Archive for the ‘Dental Training’ Category

The Ethical Case for Confidentiality

Wednesday, March 6th, 2013

By Gary T. Chiodo, DMD, FACD and Phyllis Beemsterboer, EdD

 

All health care providers are well-aware of the legal protections extended to patient information via the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.  With few exceptions, all information that patients provide to us in the form of their medical history and all data related to the care we deliver to them are protected by the HIPAA rules and may not be released to any third party without patient consent and authorization.  While HIPAA may impose strict legal parameters on how patient information must be protected and how it may be released, there are ethical obligations that provide even more persuasive arguments for the bond of doctor-patient confidentiality.  These ethical obligations are based in the ethical principles of respect for autonomy and nonmaleficence.

Respect for autonomy is the ethical principle that allows, with few limitations, patients to determine what will and will not be done to their bodies.  In normal health care practice, patient autonomy is facilitated and respected through the process of informed consent.  The well-informed patient who has capacity to consent has the right to select from various treatment options, the treatment or treatment plan that is most concordant with his/her values and wishes.  Because the informed consent process is essential in this dynamic, health care professionals must collect and analyze complete information about the patient.  For example, surgical options for repair of a periodontal defect may very well change if the dentist knows that the patient has a bleeding problem.  Plans to remove teeth may be mitigated by a history of bisphosphonate therapy.  In cases like these, patient autonomy cannot be truly facilitated and respected unless the dentist has complete and accurate information about the patient’s medical conditions and history.  If the patient is not entirely comfortable with complete disclosure because he/she doubts that confidentiality will be respected, then important information may be withheld.  When this happens, not only will the patient’s autonomy be compromised, but the dentist’s obligation of nonmaleficence, or avoiding harm to the patient, will be in jeopardy.  While most patients would not be reluctant to reveal a bleeding problem or a history of bisphosphonate therapy, some may hesitate to reveal things they consider to be embarrassing or intensely personal.  For instance, the patient who is receiving treatment for mental health issues or chemical dependency may opt to omit that from the medical history out of concern that it will not be treated with strict confidentiality.  The male patient who is using a phosphodiesterase-5 inhibitor on occasion, may decide to leave that out of his medical history so he does not need to worry about who may have access to that information.  A young woman who takes a hormonal contraceptive may decide that her dentist simply does not need to know that.  While we are well-aware of the potential harms that may come to patients when we do not have complete medical information, patients are less likely to appreciate those harms or, if they are aware of them, may simply decide to keep the information private and accept the risk.

Part of the challenge in obtaining complete and accurate medical information from our patients comes from making sure they understand why we need this information and this process takes chairside time.  However, another important part of the challenge is in ensuring that they trust us to keep it strictly confidential.  If we are not successful in creating that trust, critical information may be withheld and we will not be able to meet our ethical obligations of respect for autonomy and nonmaleficence.  In the best case scenario, breaching confidentiality will result in a patient who feels betrayed and goes elsewhere for care.  In the worst case scenario, the patient will develop a lack of trust in other health care providers, will withhold vital information, and will be seriously harmed.  If we emphasize the protections that we afford their personal information and assure them that they may trust us to keep it strictly confidential we are honoring our ethical principles and serving our patients best.

 

 

Gary Chiodo, DMD, FACD is currently the interim dean at OHSU School of Dentistry. Most recently, he served as the Chief integrity Officer for OHSU, a position he held for 10 years. He is a professor of Community Dentistry and Association Director of the Center for Ethics in Health Care. Dr. Chiodo received his Certificate in Health Care Ethics form the University of Washington School of Medicine in 1992.

 

 

 

Phyllis L. Beemsterboer, MS EpD, FACD is a Professor and Associate Dean for Academic Affairs in the School of Dentistry at OHSU in Portland. She is and associate director in the Center for Ethics in Health Care at OHSU and co-chairs the inter-professional ethics education program. Her research interest is in bioethics education and she is currently president of the American Society For Dental Ethics, a special section of the American College of Dentists.

An Analogy of Tooth Decay – How our Teeth Stay Strong

Monday, January 7th, 2013

Dr. Terri Baarstad

I have a little analogy that I use with my patients that seems to help them understand. I say something like:

There are bacteria in your mouth that “eat” carbohydrates. These bacteria have waste products and those waste products are acidic. Acid “dissolves” our teeth and makes it so we get cavities.

Imagine that your teeth are brick walls. They have all these bricks going in and out of the wall all the time- they are not static, they change. So when your mouth is at PH7 –that is neutral- the bricks go in and out at the same rate- there is no net change. Teeth stay healthy. But, when you eat or drink anything that has carbohydrate (sugar, bread, pretzels, even croutons) the PH of your mouth drops and the environment becomes acid. When your mouth is in acid- more bricks go out than come back in, so there is net loss of tooth structure. It takes about 20 minutes for your mouth to return to neutral after eating, so, if you are snacking, taking a bite or a sip of a soda pop every few minutes over an period of time, say 2 hours, then your mouth will be in acid for 2 hours and 20 minutes. If this occurs regularly over time, there is more net loss of “bricks” and eventually there begins a cavity. Once the cavity begins there is more acid because the bacteria have multiplied and they make more acid, leading to more cavities. The cure for the cavity is to have it treated with a filling or a crown. But the cure for not getting more cavities is reducing “exposure” to the acids. Fluoride on and in the teeth is like having mortar for those bricks- it makes it so much more resistant to acid.

Knowing the way that teeth “dissolve” you can understand what might help slow down this process

If you brush your teeth, chew sugarless gum, or rinse vigorously with water after eating, the Ph raises to neutral more quickly. Conversely, a dry mouth doesn’t return to neutral very quickly. The dry mouth patient is also at a higher cavity risk because the acid is that much more concentrated. Water, mints and gum, or even a change of medications might be in order.

Since it is all about acid, and acid comes from bacteria, and the bacteria live in plaque, reducing plaque (by brushing and flossing) reduces acid and therefore cavities. Xylitol (gum and mints) reduce bacteria and increases saliva flow, thereby minimizing acid exposure. Eating your food less frequently (eating the entire candy bar or drinking the entire soda all at once) will decrease exposure time, thereby reducing the risk.

 

Dr. Baarstad appreciates the value of community service, and devotes herself to improving the dental health of those who live around her.  After attending the University of Oregon, Dr. Baarstad graduated as a DMD from the Oregon Health Sciences University in Portland. She is an active member of the American Dental Association, the Oregon Dental Association and the Academy of General Dentistry, and a recipient of the Dr. William Howard Award for Excellence in Fixed Prosthetics. She donates services to charitable organizations and sponsors many community events, including high school fundraisers. Dr. Baarstad expresses a special interest in helping young men and women explore a career in dentistry through volunteering at local high school career symposiums.

Cavity Management by Risk Assessment Improves Access to Care

Monday, October 1st, 2012

By Dr. V. Kim Kutsch, DMD

Recently PBS broadcast a Frontline special report entitled “Dollars and Dentists”. The report presented a “broken dental system” in the US, amidst a rising epidemic with decay. PBS actually did a very good job describing the current issues facing dentistry today: rising healthcare costs, increasing decay rates in children and adults, limited access to care, an entitlement system that doesn’t adequately reimburse private practitioners, and corporate America seeing a profit opportunity in treating (mistreating) these children, and the concept of mid-level providers to help solve the access issue. However, the report failed to examine the real issues at play, and missed a huge opportunity to report the truth.

Here are the facts: the decay rate in our small children is rising at epidemic proportions, there is limited access to care, but the focus of the system is still in the wrong place. The Medicaid system will reimburse for crisis care for a child in a hospital setting to the tune of $12-18,000, and again when the same child needs the same procedure 20-24 months later, but won’t adequately reimburse a private practicing dentist to provide the necessary preventive management to avoid the crisis in the first place. What part of this expensive, out-dated system should we consider successful?

Corporate America got involved and suddenly there is an increase in the number of stainless steel crowns being placed on these children and less preventive services. Is anybody really surprised by that? The system rewards placements crowns but doesn’t adequately compensate a private practitioner to provide real preventive care and counseling. What might happen if the system paid $300 for fluoride varnish, professional therapy products, and nutrition counseling and $30 for a stainless steel crown?  There would be a lot fewer stainless steel crowns and there might also be fewer $18,000 crisis scenarios and better treatment outcomes.

Organized dentistry provides a lot of free care to help with the epidemic, take the success of the MOM program for example, or Donated Dental Services. Or consider the fact that individual dentists routinely provide pro-bono care to people in need. This was never mentioned in the report, but we all donate care as best we can. Unfortunately it still isn’t enough for the crisis we’re in.

Dr. Bob Barkley summed it up pretty accurately over 40 years ago. The problem we have is the house is on fire, and we’re trying to solve the problem with carpenters. We need to send in the firemen. The bottom line is dental caries is a multifactorial, complex, pH-specific biofilm disease. Too late we’ve learned that the drill has little to do with actually treating the disease. Increasing the number of Pediatric Dentists, operating suites, corporate dental practices, or mid-level practitioners isn’t going to solve this epidemic. We can’t drill and fill our way out of this crisis, regardless of who is running the drill. We don’t need more carpenters. We need to put the fire out.

To solve the healthcare crisis we face in dentistry today, we need to move from a treatment model to a healing model. CAMBRA, or caries management by risk assessment identifies and addresses the cause of the disease for each patient. By understanding the cause of dental caries we can focus on targeted strategies and effectively manage it. Armed with this knowledge we can coach patients back to long-term sustainable health. Through real preventive management of this disease we can provide the treatment outcomes we are looking for. The system we’ve got is truly broken and not functioning. The decay epidemic is direct evidence of that. But the solution won’t be found incarpenters, we need to change the “system” so that it fairly rewards firemen. That would reduce the decay epidemic, reduce the cost burden, improve access to care, and provide a genuine long-term solution. We need to fix the system. That’s the real story, and Frontline missed it completely!

 

 

Dr. Kutsch received his undergraduate degree from Westminster College in Utah and then completed his DMD at University of Oregon School of Dentistry in 1979. He is an inventor, product consultant, internationally recognized speaker, in past president of the Academy of Laser Dentistry, and WCMIID.  He has also served on the board of directors for the WCLI and AACD.  As an author, Dr. Kutsch has published dozens of articles and abstracts on minimally invasive dentistry, caries risk assessment, digital radiography and other techonologies in both dental and medical journals and contributed to several textbooks. He also acts as a reviewer for several journals.  Dr. Kutsch also serves as CEO for Oral biotech, as a clinician.  He is a graduate and mentor in the prestigious Kois Center and maintains a private practice in Albany, Oregon.

Does Botox Have a Role in Dentistry? Yes!

Wednesday, August 22nd, 2012

By Dr. James Catt

Does Botox have a role in dentistry?  This was what I was determined to discover when I registered for my first introductory Botox course.  The course was instructed by Dr. Warren Roberts from the Pacific Training Institute for Facial Esthetics (PTIFA) in Vancouver B. C. .  I was drawn here because of its recognition by both ADG PACE and ADA CERP as well as this being the most thoroughprogram that I could find. I was in search of answers, not a diluted course that spoon fed material and handedout a flowchart of “how to’s”.  I needed both a didactic and clinical perspective in order to arrive at a sound judgment on the practicality and safety of the possible utilization of Botox in my practice if Oregon were to allow dental professionals access to this therapy.  PTIFA fulfilled this requirement for me.

Admittedly, prior to attending the training I had some pre-existing bias on two levels.  Apprehension of the drug’s effects and unwanted clinical outcomes made up the bulk of my bias.  In addition, understanding the psyche of the patients who seek this type of therapy also added to my unease.  The latter was less of an issue since I learned multipleclose acquaintances evidently received Botox therapyregularly provided by individuals who at first glance appeared to have fewer head and neck anatomy credentials then I.Also, all of these acquaintances seemed like normal people and their outcomes were as expected.  In reality, it was only due to my close relationship with them and their voluntary divulging of this informationthat I had any idea they had received treatment at all.  So the question lingers; how does Botox apply to dentistry?

In short, the education that I received allayed my misgivings concerning Botox.  Let me repeat that.  The educationallayed my misgivings concerning the safety and utilization of Botox.  I’ve since taken an additional 16 hours of continuing education from PTIFA (totaling  32 hours) which focused on specific dental applications and hands on exercises.  There is absolutely no question in my mind that this treatment can provide dental advantages.  The next question would pertain to who specifically should be providing the therapy for dental applications.

In making my assessment and attempting to answer this question, I began to systematically review what my particular “job” as a dentist currently entails.  My “job”, as I would describe it, may be quite different then my dental colleague’s “job” who practices next door if he were to describe his own duties.  We are both D.M.D.’s, obtained our degrees from the same dental school and we are both required to meet the same standard of care.  However, he may state that his “job”entails extensive endodontic and pediatric treatment.  Theoretically, in these cases, I may state that my “job” is to schedule these patients with a great specialist.  My colleague has taken additional training and provides a high level of care in these cases that I don’t necessarily feel comfortable becoming involved in.  The converse may also be true.  After dental school I chose to pursue a greater level of understanding of occlusion.  I began a four year post graduate path that ultimately provided a competence in treating complex occlusion cases.  Coincidently, often times, this therapy helps with head and neck pain.  My colleague may not report this as one of his “job” objectives.  We are both working within our scope but our focuses differ.  I believe that it is well established that while working within our scope the discretion of what services we provide is based on our education.  Likewise, one practioner’s voluntary dispassion for a type of dental procedure does not, nor should it ever, preclude other practioners from focusing on this said procedure as long as it’s within the scope of dentistry.   Which dental professionals should be allowed to administer Botox for dental purposes?  The answer is the dental professionals who have taken advanced Botox training for dental purposes.   Dental purposes include, but are not limited to, muscle/frenum pulls leading to gingival recession and other periodontal concerns, bruxism and hypertrophic facial muscles, excessive gingival display, and muscle related TMD symptoms.

Some may say that the general dentist should stick with treating teeth and gums.  Some may say that facial musculature isn’t something that the general dentist should involve themselves with.   At this point I am going to use my own training as an example of how the general dentists in our state, who have had the proper advanced training, currently involve themselves with facial musculature every day.   The application of Botox by the general dentist is not an expansion of scope.  On the contrary, Botox is simply a potentially powerful new tool in our armamentarium of treatment options.    The question at hand is,which dental professionals can use Botox in a comprehensive manor and safely maximize the benefits of this therapy?By no means is this example to imply a specialty on my part.  Like many of my dental colleagues, this is simply one aspect of my “job” as I’ve defined it through advanced education and is what I’ve chosen to study and implement in my practice.

 All of us dentits have seen severely worn dentitions.  We as dental professionals know that severe dental attrition is only one sign of a systemic problem.

After ruling out other biological etiologies such as medications, eating disorders and gastric problems, it is inherent that we address the facial musculature system which attaches to and controls the grossly worn hard tissues.  It is impossible to predictably treat the teeth alone since the hard tissues and the soft tissues are reliant on one another.  Without superfluous explanation since the methods vary, the facial muscles need to be relaxed, the jaw joint needs to be passively stabilized, a diagnosis made and treatment options proposed.Botox therapy could often times be useful atmany of these junctures.After consent is given, irreversible procedures are performed on the hard tissues.  The treatment objective is to provide therapy which will lead to permanent stabilization of the occlusion and therefore provide a state of musculature stability which coincides with this new stable occlusion.    As I mentioned earlier, the consequence of this treatment is often times a reduction in myofacial pain.  Below are several photos of one of my own cases.  These photos document the muscular changes that occur when advance occlusal therapy is performed.   There is no refuting that there are permanent changes to this individual’s facial musculature.  This is an irreversible and, might I say, quite an invasive procedure.  However, the results are predictable and successful due to advanced education.  This treatment falls within today’s scope of practice for our state’s general dentists.  Not all dentists perform this type of invasive, advanced, irreversible procedures whichaffect the hard AND soft muscular tissues.  This is a voluntary choice made through the practitioner’s involvement in advanced education.  Botox therapy, even though reversible, should have similar educational requirements.

 Before and After Occlusal Therapy and Muscle Stabilization

So, should a general dental professional be allowed to provide Botox Therapy?  The answer is a resounding, YES!  The caveat being, the general dental professional should be required to meet a standard of competency based on educational requirements.  It is obvious that there are well trained general dentist who treat facial musculature every day and we do this with irreversible procedures.  Botox therapy can be used as an adjunct to such treatment as well as others. Not only is Botox proven safe to use in the right circumstances, it is completely reversible.  The real question is, who better to provide dental Botox to our patients?  Logic requires that the treating doctor has the knowledge of the masticatory system, complex occlusion, head and neck anatomy, as well as possesses the dexterity for specific injection techniques.  Certainly this treatment option isn’t for every dental practitioner, but let’s not withhold this from those general dentists who have the ability, desire, and education to serve their deserving patients.

 

Dr. Jim Catt  practices health centered comprehensive cosmetic restorative dentistry in Medford, Oregon. He received his Bachelor of  Science from  Oregon State University and was Magna Cum Laude from Oregon Health and Sciences University with his Doctorate in Dental Medicine.  Dr. Catt is  a past president of the ODA and has served as an  Trustee for 13 years, participating on many Boards and Committees. He is a member of the International College of Dentists, American College of Dentists, and Pierre Fauchard Academy. In addition, he facilitates dental health in children through dental health awareness in Medford schools, volunteering at Jackson County Children’s Dental Clinic, and acting as the Project Lead for the Southern Oregon Mission of Mercy.

 

The New OHSU School of Dentistry Building

Monday, July 2nd, 2012

By Jack Clinton, D.M.D. `64, Dean Emeritus, OHSU School of Dentistry

OHSU School of Dean Emeritus Jack Clinton, D.M.D. `64 (second from left) tells Gene Skourtes (second from right) about the new dental school building while Bonnie (left) and Nick (far right) Skourtes listen.

This is an exciting time to be in dentistry. In case you haven’t heard, a new building is under construction for the OHSU School of Dentistry!

Our new facility is located on Portland’s South Waterfront in the OHSU/OUS Collaborative Life Sciences Building (CLSB). Beginning fall of 2014, all dental education, research, and patient care will move to South Waterfront.

The dental school portion of the 480,000 square foot CLSB building is a six-floor tower on the north side. We are calling our tower the Skourtes Tower after our major donors, Gene and Bonnie Skourtes. We are truly grateful to them and to our other major donors, ODS Health and Adec, Inc., as well as to the Oregon Dental Association, which has pledged $250,000 to the project. These gifts met the university challenge of raising $18 million before Aug. 1, 2011, to gain approval to construct the new building.

Whether or not you are a graduate from OHSU School of Dentistry, every one of you has a stake in our new facility because it represents the future of dentistry in Oregon. The new building will enable us to:

  • Teach students in a setting that reflects a modern dental practice, with private, modern 120-square foot operatories—more than twice the size we have now
  • Broaden services to patients including improved privacy, extended hours, and the latest technologies and procedures;
  • Train more dental professionals by increasing our entering class size to 90 from 75 and adding an advanced education in general dentistry program (AEGD);
  • Stimulate research and clinical innovation with the interdisciplinary nature of the building providing increased potential for collaborations and basic science instruction for all OHSU and OUS undergraduates in the same location.

With a number of Oregon dentists nearing retirement age, having the expertise at hand to care for a population with increasing dental needs will be essential and a new building to continue our strong tradition of clinical excellence is the first step toward this workforce gap. With technology changing continually and increasing what dentists need to know to care for their patients, a modern facility is critical.

I’m happy to report that construction on the new building is going fast and remains on schedule. Contractors have completed the final slab pours on level one and shored up level two to begin pours there. The school’s lobby has been poured, as well as the floor for the school’s classrooms, student locker rooms and logistics space. It has been inspiring to see the building go up and to take the initial walk-throughs with representatives from JE Dunn Construction.

We have $14 million more to raise for our $43 million fundraising goal and we invite you to join us as we create this legacy for all of us. Our moment is here!

For more information on the new building, go to www.ohsu.edu/sod and click on New Building. To make a gift, contact Development Director Patrick J. Regan, (503) 494-0980, reganp@ohsu.edu.

 

Here is what our new dental school building looks like as of late May. The left side of the photo is our new lobby!

 

Jack Clinton, D.M.D., is Dean Emeritus of the OHSU School of Dentistry. He is a 1964 graduate of the dental school and has held a variety of administrative roles there over the past 30 years, most recently as dean from 2004 to 2011.