recall system, promote same-day dentistry (try to get most of the work done in one day so the patient doesn't have to keep coming back), and keep convenient office hours.

Internally, the office staff should maximize their productivity. They should use walkie-talkies for efficient communication, instead of having to walk all over the office. Another useful interoffice communication tool is Amtel. Do a morning huddle in which the dentist should be the guest. The huddle should not be longer than 10 minutes, and office staff should come fully prepared with the day's agenda.

Being courteous to patients is important, but make sure you collect on outstanding patients. Pardue suggested keeping notes on individual patients so you can track whether they have a trend of breaking appointments or have trouble paying. Also find out who has been coming to your practice for more than three years, get an actual count of patients who need to come in for follow-up treatment, and send out recall cards.

Make sure the recall cards are of a bright color that catches people's attention, and make them friendly. Show your patients they are valuable to you. Start with a message like, "Dear Marsha, we miss seeing you in your office." Don't threaten patients, gently remind them that their dental work is crucial to their health, and outline the consequences of avoiding it, Pardue said.

And be persistent. Mail recall cards out three months in a row. If patients see the same card and the same message over and over, it will hit home, she believes.

Have a daily production target and a standardized periodontal program, and do not inactivate patients too quickly. Also have an office policy manual, listen to patients' complaints about their accounts, and practice good dentistry!

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U.S. oral health declining, says NY Times


U.S. oral health declining, says NY Times

April 30, 2008 -- In a recent story on dental health aid therapists, the New York Times noted that "a study last year from the Centers for Disease Control [sic] showed that Americans' dental health was worsening for the first time since statistics began to be kept."

But the gloomy pronouncement may be in error. Last year, the Centers for Disease Control and Prevention (CDC) released its annual report on U.S. health, "Health, United States, 2007." The report had some dismal numbers on access to care, but it noted that the oral health of the nation has improved in recent times.

"Between 1988–1994 and 2001–2004, approximately one-quarter of adults 20–64 years of age had untreated dental caries, down from nearly one-half in 1971–1974," the report noted.

Another CDC report released in April 2007 -- "Trends in Oral Health Status: United States, 1988–1994 and 1999–2004" -- noted that "for most Americans, oral health status has improved since 1988–1994." Both reports relied for oral health statistics primarily on the National Health and Nutrition Examination Survey, for which 2004 statistics are the most recently available.

The second CDC report also noted that since the early 1970s dental caries have declined significantly among school-aged children, fewer adults have experienced tooth loss because of dental decay or periodontal disease, and complete tooth loss among adults has consistently declined.

But even though the oral health of the nation has improved, "oral health disparities remain across some population groups."


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Gold restorations fetch high prices


Gold restorations fetch high prices

April 29, 2008 -- Got some extra gold around the office? If you don't do gold restorations any more, it could be the time to cash in for a minivacation -- or at least a fancy outfit.

According to a recent Associated Press (AP) article, patients are using the current surge in the value of gold to cash in old dental caps, fillings, and bridgework. In March, gold topped $1,000 an ounce on the market, its all-time high, though it dropped slightly afterward.

Dental gold is worth a bit less.

"A gold crown typically uses about one-tenth of an ounce of 16-karat gold, which would fetch around $40 to $50 at today's prices," said a source quoted in the AP story. "Heavier pieces of dental gold can command prices of several hundred dollars."

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Delta Dental Foundation funds mucositis research


Delta Dental Foundation funds mucositis research

April 29, 2008 -- The Delta Dental Foundation has awarded a research grant of $22,958 to Beaumont Hospitals Research Institute in Royal Oak, MI, to study ways of reducing the severity of oral mucositis, a side effect of chemotherapy and radiation in patients with oral cancer.

Oral mucositis can cause discomfort, pain, swollen tissue, and often open sores and ulcers. Some cases are mild, but severe cases can cause life-threatening infections and interfere with eating, swallowing, and even speaking.

In some cases, chemotherapy and radiation must be interrupted or suspended, directly affecting patient survival.

"This grant will allow us to collect the primary data we need to seek additional funding from the National Institutes of Health," said George D. Wilson, Ph.D., chief of radiation biology at Beaumont Hospital, Royal Oak. "A better understanding of the biology underlying mucositis will help us to devise treatment strategies that maximize the killing of the oral cancer but minimize the damage to the tissues of the mouth."


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Maryland improves access to dental care


Maryland improves access to dental care

April 29, 2008 -- Maryland hygienists will be able to treat patients without dentist supervision under legislation passed this month in Maryland.

The Maryland Legislature also allocated more than $16 million to fund other measures aimed at improving dental care in the state.

The new rules will go into effect October 1, 2008.

Currently, public facilities needed to file a waiver with the Maryland State Board of Dental Examiners to allow dental hygienists to perform dental hygiene on a patient without the dentist first seeing the patient, wrote Stacey Chappell, governmental affairs manager at the American Dental Hygienists' Association, in an e-mail to DrBicuspid.com.

The new legislation allows hygienists to perform certain tasks in a public setting without the waiver. Some of the public places include:

Dental facilities owned and operated by federal, state, or local governments
Public health department or schools
Health facilities licensed by the public health department
State-licensed Head Start or Early Head Start programs
The tasks include

Doing a preliminary dental exam
Performing a complete prophylaxis, including the removal of deposit, accretion, or stain from the surface of a tooth, or a restoration
Polishing a tooth or restoration
Charting cavities, restorations, missing teeth, periodontal conditions, and other features observed during the preliminary examination, prophylaxis, or polishing
Applying a medicinal agent to a tooth for a prophylactic purpose
Taking a dental X-ray
Applying sealants or fluoride agents
The state budget also allocated millions of dollars to increase Medicaid reimbursement rates ($14 million), fund new dental clinics in Southern Maryland and on the Upper Eastern Shore ($1.4 million), and establish a mobile school-based dental services program ($700,000).


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FDA requests comments on amalgam


FDA requests comments on amalgam

April 29, 2008 -- Attention mercury skeptics! It is open season on dentistry's oldest bogeyman as the FDA has opened a 90-day comment period on its classification of amalgam alloy, encapsulated amalgam alloy, and dental mercury.

The FDA is considering whether the use of dental amalgam should be more tightly regulated. In 2006, the agency reached a preliminary finding that there was "insufficient evidence to support a correlation or causal relationship between exposure to dental amalgam and kidney or cognitive dysfunction; neurodegenerative disease (specifically Alzheimer's disease and Parkinson's disease); autoimmune disease (including multiple sclerosis); or adverse pregnancy outcomes."

But an FDA committee rejected that finding, leading to the agency's decision to invite further public comment.

"The agency is taking this action to provide the public with an additional opportunity to comment and to request data and information that may have become available since publication of the proposed rule," stated a FDA press release.

Following is an example of the kind of comments the FDA is looking for:

"How should labeling controls, if any, address the disclosure of composition, including mercury content?"

The deadline for submitting written or electronic comments is July 28, 2008.

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Do you need cone-beam CT? Part I


Do you need cone-beam CT? Part I

April 29, 2008 -- It began as a scan of the patient's lower jaw in preparation for implants. But what was supposed to be a routine procedure in his Fort Lee, NJ, office turned out to be an event that prosthodontist Scott Ganz, D.M.D., still talks about years later.

First, the patient was amazed that the scan -- conducted with Dr. Ganz's new cone-beam computed tomography (CBCT) scanner -- was over in a matter of seconds. But more important, the scan revealed a huge cyst in the lower jaw that would obviously need to be removed.

Both the patient and the doctor were pleased that Dr. Ganz had invested in the CBCT scanner, which offers detailed 3D images. The cyst may have gone undetected otherwise, and the system allows Dr. Ganz to monitor the patient's ongoing condition.

"We were alarmed at first," Dr. Ganz said. "Luckily, the cyst turned out to be benign. But because there is a danger of recurrence, we have to scan it periodically. The CBCT device lets us do the work quickly and with relatively low dosages of radiation to the patient."

CBCT offers a huge leap forward in dental imaging. For the first time, you can make 3D images in your own office. But any device that carries a price tag of $150,000 to $250,000 needs to be treated as "more than a piece of furniture," in Dr. Ganz's words. In this first of two parts, we examine just exactly what the new technology offers and who should take advantage of it. For anyone planning to do a lot of implants -- and various other specialty procedures -- the investment may pay off quickly. But those dentists more focused on hygiene and routine restorations could wind up paying for razzle dazzle they seldom need.

What is cone-beam CT?

CBCT is a digital x-ray technology used for the head and jaws. It differs from other types of computed tomography (CT) in that multiple diffuse x-ray beams are emitted by the x-ray source. The raw images are then reassembled using a computer algorithm to produce a 3D volumetric image that depicts skeletal, dental, soft tissue, airway, and other internal structures. What's more, it can produce a panoramic scan in as little as 20 seconds.


Yet this new technology hasn't exactly spread like wildfire. In fact, fewer than half of the Kansas dentists who participated in a recent study knew that technology such as cone-beam CT exists. "The most surprising thing," said Anas Athar, D.D.S., an assistant professor of oral radiology at the University of Missouri-Kansas City, "was that, of the 52% who have at least heard about CBCT, few fully understand what it is."

Such ignorance is common because dental schools don't teach enough about the technology, Dr. Ganz. said. And dentists have been reluctant to embrace cone-beam CT because they don't fully appreciate the difference between it and conventional CT. "The problem with regular CT is that you had to send the patient to a radiological center to get the scans," he said. "That required them to go to a huge machine and be exposed to a lot of radiation. Cone-beam CT removes those barriers. You still need education, though. You need to tell students it is a valuable tool."

What cone-beam CT can do for you

Another reason some dentists don't know about cone-beam CT is that it's not for them. If you're a general dentist with few ambitions below the gum line, cone-beam CT could be a waste of your money, said Edwin Parks, D.M.D., M.S., director of dental radiology at the Indiana University School of Dentistry in Indianapolis.

"It's a shotgun when all you need is a fly swatter," Dr. Parks said. "If you have a basic 'drill, fill, and bill' practice, you don't need it." For classic exposures, CBCT may not even work as well traditional intraoral x-rays. The images will be in 3D images but the resolution won't be as sharp as with digital intraoral scanners.

Aside from the big expense (which includes maintenance and possible upgrades to your computer and other equipment), a lot of time may be involved. You and your staff will need training on how to operate the machine, and you may need training on how to interpret the images.

"The single biggest misconception is the time required to learn the new technology," Dr. Ganz said. "A CBCT device is not a turnkey operation. You don't just turn the device on, do a scan, and start reading it. You have to manage the workflow and the flood of information you are going to get."

But if you do more complex procedures -- or want to get into them -- then cone-beam could improve your banker's smile as well as those of your patients. "If you are in a practice that does implant placement, it is pretty good," Dr. Parks said. "When you are taking out wisdom teeth, it gives you a good look at the mandibular canal."

CBCT can also help diagnose and plan treatment in periodontics, prosthodontics, oral surgery, orthodontics, TMJ dysfunction, and complex endodontics.

"It allows me to work with more confidence," said Ronald K. Shelley, D.M.D., a general dentist in Glendale, AZ. "I was doing implants and surgery before the cone-beam, but when I got close to a nerve or had to deal with the sinuses, a lot of cases were excluded [because I didn't have] firm evidence of where I was going. Cone-beam gives you 3D information that is really invaluable."

Software such as SimPlant can be used with cone-beam CT to create virtual stents that enable dentists to position implants with precision.

When investigating endodontic lesions, dentists can adjust the angle of the beam to investigate other roots, auxiliary canals, and possible radicular fractures. "With CBCT, you'll do your scans more accurately, without guessing, and with less morbidity to the patient," Dr. Ganz said.

Some orthodonists say CBCT virtually eliminates the need for conventional orthodontic x-rays.

And some dentists who create appliances for sleep apnea say that cone-beam CT helps them visualize the oral-nasal airways. "You need to know where the bone is in three dimensions so you can place it accurately," Dr. Shelley said.

Cone-beam vs. conventional CT

Of course, conventional CT can do most of these tricks as well. So what are the pros and cons of the two technologies?

Perhaps the biggest advantage of cone-beam CT is that you can keep it in your office. Conventional CT machines are too big and too expensive. And having the machine in your office means keeping the patient in your office. First, you won't risk introducing the patients to another practitioner. Second, you'll save them a trip to another facility. Third, you will impress some patients just because you own the latest technology.

And fourth, you can use the detailed images to make a more convincing case for treatment. "You can sell a case that may amount to $10,000 or $20,000 that could never have been marketed any other way," Dr. Ganz said.

But along with the delights of ownership come the headaches. Aside from the time and money involved in ownership, you'll have to take full responsibility for interpreting the images. According to some experts, that means you could be liable for malpractice if you miss a warning sign -- even for a medical problem such as a calcified carotid artery.

Until you are fully trained in reading the output, you may want to send all your images electronically for interpretation. "The images should be interpreted by an oral and maxillofacial radiologist to make sure the volume is thoroughly examined and properly interpreted," said Gail F. Williamson, R.D.H, M.S., a radiology professor at the Indiana University School of Dentistry.

This undermines some of the advantages to owning the machine in the first place. Count on $75 per interpretation -- which brings us back to the hard question of dollars and cents. Just how many images would you need to justify the big ticket of cone-beam CT? For the answers to these questions, look for Part II of this series, coming next week.

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CDA 2008 Spring Scientific Session preview


CDA 2008 Spring Scientific Session preview

April 29, 2008 -- Have implants taken the place of endodontics? Will changes in the Current Dental Terminology code affect the way you get reimbursed? Do any of the new oral cancer tests really work?

Experts will address dozens of such timely questions starting this Thursday at the California Dental Association (CDA) Spring Scientific Session in Anaheim. The session features four days of lectures; hands-on training on the latest trends, technologies, and techniques; and an exhibition floor with more than 600 participating companies.

The DrBicuspid.com team will be there from day one, covering the hottest sessions with daily reports.

Among the speakers will be L. Stephen Buchanan, D.D.S., who will conduct a hands-on course on the art of endodontics; Paul Feuerstein, D.M.D., who will talk about new products needed for a high-tech practice room; and Karen Davis, R.D.H., who will discuss effective communication and enrollment skills for the dental team.

Among the other hot topics:

Maximizing productivity and practice growth
The traumatized dentition: Diagnosis, prognosis, and treatment
Minimal intervention and maximum interception strategies for dental caries
Quality imaging in dental practice
Crystal methamphetamine: Your teeth, your health, your life
Charting the course (features of proper record keeping)
Rethinking endodontics or how to choose between endodontic treatment and implant therapy
Recognizing cultural differences in the patient population
To keep the approximately 30,000 attendees entertained, an exclusive party will be held at nearby Disneyland. And for the dentist with refined taste buds -- wine seminars!



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New lawsuits follow clinic's $10 million settlement


New lawsuits follow clinic's $10 million settlement

April 29, 2008 -- After settling a multimillion dollar federal case, North Carolina dentists specializing in Medicaid patients now face lawsuits from 13 patients.

One patient, Antavia Digsby, underwent 14 pulpotomies and received 14 stainless steel crowns in a single sitting on May 9, 2003, when she was 5 years old.

Earlier this month, the Medicaid Dental Center (MDC) agreed to pay $10 million to the U.S. government and the state of North Carolina to settle claims that it fraudulently billed Medicaid for dental care performed on impoverished children at its clinics.

Digsby's attorney, Darren Dawson, has filed the suit on her behalf and said that he will soon be filing suits for 12 more patients with similar complaints, including one who had 16 pulpotomies in a single sitting. He said that all the children were between the ages of 4 and 6 years old.

"The children were very young, the work was done without the full consent of the parent, and some were restrained with a papoose board," Dawson said. "It was unauthorized work to overbill Medicaid."

James Wyatt, MDC's attorney, called the allegations "silly" and added that all parents have to give written consent for any procedures at the clinics. "The children not only needed that work, it was imperative. The real question is why did the parents let their children's teeth get in such a horrible condition?"

The dentists named in the lawsuit are MDC owners Michael A. DeRose, D.D.S., and Letitia L. Ballance D.D.S., and Heather Berkheimer, D.M.D., the dentist who performed the procedures. MDC is now operating under the name Smile Starters.

The $10 million settlement was reached after the government alleged that the chain of clinics run by Dr. DeRose and Dr. Ballance submitted reimbursement claims for unnecessary pulpotomies and stainless steel crowns to Medicaid, and failed to obtain informed consent.

But Wyatt denies that the dentists committed fraud. "All of the work was high-quality," Wyatt said. "The disputed billings involved differences of opinion among knowledgeable experts. All procedures were supported by either X-rays or physical examination."

The charges are regarding procedures done from 2001 to 2003 at the chain's clinics in Charlotte, Raleigh, and Winston-Salem. On October 1, 2004, after the government lawsuit was filed, the North Carolina Medicaid program established a reimbursement limit of six stainless steel crowns per appointment.

This limitation does not apply to hospital operating rooms and ambulatory surgical centers.

"There was a concern that child recipients were in the chair too long, and their welfare was the main motivation behind this change," said Mark Casey, dental director for North Carolina Medicaid.

Nine dentists working for Medicaid Dental Center -- John Lyons, Jeffrey Zieziula, Erron Brady, Lori Petree, Christopher Ballinger, Michelle Wilkerson, Nermin Ballinger, Dr. Balance, and Dr. DeRose -- received written reprimands from the North Carolina Board of Dental Examiners in 2005. Dr. Ballance and Dr. DeRose were placed on probation for three years.

"Health care professionals who abuse their positions and engage in excessive treatment regimens and excessive billing practices will not be tolerated," said Gretchen C.F. Shappert, U.S. Attorney for the Western District of North Carolina, in a written statement.

M. Alec Parker, D.M.D, executive director of the North Carolina Dental Society, argues that the issue is not quite black and white.

Medicaid reimbursement rates to dentists are very low, he noted. If dentists treating Medicaid patients want to stay profitable, it pushes them into a different model of service -- one that requires them to do more procedures, he said.

"I worry about painting these Medicaid centers with a broad brush, because that will put a lot of people who are allowing more access to care out of business," Dr. Parker said.

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Build your perfect Web site: Part II


Build your perfect Web site: Part II

April 29, 2008 -- Louis Woolf, D.D.S., thought visitors to his Web site might like a snazzy video introduction to his practice, the Sachem Dental Group, in Suffolk County, N.Y. But after talking to his designers at American Eagle, he changed his mind.

Such introductions may not find their way onto search engines, the consultants said. And if patients can't find your site, there's no point having one.

Surprises like this are common for dentists as they design or upgrade Web sites for their practices. In Part I of this three-part series, we offered advice on planning a Web site and selecting designer. But design is only the beginning of your Web site's journey. In this second part, we'll look at the key issues in hosting and promoting your site, as well as integrating it into your back office.

Hosting

Hosting questions are so important that you should bring them up when interviewing prospective designers. As your practice changes, you may need to change a photo, describe a new service you offer, or provide details about a new office that has opened. So you need to figure out who will do that.

If you've signed up with a service that offers template-driven designs, you may be able to make the changes yourself, by simply filling out a Web form or changing text.

If you don't use template-driven designs, though, things get more difficult, because someone will have to change the actual page itself. It can be exceedingly time-consuming and frustrating, and if you're not a pro, you can do serious damage to your site.

Some design firms will include making changes as part of their overall fee, and won't charge for changes after that.

Also ask prospective designers if they will host your site. Hosting means they store the data that makes up your site on their computer and connect that computer to the internet, essentially giving the site its home on the Web. Larger design firms tend to do their own hosting, while smaller ones are likely to refer you to someone else.

This dental Web site was designed by TNT Dental.
Prices for hosting can vary tremendously. Sesame Dental, for example, will host your site free after they've designed it for you. (A typical design fee runs $4,990, the company says.) But the company charges for various value-added services to dental Web sites, such as integration with practice management systems.

TNT Dental, on the other hand, charges varying hosting rates, depending on the services offered. Prices range from $49 to several hundred dollars a month.

What do you get for your money? Most of all, you want reliability; you don't want your site down for the count when people are looking for it. So check references.

Finding out about how tech support is handled is also a good idea. Is it only via e-mail? That's not much help in an emergency. If telephone support is offered, at what hours is it available? Try calling the tech support number several times to see how easy it is to get through.

Promoting your site

Having a Web site may be good for your ego, but if no one can find it, it won't do any good. If your site will be primarily used for existing patients, this is no problem -- just give them the site's URL.

But if you want to find new patients, they'll need to be able to find it. You'll want your site to appear as high up as possible on the results page when patients search for a dental practice through Google or another search engine.

Cracking the algorithms that search engines use sometimes seems akin to voodoo. After you've stocked up on chicken blood, you can take a few more practical steps. One is to realize that multimedia -- such as fancy video introductions -- won't help, as Dr. Woolf learned.

Another step is to use as much unique content as possible. This is where using precreated content can hurt you. Because other dental sites have the exact same information, search engines won't list your site as high in the rankings.

Finally, come up with a limited list of terms that you would like to appear high up in search results for -- perhaps ten. Make sure that several of those terms are geographical. It will do you no good if someone in Mexico City comes across your Web site, and your practice is in Ames, Iowa. There are more and less sophisticated ways of including those terms in your site's content, which is one reason you may need to consult a professional.

Many firms promise that they will do what is called search engine optimization (SEO). This means making changes to your site's content or layout so that it will appear higher in search engine results, as well as submitting your site to search engines.

Many design firms, including TNT Dental, offer this as part of their design package. Outside firms offer this service as well.

Beware of firms that charge on a pay-per-click model -- in other words, you pay them as much as $20 every time someone clicks to your site. These charges add up fast. But even companies who charge a flat fee typically want at least a hundred dollars a month.

Is it worth the money? The answer depends on your marketing plan. TNT Dental's co-founder, Tim Kelley, points out that if you plan to use radio, TV, and print advertising to drive people to your Web site -- and you don't expect the site itself to draw users on its own -- then you won't necessarily need to hire someone to do search engine optimization.

If you do choose an SEO firm, Kelley says, you should ensure that you get detailed monthly reports, showing you the traffic to your site and where it comes from. Get a report that shows traffic before the firm begins its search engine voodoo, so you can see actual results.

Back office integration

Depending on what practice management software you use, you may be able to hook your Web site to it, to allow patients to change appointments, make payments, and so on.

Because of the technical difficulties, many design firms don't even offer the service. "It's quite complicated, and we don't think there's a payoff yet," Healey says. "We think it's something that is several years off for most practices."

Sesame Dental, on the other hand, says that it is able to connect a Web site to any of 30 practice management systems. Cost of integration is $264 per month.

The bottom line

If all this sounds like a lot of work, that's because it is. But the payoff can be substantial. Resources like the Yellow Pages directory are being read less and less, while the Web has increasingly become the de facto way that people find new services. A Web site will increase your exposure to potential patients, and help keep your existing patients happier.

Dr. Woolf has high hopes for his new Web site, which recently launched.

"I don't have unrealistic expectations about the benefits we'll get," he says, "but I expect that it will be easier for new people to find out about our services, and our patients will be happier with us. They'll be able to find more about our services, about aftercare, about how to get to our offices, and they'll even be able to print out forms and bring them to the office."

"All in all, we expect to be much better off," says Dr. Woolf.

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Build,your,perfect,Web,site:,Part,II