Archive for the ‘Dental Visits’ Category

There is No Excuse for No Dental Care – Overcoming Dental Phobias

Tuesday, April 2nd, 2013

Scared girl at Dentist's teeth checkup

By Harvey Levy, DMD, MAGD

I have been practicing clinical dentistry and been on this planet long enough to have heard every reasonable excuse for avoiding dental care. I have yet to hear a good one.

Our dental practice has successfully treated thousands of phobic, anxious, mentally challenged, autistic, and medically compromised patients. We’ve been able to accommodate infants through Alzheimers patients. What I have learned is whatever the reason given for avoiding the dental office, there’s always a way to overcome the problem.

Are you afraid of the dentist? Perhaps a dry-run walking through the office will calm you down, or learning more about the treatment using videos or demo models will make you less afraid. If it doesn’t, we can prescribe pills or liquid drugs that you can take right before your appointment. If you’re even more apprehensive, you can also take an oral sedation pill before going to bed the night before your appointment, and be treated with nitrous oxide (laughing gas) to relax you during treatment. Other options to deal with anxiety include behavior modification, hypnosis or acupuncture.

If your loved one is an infant, or is mentally challenged, autistic, or suffers from Alzheimers, they can and should still receive effective dental treatment. Intravenous sedation can be offered in an office setting, or these patients can be treated in a hospital or surgical center operating room. There, the patient is totally asleep while all the needed work is being performed, and has no recollection when they wake up.

An extremely anxious patient can also be treated in this manner, with the advantage that work that would typically require multiple office visits can be successfully performed in only one visit to the O.R.

If you cannot come to the office due to mobility issues, age, or medical complications, dentists with portable equipment can come to you, be it in a nursing home, private home, institution, or in-patient facility. Mobile vans are fully equipped to handle most dental problems. Mobile teams use hand-held x-ray units with self-developing films or laptop instant imaging systems to diagnose problems. Portable x-rays with protective radiation barriers, are coupled with mobile dental carts, and provide the same dental procedures available at the office.

Whatever reason kept you or your loved one away from the dentist, the road back is readily available and easier than you think! Over the past 38 years our practice has successfully performed over 32,000 oral sedations in our office. Three percent of the time, oral sedations at our office couldn’t be done, or failed due to autism, severe combativeness, or major medical concerns. All those patients were able to receive treatment, safely and successfully, with the help of an anesthesiologist in a hospital operating room.

Whatever excuse I hear for someone not going to the dentist, know that there’s always a way to overcome it. What is not acceptable are the complications resulting from the lack of dental care – from bad breath to infections that start in the mouth and threaten your health.

 

LevyHarvey Levy, DMD, MAGD is a 1974 Tufts Dental graduate who practices general and hospital dentistry in Frederick, MD. He holds eight fellowships, four diplomats, Board certification in Integrative Medicine, and has earned Mastership and three Lifelong Learning Service recognition awards from the Academy of General Dentistry. He is a recipient of the ADA Access to Care Award, the AGD Humanitarian Award, the Maryland Governor’s Doctor of the Year Award, and ran the 2002 Winter Olympic Torch in honor of his dental care for special-needs patients in Maryland. He has written and lectured extensively on management of anxious and special-needs patients. For more information, visit  www.DrHLevyAssoc.com or contact him at drhlevy@gmail.com

My Greatest Reward

Monday, February 4th, 2013

Dr. Stacy Geisler

July 7th, 2011 began like any other day for me. I remember that there was a beautiful  sunrise that morning. I had a compressed, busy schedule in my oral and maxillofacial surgery practice in Lake Oswego. “We have a trauma patient coming in, Doctor” my front staff informed me when I arrived at my office. We already had fifteen patients scheduled that morning for me to see, three of whom were surgery patients. How would I find the time to see this other patient?

My add on trauma patient turned out to be a wonderful woman named Sunny. From my first meeting with her, I could see why her friends had given her this affectionate nickname. Sunny has a type of effervescence which surrounds her. Joy bubbles out of her. You can’t help feeling good just by being in her presence.  At this first meeting, I was struck by her amazingly positive attitude. It was hard for her to speak clearly because part of her upper right jaw was missing. She kept holding up her hand to hide the right side of her face. Slowly she was able to tell me her story.

Sunny had been at an outdoor function with her soon to be husband on a Saturday afternoon. As she was walking along an unfamiliar path, her foot slipped and she went down. This happened so quickly that she was not able to break her fall, but landed on her right face against a curb. Stunned and bleeding profusely, she sat up. Part of her upper jaw was missing. Looking down, she saw what she thought were bits of bone and tooth on the ground.

Sunny’s partner took her immediately to the closest emergency room for care. They were hoping to have a diagnosis made and treatment. An exam was performed as well as imaging studies.  Since this hospital was not part of Sunny’s health maintenance organization (HMO), she was told by the emergency room to contact the HMO for definitive care. When she called the HMO that evening, she was told that she would have to wait a week for an exam and treatment (she was told this is their policy to allow for swelling to resolve). When Sunny was finally able to see a surgeon at her HMO hospital, it was six days later. The surgeon told her that she had a dental injury and would need to follow up with her dentist. There wasn’t anything he could do for her. She was sent home with a prescription for Amoxicillin.

Sunny called her dentist from the parking lot of the HMO in tears. She knew that something was seriously wrong with her and she was struggling to understand why she couldn’t get the care she needed. Her dentist’s receptionist asked her to come in to his office immediately. When the dentist saw Sunny, he knew that this was more than a dental injury. He could see that part of her upper jaw appeared to be missing, as well as teeth in the anterior maxilla. His office called my office, thus the “add-on” patient for an already busy morning.

Examination of Sunny demonstrated a severe, avulsive injury involving the right anterior maxilla. Computed tomography scanning performed at the emergency room six days previously demonstrated fractures extending through the frontal process of the right maxilla, including the anterior nasal spine and vomer. She had fractured teeth #7 and #8 which were displaced into the right maxillary hard palate and not visible in the oral cavity. Tooth #9 also was extruded and was in hyperocclusion with her mandibular dentition.

Sunny’s dentist had sent electronic records for me to review and I was able to review her CT scan. I was stunned by the severity of her injury. At this point in my career, I have seen many, many things. Not much surprises me any more when it comes to the maxillofacial skeleton. But I was not prepared for how bad this injury was given the mechanism of injury. What Sunny had was more similar to a gun shot wound without the accompanying soft tissue devastation seen with a high velocity injury.

I knew that Sunny needed surgery and that she needed it soon. I also knew that she needed to be asleep for what I was planning for her. Since she had eaten that morning, we scheduled her for surgery the next day. I explained to her the nature of her injuries, that the wound needed to be cleaned, the broken bones stabilized and the damaged teeth removed. I explained that she might need root canals on some of her other teeth, and that she might require more extensive reconstructive surgery to rebuild the missing part of her jaw. I told her that she would also probably require dental implants since her teeth were damaged beyond repair. I prescribed antibiotics and pain medication for her to begin immediately. Sunny agreed to everything that I suggested. One concern was her upcoming wedding. Could I have all the reconstruction done in time for her wedding which was scheduled for December 2012? I told Sunny that I would try my best.

Over the next year Sunny underwent several surgeries to rebuild her maxilla. We began with debridement and fixation of broken bones. As I suspected, the right anterior maxilla had been pulverized by her fall and her wound was quite dirty. I found pebbles and asphalt at that first surgery.  I confirmed that Sunny would require a large bone graft to reconstruct her upper jaw if she ever had any hope of having a normal facial appearance. Hip grafting to the right maxilla was completed in February of 2012 and three dental implants were placed in June 2012.

Sunny handled all aspects of her year long reconstruction with grace and humor. She is a third grade teacher and saw an opportunity to use her injury to teach her class of eight year olds about anatomy and jaw reconstruction. She told me on one follow up visit, “I took out my prosthesis and showed my students how I was missing teeth, just like them. The kids loved it and had all kinds of questions about how my teeth would be put back. They couldn’t believe that part of my hip would become my new jaw!”

It was an amazing privilege to provide surgical care for Sunny following her facial injury. I feel so grateful that things went well: healing progressed as expected and we achieved the outcomes we were hoping for.  I can’t claim sole responsibility for her healing. Sunny’s reconstruction was brought about by a dedicated group of professionals whose sole goal was to restore her to health.

Sunny’s health maintenance organization initially denied medical  benefits for her reconstruction. Several letters were written from those involved in Sunny’s care and eventually she received the benefits needed to cover the cost of her reconstruction. Martha, my front office insurance expert, was instrumental in making this happen. I am grateful to Sunny’s dentist who recognized that she needed speciality care. I also feel lucky to have such a positive working relationship with Dr. Scott Dyer, who handled Sunny’s prosthodontic reconstruction.

Sunny recently stood before her friends and family as a bride and made a commitment to her partner just a few weeks ago. She told me via email “The wedding was spectacular and everything that we had both hoped for.” For a surgeon, there just isn’t any higher reward than that.


Stacy Geisler, DDS, PhD is a board certified oral and maxillofacial surgeon practicing in Lake Oswego, Oregon. She lectures extensively throughout the Pacific Northwest and is known for providing outstanding surgical care of her patients. Dr. Geisler serves as an evidence-based reviewer for the JOurnal of the American Dental Association and has had numerous peer-reviewed publications.

 

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.

Dental X-Rays

Monday, August 6th, 2012

By Dr. Medhi Salari

Benefits of Dental X-rays

Dental X-rays help us detect cavities, infections, gum disease, cysts, tumors and developmental abnormalities much sooner than waiting for these problems to get large enough to become evident to the naked eye; or painful enough to become uncomfortable and noticeable to the patient.

Dentistry has led the healing professions in preventive care since the 1940’s and x-rays help us each and every day in finding and treating dental disease in its earliest and easiest to treat stages.

Patients who receive regular exams and x-rays tend to retain their teeth for life, while patients who go without exams and x-rays tend to have more extensive dental work, such as root canals and extractions.  By the time the problem has become uncomfortable or noticeable to the patient, the decay or problem has already progressed too far.

Risks of Dental X-rays

A large number of patients cite exposure to radiation as a concern in consenting to regular dental x-rays and exams.  We gathered the following information from the American Nuclear Society website to put the amount of radiation from Dental X-rays in perspective.

Source of Radiation

Estimated Exposure (mrem)

Air Travel

0.5 per HOUR

Dental Bitewings (4 films)

2

Dental Complete Series of X-rays

10

Medical Chest X-ray (1 film)

10

Natural Radiation from the ground

30 per year

Natural Cosmic Radiation in Central Oregon (elev. 3,000 – 4,000 ft.)

41 per year

Medical X-ray – Mammography

42

Medical CT Scan – Head

200

Internal Radiation from food & air

268 per year

Medical Upper GI X-rays

600

Medical CT Scan of Abdomen/Pelvis

1000

 As you can see from the table above, radiation exposure from dental x-rays is extremely low, in comparison to other forms of radiation that we are routinely and often times naturally exposed to.  We also take the added precaution of routinely covering our patients with a lead apron and Thyroid collar to further minimize the already low exposure levels.

International standards have recommended a maximum amount of radiation for humans working with or around radioactive materials at 5,000 mrem per year.  The average accumulated amount of radiation per person is approximated at 620 per year.  You can calculate your own annual radiation dose by visiting the American Nuclear Society website (www.ans.org), and clicking ‘Public Information’, ‘Resources’ and then ‘Dose Chart’.

General Recommendations & Protocol

Our goal is to take the very best care of your teeth and mouth as possible.  In order to do that, we need periodic x-rays to properly diagnose and treat conditions that might exist or arise in your mouth.

We realize that different patients and different dental conditions require different protocols.  We have always strived to minimize our patient’s x-ray exposure and at the same time reduce the costs associated with necessary x-rays.

We do not have a one-size fits all x-ray routine in our office, but have tailored our X-ray Protocol to benefit each specific patient’s dental and medical conditions.

Patients who have a higher risk of decay, multiple existing restorations or more complex treatment plans require more frequent and regular dental x-rays.

Patients who have experienced fewer cavities and restorations in their past, and have exhibited a smaller risk of dental disease, will continue to have less frequent dental x-rays recommended to them.

Our X-ray Protocol also takes into account numerous other important factors; such as pregnancy, patient’s age, list of medications and concurrent medical conditions (dry mouth, acid reflux, concurrent radiation therapy, …).

We will continue to honor the trust that our patients have placed in us, by taking the necessary steps to properly diagnose and treat their dental problems, while remaining respectful of our patient’s wishes for a protocol that caters to each patient as an individual.

With our X-ray Recommendations and Protocols, we hope to provide the right balance between our patient’s wishes for reduced exposure to radiation and the Oregon Board of Dentistry’s Standard of Care for dental practices.

Excerpts from  American Dental Association (www.ada.org) and American Nuclear Society (www.ans.org) 

 

Dr. Mehdi Salari is a 1993 graduate of the OHSU School of Dentistry.  He has been in private practice in Bend, Oregon for 19 years and along with his wife, have three kids under the age of nine.  He is a Past President of the Central Oregon Dental Society.  He has been actively involved in the Central Oregon soccer community through coaching, playing and officiating.  He also volunteers with the Central Oregon Community College Dental Assisting Program, Healthy Beginnings, Volunteers in Medicine and the Kemple Children’s Clinic Give Kids a Smile program.

 

The Clinical Record, the Ultimate Communication Tool

Monday, June 11th, 2012

By Dr. Roy Shelburne

The true success of the dental practice hinges on good communication.  The method and rate of exchange of information is one of the greatest determiners of patient satisfaction, office morale and ultimately successful outcomes in the clinical treatment of our patients.  Good communication leads to success and the better the communication the better and higher the level of success.  Bad communication leads to varying levels of frustration and confusion with a complete failure to communicate leading to a “crash and burn” scenario.  My hope is that learning how to communicate more effectively is a goal of every practice and methods of improving communication is an area of focus of the practice.   To highlight the importance of good communication, let’s look at communication as it relates to the clinical record and how excellent communication may lead to greater satisfaction, increased reimbursement, reduced stress, and better clinical outcomes for the doctor, the staff, and our patients.

Take, for example, an oral cancer screening performed during the patient examination and recorded as part of the patient’s evaluation.  In fact, the ADA’s CDT nomenclature states:  “This (D0120) includes an oral cancer evaluation and periodontal screening, where indicated, and may require interpretation of information acquired through additional diagnostic procedures.”   An oral cancer screening should be performed “as indicated” as part of the evaluation process.  What is “as indicated”?  My interpretation of “as indicated” would be for every patient that presents to the dental office who might be at risk for oral cancer…and isn’t that every patient?  With an increase in the number and severity of oral cancer cases observed in today’s environment, it’s just good for our patients.  Performing an oral cancer screening doesn’t take very long to perform and, in my opinion, the time taken is well spent.  How then, is the oral cancer screening and its result communicated?  How is it recorded?  My recommendation requires that the doctor and team member work together to perform and record the oral cancer screening.  (Working together, hum…what a concept!)  Here’s how I suggest the system be implemented.  The doctor, during the examination, explains to the patient that he/she will be performing an oral cancer screening.  The doctor then proceeds to perform the screening and verbally communicates that “Mr./Mrs. Patient, I’m taking a look at your tissues here to see if there are any suspicious areas in your mouth.  I see here on the roof of your mouth, there is a red, blistered looking area.  What can you tell me about that?”  The patient responds, “Oh, I burned that last night.  I bit into a piece of pizza that was too hot and it burned me.”  The doctor then responds, “Sorry to hear that.  Typically burns like this heal in a week or so.  Please, if it doesn’t heal by next week, give me a call and I’ll want to take another look.”  All the while this conversation proceeds, the office staff is taking note of what is said and the information is recorded in the clinical record.  This note establishes the cancer screening was done as well as records the outcome of that exam and notes any recommendations made by the doctor.  The clinical record is complete and the criterion necessary to bill for and be reimbursed for the clinical evaluation has been met.  Certainly, the standard of care has been achieved and the patient is very impressed at the thoroughness of the doctor.  The team is working together with one goal; complete, comprehensive and excellent care for the patient.  This information has been recorded by a well trained staff member and the patient’s needs have been met.

The scenario above is a single instance where a system of communication may be implemented to meet the needs of the patient and provide excellent care.  I encourage you to examine your practice for similar situations were communication can be improved for the betterment of your practice and for your patients.  It’s just good practice.

 

Dr. Shelburne is a 1977 graduate from the University of Virginia and 1981 Honor Graduate from Virginia Commonwealth University’s School of Dentistry.  After graduation, Dr. Shelburne opened his practice “back home” in his grandfather’s hardware store building and practiced there for 27 years. He has been a past president of the Southwest Virginia Dental Society and has volunteered at Virginia’s various MOM projects across the state. Dr. Shelburne specializes in record keeping and business systems that protect and defend.

ODA Peer Review

Monday, May 21st, 2012

By Timothy J Edvalson, DMD

Today I’d like to write about a little discussed benefit of your ODA membership:  Peer Review.  I have worked behind the scenes at the constituent and state committee levels for more than 20 years with a dedicated group of dentists and ODA staff who serve to help their fellow dentists and the public resolve differences in anticipated and actual outcomes of treatment.

Peer Review is defined as the evaluation by fellow professionals of diagnostic and clinical treatment outcomes.  The goals of Peer Review are (1) to detect professional problems, (2) devise educational and disciplinary solutions so that the quality of care can improve, and (3) resolve patient-dentist disputes without litigation.

As members of the Oregon Dental Association, we are bound by the ADA code of ethics as well as agreeing to Peer Review evaluation when it is requested by a patient or another dentist.

Most Peer Review requests are initiated by a patient when the outcome of their treatment did not meet their expectations and they feel unable to have their complaint adequately addressed by their provider.  Requests are received at the ODA office by Margaret Torgeson, our ODA staff specialist in processing these requests.  Once the information is assembled, it is reviewed by the State Peer Review chairman (and committee if necessary) to determine if the complaint is within the scope of peer review guidelines.  Once accepted, the request is assigned to a constituent society’s local Peer Review committee for evaluation.

All Peer Review cases are assigned for mediation as a first attempt at resolution.  In this case, the mediator (a member of the constituent committee assigned by the local chairman) reviews all the documents and has a series of conversations with both the patient and the dentist to see if a mutually agreed upon resolution can be negotiated.  I am happy to say that the majority of cases are resolved in this step.  Patients appreciate having their complain heard by an objective third party and dentists have the advantage of explaining their perspective to someone who is also “in the trenches” and knows what it’s like to try to deliver excellent care in situations that are not always ideal. Through mediation, both parties work out a mutually agreed upon resolution.

If a mediated resolution is not attained, then the Peer Review case is presented to the local component Peer Review committee for a formal hearing.  In the hearing, the patient is examined and interviewed by the committee members until all their questions are answered.  The dentist is then interviewed and allowed to explain all the aspects of the case to the committee members.  The committee of 3 or more dentists then makes a decision as to the outcome of the Peer Review Request.  The possible outcomes can be a range of possibilities from finding no fault with the care provided all the way to having the dentist refund all or part of the fees paid for the services in question.  The parties agree in advance to be bound by the committee’s decision and all documents are returned to the ODA staff to process the final decision documents.

While this all sounds like a formidable process, it is much less stressful than litigation and has the added benefit of remaining confidential without any requirements for being disclosed to the National Practitioner Databank or Board of Dentistry review.  If either party in the Peer Review process feels that other evidence was not heard or has legitimate grounds for appeal, the State Peer Review committee reviews these cases.

In practice, I have seen many cases be successfully resolved by Peer Review which otherwise would have ended in some form of litigation and both patients and dentists have been spared the emotional toll and actual cost of going through such an adversarial challenge.  My thanks go out to all who serve on the various local and state committees who dedicate their time and talents to helping us all be better dentists as well as protecting the integrity of the profession and safeguarding the public.

 

Dr. Edvalson maintains a private practice inLake Oswegowhere he has practiced for the past 31 years.  He was a member of the Clackamas County Peer Review committee for many years, serving as its chairman before being asked to join the State Committee and subsequently serve as Chair of that committee since 2009.  He wishes to especially thank Drs. Don Sirianni and Daren Goin (past chairs of the state committee) for mentoring him along the way.

How to help our Parents, Grandparents and other Elders keep their teeth

Monday, April 23rd, 2012

By Dr. Janet Peterson

My grandfather lost his first permanent tooth at the age  of 89.  A lifetime of wear and tear on this upper canine had resulted in a crack that split the tooth and it had to be extracted.   He was lucky, though, in that a lifetime habit of brushing  twice a day and little or no snacking  between meals, in addition to good memory, allowed him to keep his oral  health.

My aunt was not so lucky.  In her mid-eighties she began to experience some memory problems.  Living alone, meals disappeared and she snacked on cookies and milk throughout the day.  She pretty much forgot to brush her teeth.  Her six month cleanings were followed by more and more repairs as decay encircled her teeth and  they broke off.  It was finally decided that a complete denture was the only reasonable solution.  Because of her frail health, two teeth would be extracted every two months to allow for healing.   Unfortunately, she passed away before the treatment plan could be completed – with only three teeth left and with  considerable embarrassment at the demise of her smile.

Memory loss is a big factor in the catastrophic increase in tooth decay  that so many elderly people experience.  It can be difficult to determine if this is a factor as elders  learn to “cover” memory lapses and we tend to respect their assurances that everything is all right.  Asking when their next dental appointment is may give a clue as to whether they are keeping up on dental check-ups.  If they have no appointment scheduled, getting an appointment is the first step.  Having someone go with them can be a good way of getting information from the dentist or hygienist as to whether there is an increase in the rate of decay in their mouth.  Because of the privacy rules of  HIPPA ( Health Insurance Privacy and Portability Act) ,  staff may be unwilling to discuss an elder’s health over the phone or by letter, whereas it is easy to have a three way conversation with the elder and their dentist or hygienist in person.  If there is an increase in rate of tooth decay,  it is necessary to find out what are the contributing factors and to start trying out possible solutions to slow this rate of decay.

The usual contributing factors and some first steps to mitigate them are:

Change in dietary habits with more frequent  snacking,  more sweets.

  • Provide balanced meals that require little or no preparation
  • Try to group sweets with a meal and decrease snacking between meals

Physical difficulty with brushing with weakness or uncoordinated hand movements or pain

  • Try an electric toothbrush,
  • Adapt the manual brush by bending the handle or enlarging it with foam

Apathy or depression – the attitude of “why bother?”

  • Engage the professional services of a psychologist or counselor
  • Discuss the benefits of good oral home care, and the downside of neglect – pain or missing teeth

Memory  problems leading to the forgetting of established daily habits

  • Place the toothbrush by the bathroom  sink in plain sight
  • Tape a note on the bathroom mirror – “Brush Teeth”
  • Remind the elder daily to “ go right now and brush your teeth”
  • Have staff at assisted living residence or nursing home remind the elder or brush for them

Problems of calling for a dental appointment or transportation to the office 

  • Have family or caretaker make appointment and arrange for transportation
  • If necessary, have office front office staff call to make appointment and arrange transportation

 

Dr Janet Peterson is a 1983 graduate of the Oregon Health Sciences University School of Dentistry and just recently retired after practicing as a general dentist in the Salem area for over 25 years.

What is the gold standard in dentistry? Gold!

Monday, March 26th, 2012

By Dr. Daniel Saucy

What is the gold standard in dentistry? Gold! Gold foil fillings are gold restorations that are accomplished in one visit. Gold foil restorations are the most biocompatible dental material available. Pure gold is inert and causes no local tissue reaction. Gold foil restorations expand and contract at the same rate as the natural tooth. Gold foil restorations don’t break down around the edges of the fillings like our other filling materials. Gold foil does not turn the tooth grey as it ages.

What is the problem with providing gold foil restorations for every patient? The number one reason in my patients’ minds is that, “It is not white!” The other main reason is the expense of the treatment. However, if performed in a timely manner the cost can be greatly reduced. We have to use a rubber dam for our composit plastic restorations; using gold isn’t much more of a project.

Gold foil restorations are best used as the initial restoration for a tooth; it can help avoid repetitive replacement that many of our filling materials eventually require. I like to do buccal pits and occlusal restorations on children and teenagers.  Gold foil restorations require great skill and attention to detail by the dentist. Talk to your dentist about your options.

The above information is provided by the American Academy of Gold Foil Operators.

 

 

Dr. Saucy is a general dentist that practices in Salem, Oregon. A graduate of the OHSU School of Dentistry, Dr. Saucy has been practicing in Oregon for 30 years. Dr. Saucy is a member of the Alex Jeffery Gold Foil Research Group, a gold foil study club that meets and operates monthly at the OHSU Dental Continuing Education Department.  Dr. Saucy is the Chair of ODA’s Government Relations Council.

 

How to Manage An Apprehensive Child Before and During a Dental Visit

Monday, March 19th, 2012

By Dr. Jane Soxman

Apprehensive children may create many concerns and anxiety for parents, dentists and staff. The following recommendations offer some tips for behavior guidance.

  • Parents should not offer presents or rewards for good behavior prior to the visit. This may prompt additional fear that something really difficult is about to occur. A surprise to be given just after the visit may be more appropriate.  Do not tell a child to be brave or that nothing will hurt.  The idea that dental care requires bravery or that pain may be involved may have never occurred to the child.  Positive preparation may include a story about going to the dentist, placing the child in a reclining chair to experience the sensation of moving backward and brushing with a battery powered spin brush to experience a sensation similar to the rubber cup used to clean teeth. Minimizing comments or explanation by parents is advisable. Parents may unintentionally create more anxiety in the child with their silent cues, especially if there is any parental fear regarding dental visits.
  • Only one parent should accompany the child for the visit and that parent should be the one who is more comfortable with dental treatment.  Consistency is very important. The dentist, parent and child function as a team.  If the visit went well with Dad, he should be the parent who returns for subsequent visits.
  • Morning appointments are always recommended for apprehensive children. The children are more rested in the morning and morning appointments usually have less waiting time. Also, the child may worry about the appointment throughout the school day and being tired after school will result in reduced coping skills.
  • In the reception room, the parent should sit closely beside the young child, reading a story. This not only provides distraction but also places the child in a more relaxed frame of mind. Free play should be avoided.
  • Parents may share their primary concerns regarding their child’s anxiety or fears with the dentist or staff prior to taking the child to the examination area. Some advice or reassurance may help to ease the parent’s concerns and the child may be eased into the dental chair with a slightly different approach. Parents must understand the child’s behavior may impose limitations on dental treatment, but most apprehensive children can be treated with empathetic guidance.
  • Parents should not attempt to describe the events of a visit for restorations (fillings).  If the child asks, the response should be that the dentist or his helper will carefully explain everything planned for the visit. Parental tone of voice or body language could accidentally create a sense of fear or apprehension in an unsuspecting child.  The dentist should determine how much and what should be said prior to the visit. The child’s perceptions and level of anxiety are strongly influenced by his parents, particularly by Mom.
  • If local anesthesia (a shot to numb the teeth) is to be used, this should never be discussed prior to the appointment. “Shots” are universally the most feared aspect of the dental visit for children, however most often injections can be performed painlessly, without the child being aware of the occurrence. A child who comes to the appointment already intensely worried about the “shot” is much more difficult to calm. Studies have shown that anxiety may reduce the efficacy of the local anesthetic. Because some procedures may be performed without local anesthesia, parents should not assume that an injection is necessary.
  • Expectations of a child’s behavior must be age-appropriate. By four years of age, an emotionally and physically healthy child should be able to separate from the parent for an examination and possibly treatment. Opinions vary amongst dentists regarding parental presence for treatment.  Parents should agree with the dentist’s philosophy regarding parental presence for treatment and this should be discussed and clearly understood prior to the visit.
  • Most children under four years of age are not yet emotionally capable of separating for treatment, and a parent should be present. Some parents and children over age four insist on parental presence.  If the parent is present for treatment, he or she must be the dentist’s silent partner.  The parent must remain calm and quiet. The mere presence of the parent provides support for the child. Children are very aware of silent cues from parents; body posture and facial expressions may speak volumes to a child. The dentist must give the child undivided attention and the parent should not divide the child’s attention between herself and the dentist.
  • Prior to reclining the dental chair, the dentist should place his or her hand on the child’s shoulder, while informing the child that the chair is going to move backward. Both the dentist and staff should ask the child, “Do you know my name?” Make sure the child has been re-introduced with a smile and comforting attitude.
  • Voices should be low and soft, never attempting to speak louder than the child’s crying. The parent (only one present) may need to be reminded of this. A small hand mirror may offer good distraction after the local anesthesia has been administered. The dentist may count backward, tell a story, sing a song or ask about pets, requesting a “yes” with the child showing one finger or  “no” with two fingers. The dentist and assistant can guess what kind of pet, boy or girl, color and name. Always very distracting, humorous and incredibly successful for calming an upset child after treatment has begun.  Just an occasional pat on the shoulder may be adequate for some children, offering some non-verbal assurance from the dentist.
  • If a child is crying, listen to the sound of the crying. Compensatory crying does not change in pitch and is a means for the child to cope.  The parent should not become the “court of appeals”, permitting the child to delay treatment by reaching for one more hug or to tell the parent one more thing.  The dentist must direct the treatment, not the child.
  • If unable to gain the child’s cooperation with parental presence, the parent may be asked to leave the operatory. This would occur only if the child is four years of age or older. The door to the operatory is left open so the parent can check on the child.
  • Parental love must permit age-appropriate independence.  A parent’s permitting his or her child to undergo treatment without being present sends two messages. First, “It is ok. I really do not need to be right beside you for this.” Second, “You Can Do It! I have confidence in you.”  This child has been given a very positive message and a sense of empowerment.
  • Some parents prefer not to be present, but if a child becomes extremely upset or borderline hysterical during the procedure, the parent should be present to possibly assist in calming the child and to be assured that the child is not being harmed.
  • Age-appropriate expectations, individual temperament, previous experiences and social influences must be considered for each child. Parents also should be guided with insight and recommendations to gain an understanding of the dentist’s treatment goals and the limitations imposed by behavior. This preparation provides a positive influence for not only the parent and child, but also the dentist and staff, assuring a less stressful and more successful visit for all.

 

Dr. Soxman is a diplomat of the American Board of Pediatric Dentistry, a Fellow in the American College of Dentists, on the board of advisers for General Dentistry and is a seminar instructor for two General Practice Residencies.

Dr. Soxman presented at the 2012 Oregon Dental Conference and is from Pennsylvania.