AGD applauds proposed U.S. oral health initiative

AGD applauds proposed U.S. oral health initiative

May 29, 2008 -- The Academy of General Dentistry (AGD) is giving two thumbs up to the recent introduction of the Oral Health Initiative Act of 2008 by Sen. Benjamin Cardin (D-MD) and Sen. Susan Collins (R-ME). The bill, S. 3064, proposes the establishment of a multifaceted approach to oral healthcare through the creation of an expert oral health working group to assess existing U.S. oral health programs and recommend improvements.

"Dental disease presents a very serious problem for our children, particularly those from lower-income families," said AGD president Vincent Mayher, D.M.D, M.A.G.D. "This working group should look closely at all federal oral healthcare programs and make recommendations for improvement to ensure that no child is without dental care." The working group would also develop programs to improve the oral health of and prevent dental disease in children, Medicaid-eligible adults, and other vulnerable populations who are among those Americans at highest risk of dental disease.

The AGD will be issuing an action alert this week to its members, urging them to send letters to their senators asking them to support this measure, according to Janet Kopenhaver, AGD's Washington lobbyist. Cosponsorship of the bill will be a component of the AGD Scorecard of the 110th Congress, to be issued at this session's adjournment, she added.



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Saliva provides early warning signs of cancer

Saliva provides early warning signs of cancer

May 29, 2008 -- Looking inside someone's mouth may one day involve more than dental care. It could enable early diagnosis of various cancers, leading to more effective treatment outcomes and better survival rates.

According to research presented at the 2008 American Association for Cancer Research (AACR) meeting in San Diego, analyzing the DNA in saliva can provide clues about the molecular damage that can lead to cancer. In particular, the investigators found that analyzing this DNA may help detect the early signs of head and neck squamous cell cancer (HNSCC).

While this research is still in its infancy, the researchers say sampling cells in saliva could become a cancer screening method for large populations, and dentists might play an important role in such testing.

"The test is a very noninvasive one and very patient-friendly," said Seema Sethi, M.D., of Henry Ford Hospital in Detroit, the lead researcher of the study. "At the same time, it was very good at differentiating those with cancer from healthy people without the disease."

At present, more than 40,000 Americans are affected by HNSCC, and approximately 12,000 die from it each year. The development of HNSCC in people at risk, such as smokers, takes many years, and most cases are diagnosed at an advanced stage when prognosis is poor. Often, the treatment is surgery that can lead to significant disfigurement.

"Patients are sometimes unable to eat and speak afterward," Dr. Sethi said. It would be much better if clinicians could diagnose this cancer before such drastic surgery is needed, she added.

In her study, Dr. Sethi and fellow researchers took saliva samples from 27 patients with HNSCC and 10 healthy participants and extracted DNA from the samples. They then examined 82 genes with known associations to HNSCC. Eleven genes were found to have some ability to predict the presence of HNSCC in the cancer patients. Upon further assessment, the researchers found that increases in a gene called PMAIP1 alone or together with a gene called PTPN1 identified all patients with HNSCC with 96% sensitivity and 90% specificity.

While emphasizing that this research is in its early stages, Dr. Sethi hopes that it could one day be used to screen for HNSCC on a widespread basis. The noninvasive test that Dr. Sethi and fellow researchers developed could be administered by dentists, she added. So just as dentists screen for oral cancer today, they may one day screen for more pervasive cancers such as HNSCC.



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Most U.S. dental faculty like their jobs, study finds

Most U.S. dental faculty like their jobs, study finds

May 28, 2008 -- A recent study that surveyed 17% of the dental faculty in U.S. dental schools found that an overwhelming 71% are satisfied with their jobs.

Areas of high satisfaction included nature of teaching assignments and interaction with colleagues. Areas where participants showed less satisfaction included amount of time for research and the extent and quality of the faculty practice program.

"It is extremely positive to see how many current faculty are enjoying their academic careers, which sends a good message to individuals exploring academic dentistry," said ADEA President Charles N. Bertolami, D.D.S., D.Med.Sc.

However, "tenured associate professors expressed the greatest level of dissatisfaction," the study authors noted. "Opportunities for and support of professional development emerged as an area requiring substantially more attention from dental schools."

The study took into account 1,748 responses from 49 U.S. dental schools. Other findings included the following:

While 71% of the respondents were satisfied with their job, 8% expressed dissatisfaction.
73% said they were satisfied with the intellectual challenges associated with their teaching responsibilities, while 7% were dissatisfied.
18% were satisfied with the extent and quality of the intramural private practice program, while 25% were dissatisfied.
23% felt satisfied with the amount of time they have for research, while 31% were dissatisfied.
The study, "The Quality of Dental Faculty Work-Life: Report on the 2007 Dental School Faculty Work Environment Survey," was conducted through a survey developed by the Academy for Academic Leadership on behalf of the American Dental Education Association Commission on Change and Innovation in Dental Education (ADEA CCI). The results were published in the latest issue of the Journal of Dental Education (JDE, May 2008, Vol. 72:5, pp. 514-531).


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Making early detection of oral cancer a priority

Making early detection of oral cancer a priority

May 28, 2008 -- Oral cancer has a five-year survival rate of only 50%. A patient's best chance of surviving is early detection. While a number of methods and new technologies are now available to enhance early detection, the panel is still out on whether there is any one best approach for detecting oral cancer.

As we report this week, questions have been raised about the ADA's heavily promoted oral cancer campaign, which prominently features the BrushTest made by OralCDx Laboratories. Mark Lingen, D.D.S., Ph.D., a University of Chicago associate professor of pathology, has been among the most prominent critics of the campaign. So when he outlined his approach to detecting oral cancer at a recent meeting of the California Dental Association, an avid crowd showed up to listen.

"About 10% of all patients have some sort of oral mucosal abnormality," Dr. Lingen noted. Because it is extremely difficult to tell premalignant lesions apart from the harmless ones, the deadly disease often goes unnoticed until it is advanced and thus much harder to treat.


A crater-form ulcerated lesion with rolling borders that turned out to be squamous cell carcinoma.
Oral cancer is indicated through two kinds of tumors: leukoplakia (white lesions) and erythroplakia (red lesions). Five percent to 25% of leukoplakias and 90% of erythroplakias have histological evidence of premalignancy when dentists see them.

It is important to keep in mind that not all white and red lesions are premalignant, Dr. Lingen explained. And the size of the lesion won't give you a significant clue.

His take-home message: If your patient has a white or red patch and you cannot figure out why it's there, it could be precancerous or cancerous. After seeing this lesion in a patient's mouth, a dentist usually has a 10 to 14-day window to check if it has subsided. If it hasn't subsided in that time, he said, do a scalpel biopsy.

Some common areas to look for lesions are:

Floor of mouth
Ventral surface of tongue
Retromolar trigone region
Soft palate
Less common areas include:

Gingiva
Buccal mucosa
Hard palate
"I don't care how you get there -- tongue depressors, mirrors. The floor of the mouth is a very common place to get oral cancer. Examine it thoroughly," Dr. Lingen said.

Another area to check is the ventral surface of the tongue. Dr. Lingen showed a picture of a clinician using a piece of wet gauze to extend the patient's tongue.

"The most common location for oral cancer of the tongue is the posterior aspect of the anterior tongue," he said. "To get a good look at this region, you have to pull the patient's tongue out."

Another compelling reason to conduct a thorough exam is that dental-related malpractice suits associated with oral cancer are on the rise. Here are a few scenarios in which the cases are deemed indefensible:

Failure to biopsy.
Failure to re-examine a lesion. If you have a patient with a lesion, you need the patient to come back in 10 to 14 days to make sure the lesion is healing. If he or she comes back and the lesion is still there or has become worse, you need to biopsy.
Failure to follow up on diagnostic report.
Diagnostic devices

A number of devices now on the market are designed to enhance early detection of oral cancer, including:

The BrushTest (OralCDx)
Toluidine blue staining
ViziLite Plus (Zila)
Microlux (AdDent)
VELscope (LED Dental)
Here are the key advantages and disadvantages of each, according to Dr. Lingen:

The BrushTest

Dentists can use the BrushTest to collect cells from white or red lesions and send them to a lab for diagnosis. If the cells are abnormal, a biopsy will determine if the spot is potentially cancerous. You can get back three possible results: positive, negative, and atypical. If the result is atypical or positive, a scalpel biopsy is mandatory.

If the results are negative (and nothing else causes concern), then simple follow-up is probably sufficient.

Advantages:

FDA-approved.
Useful in cases in which a patient has multiple lesions throughout the oral cavity because it's painful to have multiple scalpel biopsies.
Useful for a noncompliant patient. If you see suspicious lesions and want to refer a patient for a scalpel biopsy, but are quite certain he or she won't comply, do the brush biopsy to check for positive or atypical results.
Disadvantages:

Often used inappropriately by the dentist. For example, some use it on papillomas.
Cells are seen out of context, which can result in misinterpretation. For example, if the BrushTest is used to collect cells from a patient who has lichen planus and the cells are spread out on a slide, they will be out of context and will be read as atypical.
"Don't brush biopsy everything that looks atypical," Dr. Lingen said. "You do that, and you will get back a lot of atypical results which you will then be obligated to scalpel biopsy."

Toluidine blue staining

This technology is not yet approved for use in the U.S. and is more common in Canada and the U.K. It is a liquid dye composed of tolonium chloride. Practitioners swab the blue dye onto suspicious oral lesions and look for ones that retain the blue dye, as they can be cancerous.

Advantages:

May help to better define gross extent of areas of lesions. These fields can be as large as 6 cm in diameter. If you have a patient with a field that large, but only a centimeter is clinically evident, and you excise it, you will still be left with 5.5 cm of molecularly altered tissue that has the potential to become cancerous.
Disadvantages:

Not FDA-approved.
High rates of false positives and false negatives.
Works well on erythroplakias but not on leukoplakias, which is where clinicians need more help.
May be better than visual acuity but does not identify the true margins of the field.
ViziLite Plus and Microlux

These competing technologies are similar. For the ViziLite Plus test, the patient rinses for 30 to 60 seconds with a solution that contains 1% acetic acid, and then the dentist uses a disposable light device to examine the oral mucosa. Any abnormalities will appear acetowhite. They can then be marked using the TBlue marking system.

Microlux is the same technology, except that the light device used in this system is not disposable.

Advantages:

FDA-approved.
May be better to define areas with increased amounts of DNA.
High degree of sensitivity.
Disadvantages:

Low degree of specificity. It will light up things that are not premalignant.
May be better than visual acuity but does not identify the true margins of the field.
VELscope

The VELscope is a handheld device that shines a light into the oral cavity, which excites the tissue and causes it to fluoresce. The clinician can view the different fluorescence responses to help differentiate between normal and abnormal tissue. Healthy tissue fluoresces green, while abnormal tissue does not fluoresce and may appear dark.

Advantages:

May help to better define surgical margins.
FDA-approved.
Disadvantages:

Low specificity as described for ViziLite Plus and Microlux.
May be better than visual acuity but does not identify the true margins of the field.

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OralCDx wants to revise ADA-endorsed BrushTest ads

OralCDx wants to revise ADA-endorsed BrushTest ads

May 28, 2008 -- Controversial advertising in an ADA-endorsed oral cancer awareness campaign is likely to change, according to the campaign's sponsor.

The advertising, which began appearing on buses, trains, and in magazines in September 2007, has drawn criticism for two reasons. Some experts, including prominent oral pathologists, have faulted the way the nonprofit ADA is working with the for-profit OralCDx Laboratories. Others have challenged the reliability of the company's BrushTest as a means of detecting precancerous cells.

OralCDx CEO Mark Rutenberg on Tuesday released to DrBicuspid.com the draft of a new disclaimer that he hopes will clarify the relationship between the two organizations. But in an interview, he and company president Howard Kramer maintained that the test is highly accurate. And in an earlier interview, ADA president Mark Feldman, D.D.S., defended the text of the ads as they stand.

The price of promotion

Just about everyone agrees with the goal of raising awareness about oral cancer. An estimated 34,360 Americans are diagnosed with the disease each year, and on average only half of those who are diagnosed survive more than five years, according to the ADA.

And even some of the campaign's most prominent critics accept the approach of raising money from a private company. "The oral cancer campaign is important," Mark Lingen, D.D.S., Ph.D., a University of Chicago associate professor of pathology, told DrBicuspid.com. "And you have to pay for it somehow."

OralCDx is paying the entire cost of the $9.5 million, three-year campaign (something the ADA disclosed from the beginning). In fact, as Rutenberg pointed out, OralCDx isn't giving the ADA any money. "We have never given the ADA a dime," he said. "We have committed to spend $9.5 million on advertising. The ADA doesn't get that money. The ad companies get that money."

So what's the beef? In its most controversial version (click here to view the ad), the ad is labeled "IMPORTANT MESSAGE ABOUT ORAL CANCER FROM THE ADA." A headline reads, "Ask your dentist about a routine test as powerful as a Pap smear or colonoscopy." The next sentence reads, "Ask your dentist if a BrushTest can help you by accurately detecting unhealthy cells -- years before they can turn into cancer." The ad also bears the ADA's logo, and the academy's name appears in three other places.

Critics say the ads make it look as though the ADA is endorsing the BrushTest and ignoring competing tests. "I don't think it's appropriate to have a campaign that says, 'Go get this product,'" Dr. Lingen told DrBicuspid.com. "We have not had a campaign that says, 'Brush twice a day with Colgate toothpaste.'"

Dr. Lingen made that point at length in an editorial published in the April 2008 issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (OOOOE, April 2008, Vol. 105, pp. 407-409), where he serves as an editor. He's not satisfied with the fine-print disclaimer currently on the ad, which says that the ADA doesn't endorse a particular product. "One cannot have it both ways," he wrote. "You cannot develop an awareness campaign that focuses on a specific product and at the same time claim that you are not endorsing a product."

"Frankly, I agree with him on that point," Rutenberg said. He explained that people who read the ad should understand that the ADA is endorsing brush biopsy in general, not the BrushTest in particular. The current disclaimer doesn't go far enough in that direction, he added.

The current disclaimer reads, "The ADA does not endorse any specific product in connection with this awareness campaign and has no financial interest in the product featured here. For more information on oral cancer, visit www.ada.org. Part of an education campaign underwritten by OralCDx Laboratories."

The proposed new disclaimer provided to DrBicuspid.com by Rutenberg reads, "The OralCDx brand of brush test is an adjunct to the professional oral examination in the early detection of oral precancer. This test is not a substitute for a scalpel biopsy, which should continue to be utilized to evaluate suspicious oral lesions. The ADA has no financial interest in this product. This poster is part of an educational program supported by a grant from Oral Cancer Prevention International, Inc., provider of the OralCDx brand of brush test. For more information please visit www.ada.org."

Rutenberg said his company is close to agreeing with the ADA on the new draft. He also said he'd like to see less overall text on the ads, which are too "wordy."

But he didn't foresee any change in the headline that compares the brush biopsy to a Pap smear and colonoscopy. And he acknowledged that the OralCDx BrushTest dominates the market for brush biopsy tests. In fact, he said, the company's patents for the technology make it difficult for competitors to mount a challenge.

As for the ADA, Dr. Feldman defended the ads as they are. "The campaign is not product-specific at all," he told DrBicuspid.com. "The message with the ADA logo informs patients to ask their dentists about a test as powerful as a Pap smear or colonoscopy."

Tracking oral cancer

Is a brush biopsy indeed "as powerful" as a Pap smear or colonoscopy? If so, it could have great benefits. Some dentists "frequently don't examine the oral mucosa carefully and have inadequate experience in the identification of lesions," noted Martin S. Greenberg, D.D.S., oral medicine section editor at OOOOE and chair of the department of oral medicine at Penn Dental Medicine, in an OOOOE editorial. If a dentist does find something suspicious, the next step is to send the patient out to an oral surgeon or oral pathologist for a scalpel biopsy.

On the other hand, brush biopsy devices like the BrushTest let a dentist collect cells from suspicious white or red spots in the patient's mouth with much less discomfort; the sample is sent to an OralCDx laboratory for diagnosis. If the cells are abnormal, then a scalpel biopsy can confirm a potential cancer and the spot can be removed.

"The lifesaving reality and potential of the BrushTest is very obvious, and we seek to apply this in all dental offices across the country," said James Sciubba, D.M.D., Ph.D., a Johns Hopkins University pathologist, at a November ADA media briefing announcing the new oral cancer awareness campaign.

But Dr. Lingen believes that the BrushTest should not be compared to the Pap smear and colonoscopy. "Drawing analogies between these two tests and brush cytology is inaccurate," he wrote in his OOOOE editorial. For example, if there's evidence of some type of pathology during a colonoscopy, the patient receives a definitive diagnosis because the lesion is biopsied on the spot and histologically diagnosed. "Oral brush cytology never results in a definitive diagnosis," he wrote.

More to the point, should the BrushTest be your first choice? "The OralCDx procedure is neither optimum nor in the patient's best interest. Why go through the convoluted path [of BrushTest followed by a scalpel biopsy] to get definitive results?" said Dolphine Oda, B.D.S., M.Sc., a professor of oral pathology at the University of Washington.

"A scalpel biopsy is still the gold standard," said Gordon M. Rick, D.D.S., M.S., director of the Scripps Oral Pathology Service. "Why waste time and money on something else?"

To these criticisms, Rutenberg responds that a brush test saves patients the discomfort of having all their lesions tested by scalpel.

To see how Dr. Lingen thinks dentists should detect oral cancer, click here.

Rutenberg also questions the motives of some critics, who he says are afraid the BrushTest will undermine their business interests. "Some oral pathologists are concerned that the OralCDx brush biopsy is somehow competitive with the scalpel biopsy," he said, although he thinks the test will actually drive more business to practitioners of scalpel biopsy.

So far the ADA -- which stirred controversy in 2002 in a similar collaboration with OralCDx -- remains firm in its position on one side of the debate. "If research came out that said that the [BrushTest] is not accurate, then we would obviously have to shut down this campaign and remove our seal," Dr. Feldman said.

But he thinks that's unlikely. He believes the campaign will save lives by getting people into the dentists' office. "That's what this is all about," he said.




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ADA: Bisphenol A deemed safe in dental products -- so far

ADA: Bisphenol A deemed safe in dental products -- so far

May 28, 2008 -- The research so far suggests that bisphenol A (BPA), a compound in some plastic dental materials, won't hurt consumers, the ADA said Tuesday.

Bisphenol A, found in many consumer plastics and in dental sealants and composites, has been linked to reproductive problems and other forms of illness.

In a press release posted on its Web site, the organization said it had been in contact with trade groups and government agencies to share information on the compound. It quoted a letter in which the ADA told the National Institutes of Health that the latest peer-reviewed evidence found no risk from BPA in dental materials.

However, the ADA also believes that more information is needed. "Consumers must be assured that the materials used to maintain oral health are safe," said President Mark Feldman, D.D.S.


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Lasers treat gum disease with positive results By DrBicuspid Staff

Lasers treat gum disease with positive results By DrBicuspid Staff

May 27, 2008 -- Photodisinfection -- which combines low-intensity laser energy and microbiological stains to target and destroy microbial pathogens -- continues to demonstrate its effectiveness in the treatment of chronic adult periodontitis. According to Ondine Biopharma, the Vancouver-based company commercializing this technology under the product name Periowave, results from the Canadian Multi-Center Gum Disease Trial demonstrate that photodisinfection compares favorably to traditional scaling and root planing for the treatment of periodontal disease.

The Canadian Multi-Center Trial was a prospective, randomized, examiner-blinded study that included 121 patients and 4,500 defect treatment sites. Fifty-eight patients were included in the Periowave treatment arm and 63 patients were included in the control arm. The study was conducted at the University of Western Ontario, the University of Alberta, the University of Saskatchewan, and at a large private periodontal clinic in Toronto. This trial was Ondine's fourth and largest study to date, comparing the Periowave to scaling and root planing for the treatment of periodontitis.

"The trial results confirm the positive in-field experiences of clinicians using the Periowave system in Canada and the European Union," said Carolyn Cross, president and CEO of Ondine. "Periowave represents a significant, nonantibiotic, minimally-invasive adjunctive approach to the treatment of gum disease. In addition to the latest clinical efficacy data, there have been no reported product-related adverse events."

The company intends to submit detailed results of this study to the FDA as part of its ongoing discussions with the FDA regarding marketing approval for Periowave in the United States. The product is currently approved in Canada and the European Union for several oral indications. Ondine submitted its 510(k) application for the Periowave to the FDA in September 2007.

The original photodisinfection technology behind the Periowave was developed by Professor Michael Wilson and colleagues at the Eastman Dental Institute, University College London, and licensed to Ondine by UCL Business, University College London.


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Financial reports reflect slowing demand for dentistry

Financial reports reflect slowing demand for dentistry

May 23, 2008 -- Confirming analyst predictions, three major dental supply companies' recently announced financial results show that they have been hit by a slowdown in the dental market.

The companies still registered growth, but some areas of the market slowed down compared to last year. In April Robert W. Baird analyst Jeff Johnson lowered the target stock prices of Dentsply, Patterson Dental, and Henry Schein based on a survey that showed the demand for dental care would hit a speed bump over the next few months. Following his projection, the stock prices of all three companies fell.

Johnson downgraded Dentsply's projected stock price to $42 from $48 last month. The stock value today is $40.59.

“We do believe that in certain high-priced procedures like implants, certain prosthetics, there is a bit of softness in the market.”
— Steven Paladino, executive vice president and chief financial officer of Henry Schein
The market has softened in some speciality areas such as orthodontics and dental implants, William Jellison, chief financial officer and senior vice president of Dentsply, told DrBicuspid.com. The lab market and endodontics held up slightly better. The strongest market was consumables, which includes preventive and restorative care, he added.

However, even this market is weaker. "On the broader market indicators, what I refer to as the normal consumables, we believe the market has slowed slightly from the pace of late last year," said Bret W. Wise, chairman and CEO of Dentsply, at the company's financial results conference call.

Dentsply announced an internal growth rate of 4% in the U.S., compared to a higher growth rate of 8.5% in Europe and 6.3% in the rest of the world.

"Even though the dental market has slowed down slightly because of the overall economy, it is still more resilient than a lot of other harder-hit industries," Jellison said.

Johnson dropped Patterson Dental's projected stock price to $38 from $41. The stock price today is $33.66.

Patterson Dental fell short of analysts' revenue expectations of $800.5 million, coming in instead at $778.4 million.

"The overall conditions in the economy have only had a nominal effect on the company," Steve Armstrong, executive vice president and chief financial officer of Patterson Dental, told DrBicuspid.com. "Dental equipment is the most vulnerable category," he added.

For its latest quarter, Patterson Dental reported an increase of 5% in sales for consumable dental supplies, 1% for dental equipment and software, and 2% for other services and products, consisting primarily of technical service, parts and labor, software support services, and artificial teeth, compared to year earlier quarter.

"Sales of basic dental equipment were affected by lower-than-forecasted sales of digital radiography systems, including chair-side software and related computer hardware," James W. Wiltz, president and CEO of Patterson Dental, said in a press release.

Johnson dropped the projected price on Henry Schein's stock to $64 from $70. As of today, the stock price is $54.72.

The dental market has been affected by economic conditions to a minor extent, admitted Steven Paladino, executive vice president and chief financial officer of Henry Schein, at the company's financial results conference call.

"We believe that the dental marketplace is relatively resistant to macroeconomic trends but certainly not immune," Paladino said.

Henry Schein announced that internal dental consumable merchandise sales increased 4.3%, while dental equipment sales and service revenues were up 9.8%.

"We do believe that in certain high-priced procedures like implants, certain prosthetics, there is a bit of softness in the market," Paladino said. However, "we don't think it's dramatic. We think it's very modest."


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Dentists and physicians should comanage osteoporosis patients, study says

Dentists and physicians should comanage osteoporosis patients, study says

May 23, 2008 -- Dentists should not discontinue bisphosphonate therapy or other medical treatment for people suffering from osteoporosis without consulting the patient's physician, according to a May article in the Journal of the American Dental Association (JADA, May 2008, Vol. 139:5, pp. 545-552).

Although bisphosphonate drugs are great at battling osteoporosis, they can also cause the rare but serious condition of osteonecrosis, as reported in an earlier DrBicuspid article. Bisphosphonate-related osteonecrosis of the jaw (BRONJ), for example, is a relatively new condition triggered mainly by the increased use of bisphosphonate drugs.

The authors of the JADA article looked at medical and dental literature to review the effect of osteoporosis on public health. They also looked at the implications of providing dental care to patients with osteoporosis.

The oral healthcare of patients with osteoporosis is important, and dentists and physicians need to work in collaboration to provide them care, the authors wrote.

"All healthcare professionals involved in the care of all dental patients, particularly patients who are taking oral bisphosphonates, should discuss patient-care decisions," they concluded.


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Keep your patients coming back By Rabia Mughal, Contributing Editor

Keep your patients coming back By Rabia Mughal, Contributing Editor

May 22, 2008 -- The issue of "lost patients" isn't just annoying; it can be costly. If you have been in practice for five years, you have probably lost more than a million dollars due to unscheduled dental work that needs to be done on existing patients, according to Joy Millis, C.S.P., a presenter at the California Dental Association (CDA) conference in April.

"A patient without an appointment is not a patient in your practice," explained Millis. As soon as a patient completes treatment, schedule a follow-up appointment. When recommending an appointment, use phrases like "Let's go ahead ..." rather than "Do you want to?" Send the message that follow-up care is a priority, Millis emphasized.

If patients leave without scheduling an appointment for recommended necessary care, make a note of why they are not scheduling. For example, patients can say they need to check their schedule or talk to their spouse. You should then call them within five to seven days after their last appointment to see if they have done so. If there is no follow-up, the patient believes the treatment is not a priority, time goes by, and the patient is lost.

When making an appointment, ask your patient, "If we have a change in the schedule and can see you sooner, may I give you a call?" This is an efficient way of filling holes in the schedule. When there is a cancellation, you can call any patient on the schedule and say, "I have good news. I promised to let you know if we had a change in the schedule and could see you sooner. We can see you today!" Millis said. It is better for patients to learn to come in sooner than to learn that canceling an appointment is perfectly fine.

If a patient does cancel an appointment -- even a three-hour crown and bridge procedure -- don't immediately deactivate them or label them as "bad patients." Patients have a life that has nothing to do with their teeth, Millis noted. Something urgent might have come up that made them cancel or miss their appointment. Many professionals make the mistake of thinking, "Why bother? If the patient wanted his dentistry done, he would be here." Meanwhile, boxes of charts representing lost patients continue to pile up in storage.

Rather than throwing up your hands in frustration, tackle those charts. "What if each member of your team contacted just one lost patient every day?" Millis asked. "What value could the team member return to the practice?" Dental insurance values a patient at $1000 per year. What are patients worth if they're lost?

Another Millis recommendation is to call patients for the right reasons. Don't call patients because the doctor told you to call or because there are holes in the schedule. "Call patients because you are concerned. Call because you care," Millis said. "Call for the right reason and you will get the right response."

It is also important to prevent buyer's remorse -- patients changing their mind about receiving care. Immediately after appointments with new patients, send a letter stating it was great to meet them and that you look forward to seeing them at their next appointment. Always act like patients are proceeding with the recommended care.

Millis also recommends not limiting patients to their insurance-covered care. In fact, the patient and the practice might be at risk when doing only this type of care, she noted. Patients don't always understand that dental insurance has limitations. They often believe their dental insurance covers everything.

"We lose patients every day because we tell them they have reached their maximum coverage and they believe they have to wait to have anything else done," Millis said. "If a patient needs treatment that is not covered by insurance, encourage them to make financial arrangements to receive care, and warn them about the possible dental loss that could occur if they do not proceed and that dental loss could lead to additional expense."

As it is, dental insurance does not cover a lot of treatment. "I see a patient walk into a practice with insurance, and I think to myself, 'Oh, you have insurance, which tooth do you almost want to fix?' " Millis told a laughing audience during her CDA presentation.

A patient who initiates care in your practice is your responsibility. In most states, you are responsible for a patient's continuing dental health for up to seven years after the first appointment. Patients should be warned about the possible loss they might experience should they not proceed with recommended necessary care -- whether they have insurance or not.

"When patients say they want to delay treatment, tell them their dental condition could get worse and more expensive. Then document your warning," Millis said. There are procedures for following up with patients who do not proceed with necessary dental care, along with procedures for ending your legal responsibility for them. Millis recommends that your state board of dentistry and attorney be contacted for ethical and legal advice regarding the termination of any relationship with patients.

The bottom line, Millis concluded, is to make every effort to bring patients back into your practice. "Do the right thing and you will never need to lose another patient again," she said.



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U.K. dental conference attracts biggest crowd to date

U.K. dental conference attracts biggest crowd to date

May 22, 2008 -- Organizers are calling this year's British Dental Conference and Exhibition "the biggest ever staged," with record numbers of both attendees and exhibitors. The annual event, held May 1-3 in Manchester, U.K., attracted 4,263 visitors and 180 exhibitors, up from 3,266 visitors and 128 exhibitors in 2007.

With a theme of "Strategies for success: you and your team," highlights of the three-day event included the introduction of a new MasterClass business education program and a debate by representatives of the U.K.'s two main opposition parties on the future of National Health Service dentistry.

"The 2008 British Dental Conference and Exhibition was a fantastic event," said Peter Ward, chief executive of the British Dental Association (BDA). "Across the U.K., dentists and dental care professionals are confronting change and facing significant challenges. This event brought together visitors from all branches of the dental family and underlined the importance of working together to build success in the future."

The 2009 British Dental Conference and Exhibition will take place June 4-9 in Glasgow, Scotland, under the direction of the newly installed BDA President Peter Ward.



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U.K. dental conference attracts biggest crowd to date

U.K. dental conference attracts biggest crowd to date

May 22, 2008 -- Organizers are calling this year's British Dental Conference and Exhibition "the biggest ever staged," with record numbers of both attendees and exhibitors. The annual event, held May 1-3 in Manchester, U.K., attracted 4,263 visitors and 180 exhibitors, up from 3,266 visitors and 128 exhibitors in 2007.

With a theme of "Strategies for success: you and your team," highlights of the three-day event included the introduction of a new MasterClass business education program and a debate by representatives of the U.K.'s two main opposition parties on the future of National Health Service dentistry.

"The 2008 British Dental Conference and Exhibition was a fantastic event," said Peter Ward, chief executive of the British Dental Association (BDA). "Across the U.K., dentists and dental care professionals are confronting change and facing significant challenges. This event brought together visitors from all branches of the dental family and underlined the importance of working together to build success in the future."

The 2009 British Dental Conference and Exhibition will take place June 4-9 in Glasgow, Scotland, under the direction of the newly installed BDA President Peter Ward.



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Patients not always honest, survey finds

Patients not always honest, survey finds

May 21, 2008 -- Are your patients being completely honest with you? In a recent survey, 41% of respondents said they tell their dentist they brush for the recommended two minutes even if it isn't true or they're unsure.

The public opinion survey, conducted by Harris Interactive, polled 1,001 adults ages 18 years and older between May 1 and May 4, 2008.

Some of the survey's other findings:

64% of the people surveyed considered their oral health a top health priority.
However, 82% did not know how infectious bacteria cause cavities and dental decay.
59% of the respondents said they brush their teeth for two minutes on weekdays, while only 23% admitted they brushed for the recommended time on the weekends.
70% said they replaced their manual toothbrush or power toothbrush head once every three months or more often.
49% said their dental professional asked about overall health at their last dental appointment. However, when asked if their primary care physician enquired about their oral health, only 23% said yes.
The survey was sponsored by Oral Health America and Philips Sonicare and is part of the U.S. National Smile Month, from May 18 to June 17, which aims to raise awareness of good oral health habits.

"The survey results make it clear that Americans know the benefits of dental care, but lack a greater understanding of the disease processes that can cause tooth decay," said Robert Klaus, president and CEO of Oral Health America in a press release. "By empowering people with information about good oral care habits, we can help prevent painful and costly dental problems and potentially impact overall health."




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UHC Specialty Benefits enhances coverage of oral cancer screening

UHC Specialty Benefits enhances coverage of oral cancer screening

May 20, 2008 -- UnitedHealthcare (UHC) Specialty Benefits now covers all light-contrast technology-based oral cancer screening tests under its dental plans.

Light-contrast technology increases a dentist's ability to identify, evaluate, and monitor lesions that are difficult to see under conventional lighting, according to the Golden Valley, MN-based company.

"By covering this type of oral cancer screening, UnitedHealthcare Specialty Benefits dental unit is renewing its longstanding commitment to early detection of oral cancer," the company stated in a press release.

The company has covered brush biopsies since 2005.


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Cone-beam and multislice CT measurements found equally accurate

Cone-beam and multislice CT measurements found equally accurate

May 16, 2008 -- What kind of scanner should you use to plan complex implants? In a shoot-out between multislice computed tomography (MSCT) and small-field cone-beam CT (CBCT), both imaging modalities lived to see another day.


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Using a head from a human cadaver, researchers compared the results of both techniques to physical measurements. The result? The researchers wrote in the April issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (Vol. 105:4, pp. 512-518) that they could find no statistical difference in the two types of imaging; both came within a millimeter of the measurements taken with a caliper.

The results are "a good thing for dentistry," says Gary Orentlicher, D.M.D., chief of oral and maxillofacial surgery at White Plains Hospital Center in White Plains, N.Y. "From an accuracy standpoint, cone-beam is an excellent technology, and I think this article is basically just saying that. If you have an in-office cone-beam machine, it's a very accurate image that you're going to get."

The researchers, from the Katholieke Universiteit Leuven in Leuven, Belgium, fastened the formalin-fixed human head on a wooden stand so that they could scan it in either an upright position for the CBCT system or supine for the MSCT scanner.

They glued small gutta-percha markers to the soft tissues on the top and both facial and palatal sides of the alveolar ridge to define a set of reproducible linear measurements.

The accuracies of the linear measurements using an Accuitomo 3D CBCT (J. Morita, Kyoto, Japan) and two MSCTs (four-slice Somatom VolumeZoom and 16-slice Somatom Sensation 16; Siemens Healthcare, Erlangen, Germany) are shown in the table. Measurements from two observers of the images were compared to those obtained from three observers using calipers, which were considered the gold standard.

Accuracy of linear bone measurements by different imaging protocols
Scanner type Somatom VolumeZoom Sensation 16 Accuitomo 3D
Reconstruction filter U70u U90u H60s H30s --
Accuracy (mm) 0.35 ± 1.31 0.06 ± 1.23 0.24 ± 1.20 0.54 ± 1.14 -0.09 ± 1.64
(radiological - physical measurements ± standard deviations)
So does this study mean that CBCT and MSCT are equally useful? As the researchers wrote, their study only focused in on bone measurements. If you're choosing which type of scanner to use, there are other considerations. For example, they wrote, the small field-of-view of CBCT could pose problems if you need to visualize a full jaw. On the other hand, the CBCT's image quality would be good for identifying an intraosseous anatomic landmark such as the mandibular or nasopalatine canal.

Other advantages of CBCT are its lower radiation dose, shorter acquisition time, and reduced costs, the authors wrote, as well as in-office imaging. Disadvantages are scatter radiation, limited dynamic range of the x-ray area detectors, truncated view artifact, and artifacts caused by beam hardening. MSCT gives sharper pictures, but at the expense of more radiation, higher cost, longer acquisition time, and the need to send patients out to an imaging center. Both modalities produce 3D images.

The study doesn't completely settle the question of which system offers better measurements, the investigators wrote, because the study was limited by the small distances that could be measured and the small number of measurements.

While agreeing with these limitations, Dr. Orentlicher believes the two modalities truly are equal when it comes to accuracy of measurements. "If the implant surgeon is really interested in just viewing the anatomy of the area," he says, "meaning being able to measure the widths of the bone, being able to see the proximity of nerves, vessels, sinus, to the site that he's planning on placing an implant, then a cone-beam scan or [an MS] CT scan will be of equal value."

One of the limitations with CBCT, he noted, may be a lack of clarity because of the use of a lower radiation dose. Therefore, it may not reveal the definitive anatomy of upper jaws with soft bone or a less dense cortical plate as would medical-grade MSCT. But both CBCT and MSCT are "far, far superior than just taking a panorex or a standard dental periapical as far as the information that the doctor is going to get."

In this study, both four- and 16-slice scanners were evaluated, as well as CBCT. Dr. Orentlicher says the choice of four- or 16-slice scanner here may not be as critical as in actual practice since the cadaveric maxillary specimen was fixed to a stationary mount whereas live patients' heads may tend to move more. He advised that the CBCT results of the present investigation apply to the Accuitomo scanners tested and that other studies have shown variability in results from other makes and models. Dr. Orentlicher estimates that there are probably 10 to 12 other CBCTs currently on the market.

He says that 3D imaging may not yet be the standard of care for the way implant dentistry is practiced today. But in his own practice, he says over the past four years 28% of his cases and 52% of implants are placed "guided," meaning using 3D radiographic imaging, software for planning, and computer generated surgical guides. "The cases (in which) I'm using 3D implant planning technologies are more of the cases that have anatomic issues or (where) I'm placing multiple implants," he said.

Dr. Orentlicher reported speaking and/or consulting relationships with Nobel Biocare, Materialise, and Keystone Dental. He is also a partner in Facial Imaging, LLC, a dental image analysis company.

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3M to acquire Imtec By DrBicuspid Staff

3M to acquire Imtec By DrBicuspid Staff

May 16, 2008 -- 3M of Maplewood, MN, will acquire Imtec, a manufacturer of dental implants and cone-beam computed tomography (CBCT) scanning equipment, the two companies announced May 15.

Ardmore, OK-based Imtec is best known for its mini dental implants, which are small-diameter, single-unit dental implants primarily used for denture fixation and also appropriate for orthodontic anchorage.

"Our combined digital products and expertise will enable a digital 'total restorative' approach with more options than ever, including Imtec implants, 3M lava crowns, and 3M's advanced digital workflow solutions," said Jeffrey Lavers, 3M vice president and general manager. "Together, we will have an end-to-end implantology solution, making the process easier, faster, and better for dentists everywhere."


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Study: Wireless sensors better for endo x-rays

Study: Wireless sensors better for endo x-rays

May 16, 2008 -- If a picture is worth a thousand words, a good radiographic image is worth at least a hundred gutta percha points to endodontists who want to perform successful root canal therapy. Digital radiography is the technique of choice for many professionals because of its speed and accuracy. But which kind of digital image receptor gives you the best bang for your gutta percha "buck"?


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Wireless. That's according to group of researchers at the University of Missouri at Kansas City (UMKC) who recently hit upon an innovative way to evaluate sensors. They located 14 cadavers with intact third molars and tried to locate file tips inside the molars using different sensors. The results, published in the April Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (Vol. 105:4, p. e48), pointed to a "significantly lower" measurement error with a wireless sensor compared to wired and storage phosphor plate (SPP) sensors.

Despite its small sample size, the study offers useful information for dentists, commented Gail F. Williamson, R.D.H., M.S., professor of dental diagnostic sciences at Indiana University. "The ability to evaluate fine files to determine working length has been a common topic reported in the radiographic and endodontic literature. What I take away from this study is that of the three digital receptors tested, the CDR sensor had the best resolution, which allowed better visualization of the file."

The UMKC researchers introduced a fine endodontic file (#10) into the canals of the molars at random distances from the apex of the tooth. Three #2 image receptors were used to take images of the file: DenOptix SPP, Gendex charged-coupled device (CCD) sensor (wired), and Schick computed dental radiography (CDR) Sensor (wireless). Six raters viewed the images to identify the radiographic apex of the tooth and the tip of the endodontic file. After the observations, teeth were extracted and the length of the canals measured to obtain a gold standard.

The study found that errors were significantly higher for the DenOptix SPP sensor and that the Schick CDR had the fewest errors. Although wireless sensors are new to the market and more highly priced than wired devices, they may be a good option, said lead author, Anas Athar, D.D.S., M.S., an assistant professor of oral pathology, medicine, and radiology at UMKC.

"At the last American Academy of Oral and Maxillofacial Radiology meeting in Charleston, S.C., we presented a study, in which I took part, indicating how convenient both operators and patients are with wireless sensors," Dr. Athar said. "Positioning the sensor in the mouth is difficult and inconvenient for the patient because the wires coming out of the mouth don't look good. If the prices for wireless sensors will go down, as it always happens with new technology, and if you have a choice, you should consider wireless."

Dr. Athar reported no conflicts of interest.


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UCLA orthodontics resident resigns, citing harassment

UCLA orthodontics resident resigns, citing harassment

May 16, 2008 -- A resident who accused the orthodontics program at the University of California, Los Angeles (UCLA) School of Dentistry of demanding donations from applicants has resigned from the program, the Daily Bruin student newspaper reported May 15.

In his resignation letter addressed to department chair Kang Ting, D.M.D., Ph.D., Kent Ochiai, D.D.S. "alleges that Ting unfairly took away his clinic patients, limited his access to study materials, halted his progress in the three-year program, and discredited him among his colleagues," the Daily Bruin reports.

Earlier, in November 2007, the Daily Bruin reported allegations that the school gave preferential treatment to candidates who could bring in hefty donations. The story was the result of a five- to six-months-long investigation, said Robert Faturechi, the reporter who broke the story. It was later picked up by some mainstream media as well.

Dr. Ochiai's involvement in the investigation was indirect, Faturechi explained. Dr. Ochiai applied to the school in 2006 and was asked for a $60,000 donation by a member of the admissions board, and he reported this to a faculty member. After an alumnus got wind of this incident, he tipped off the Daily Bruin.

The UCLA School of Dentistry dean, No-Hee Park, D.M.D., Ph.D., issued a statement following the story in which he said that an independent investigation "found no credible and convincing evidence to support allegations of a donor legacy program in the orthodontics admissions process."

However, the school would look into improving the oversight and clarity of the admissions process, the statement claimed.

The school refused to comment on these recent developments citing privacy of personal information regulations.

Dr. Ochiai deferred questions to his attorney who could not be reached for comment.

In his resignation letter made public by the Daily Bruin, Dr. Ochiai states that the treatment he received at the program was retribution for his failure to pay a donation and his imagined association with the Daily Bruin article.


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