medical insurance vs. dental “insurance”

“Dental insurance” isn’t even close to being actual insurance. Real insurance is about investing a small amount to help manage the risk of rare but potentially catastrophic events. From Wikipedia:

Insurance is the equitable transfer of the risk of a loss, from one entity to another in exchange for payment. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss.

You buy car insurance in case of a car accident or theft. These are relatively rare events, but they’re also undesirable events. You’re glad  you have insurance when you have a car accident, but rational people are more interested in avoiding them.

Even “health insurance” (which is probably better termed medical insurance) is mostly like real insurance. You (or your employer, or the taxpayers) pay a premium so that catastrophic and expensive medical treatment is available to you if you need it. Imagine someone having some kind of cancer and their medical insurance carrier explaining to them: “I’m sorry, but you’ve spent all of your insurance dollars this year on that broken wrist back in February so I’m afraid you’re going to have to wait until January for your chemotherapy unless you just want to pay out of pocket.” The ramifications of the ACA (a whole other topic) notwithstanding, the idea of health, or medical, insurance mostly lines up with what real insurance is about.

Dental “insurance” is a contract, usually between your employer and a 3rd party payor. If a patient breaks a tooth or needs a root canal their benefit should pay a certain amount each year for certain procedures specified by the contract. The insurance company isn’t interested in your dental health. They are interested in paying out as little as they can while still staying within the specified conditions of the contract. In almost all cases there is a maximum dollar amount that the insurance company will pay and no more. What you’re getting here is a crappy gift card that pays toward some dental treatment. This has been covered by myself and others ad nauseum and isn’t really the point of this rant.

Something that’s really important to realize is that the patient’s dental health and potential need of dental services is completely independent of what dental benefits they have. You can have a low caries nonsmoker with a premium dental benefit that only uses a small amount of the dental benefit for prevention or a chain smoking, pop drinking dude with ectodermal dysplasia and “Healthy Kids Dental.” The two things have no bearing on each other.

So, is it reasonable to ask the question: “what’s the right amount to spend on dentistry in a given year?” Not really. This is obviously going to depend a lot on the patient’s individual risk factors and habits. However, I promise you that insurance companies have given a lot of thought to that question. I would suggest that the dollar amount of a patient’s dental benefit has a huge bearing on what they perceive as being the right amount of treatment necessary.

For many, perhaps most of our patients, the right amount of treatment in a given year is how much their insurance will cover and no more. I think this comes from the experience we have as patients with medical insurance. When you go to the doctor’s office or hospital for something, there is an expectation that your insurance will cover any services there. It’s rare that there is a conversation about costs incurred by whatever services the patient receives. Whether it’s a $200 office visit or a $50,000 knee replacement, it’s a reasonable patient expectation that their medical insurance is going to cover it once their deductible (if they have one) has been met.

This is not so with dental benefits. If a patient needs a certain amount of dental treatment and it costs significantly more than any given year’s benefits, they’re less likely to pursue any treatment at all. I promise you that insurance companies are banking on this reaction.

I think this is where patient expectations get mixed up. Medical insurance covers what you need, no matter what the need is. If they apply this logic to their dental benefit, then whatever their dental benefit amount is must be the right amount to spend on dental care! So clearly if a dentist diagnoses a patient’s dental needs and it’s more than their insurance will cover, a patient might become suspicious of the diagnosis.

This is a complicated problem. To pretend that patients simply don’t value dental treatment enough is short sighted. It’s probably accurate for some people, but for others they just can’t or won’t spend any more than they need to on dental care. People react to incentives and if a patient has dental benefits, they’re going to want to use them. After all, they paid for them…either directly or indirectly. They shouldn’t be made to feel ignorant for wanting to use the benefits that they have. But I think it helps to illustrate the differences between medical insurance and dental benefits and how that plays into a patient’s expectations of how much treatment should cost.

 

Delta Dental, crystal balls and ridiculous incentives

I have a few patients with poor oral hygiene. The patients I’m thinking of right now are between the age of 17 and 24 and they’re male. I think of them as my “scuzzies.” Personal hygiene isn’t a priority. I make an effort to encourage them to step up their game. I strenuously suggest that they reduce their intake of sugary and acidy drinks. I even write blog posts about it. I suggest powered toothbrushes. I stop short of actually going to their house and brushing their teeth for them. That would be creepy. The bottom line, the scuzzies are high risk patients for tooth decay.

So let me tell you a little story. I did a two surface restoration on a scuzzy last year. It was radiographically evident (an MO on #14). The distal did not have any radiographic decay. When I was preparing the tooth for a MO restoration, I visually inspected (with a microscope, naturally) the distal marginal ridge. Nada. Nothing. Zilch. So, as an ethical and reasonable dentist…I didn’t prepare the distal.

Fast forward to a year later. The restoration I placed looks great! However, there is radiographically evident decay on the distal of #14. Anyone who participates with insurance knows exactly where this is going.

His insurance wouldn’t pay anything for restoration of #14. You see, I did a restoration on it last year, and they won’t pay for any other restorations on this tooth for a period of years. I think it was three in this case. So the patient will have to pay for this entire restoration out of pocket.

This is part of the contract. I get that. But the patient’s parents (you know, the ones who have money taken out of their paycheck for dental benefits who are going to have to pay for this entire restoration) are frustrated. I frankly don’t blame them. We explained that their child is a scuzzy and we’ve been all over him to reduce his risk factors (e.g.–stop guzzling pop, step a little closer to the toothbrush, figure out what that minty flavored string is all about). Their main question: why didn’t you fill it when you were placing last year’s filling?

Point of fact…this kid is creating cavities fast! He may be a world record holder. But, he’s not alone. This happens most often in the 55 and older crowd when they start taking medications for their blood pressure, their heart and maybe for depression. Combine medication induced dry mouth with the idea of high sugar comfort foods and you’ve got a recipe for some serious tooth decay, and seriously fast.

I cannot know when someone is going to form a cavity. There is no crystal ball technology available although I hear Sirona is working on it. I can help them understand their risk factors, but I can’t tell you when and where a cavity will show up. I’m not going to start second guessing, either. When a representative from a dental benefit company explains to the patient that I probably should have restored that surface when the original restoration was done, it makes my blood boil.

I ended up writing Delta Dental a narrative and sent some photos, but they turned the appeal down. Now the patient thinks I’m a jerk. Awesome!

A high caries risk is not incentive enough for me to overtreat. No matter how good our materials are, natural tooth structure is better. If I can’t see the evidence with a radiograph or my own (incredibly enhanced) eyes, then I’m not going to restore the tooth. Even if the “insurance” company thinks that I should.

Can I use The Blogging Dentist to promote my product/idea/class?

I get requests to write a guest blog or advertise in some way on The Blogging Dentist quite often. Since this blog is purely for my own amusement, I haven’t really considered this in the past. But now I’m thinking about it.

Why would someone want to use “The Blogging Dentist” to promote their product or idea? I’m not exactly sure. I’m quite certain that my readers are overwhelmingly dental types, so maybe they think that by reaching the people who read this blog they’d be getting their message out a well selected audience. Maybe they figure that it’s a super cheap and low risk way to connect with said “dental types.” They’re probably right on both counts. My promise to my readers is this: I won’t allow cheesy and hollow sales pitches on The Blogging Dentist.

Since I’m the king of this castle, I’m going to lay out my rules.

  1. Ideally, you’re a dentist or dental business that has an idea or product that you think should be shared and talked about. Hopefully you aren’t selling insurance or Amway.
  2. As mentioned, I will allow no “sales pitches.” Blogs are about spreading ideas. That’s what I try to do here. I spread ideas that I’ve had and that I’ve heard about. I can’t stand the bald sales pitch. I understand that it is sometimes necessary, but I rarely react well to it. I need to be romanced. Give me some clever copy. Explain what the problem is and how you fix it. Link to your website if you like, but keep it classy. I don’t endorse products, but I might let you discuss a novel way of doing things that involve a product. It’s about the ideas, not products.
  3. You may not bad mouth your competition on the Blogging Dentist. I’m going to buy a Ford because I think the Ford is a great fit. Not because the Ford sales guy thinks that Dodges suck.
  4. I reserve the right to edit your copy. I won’t put words in your mouth, but I might change your syntax. Sorry…it’s a curse.
  5. Amuse me. This is the most important rule. If I think it’s funny, I’m more likely to share it.
  6. If you have a blog about your ideas or products I’m MUCH more likely to allow you a guest spot. I would enjoy having other bloggers come on board. As long as you’re O.K. with following the above rules.

 

What won’t fly:

  1. If you’re the web guy for some dentist’s website and you send me a generic blog post about the top 10 most cavity causing foods that you didn’t write and you put your client’s name in the byline even though they didn’t write it either…I’m not going to put it up. No chance. If I even think that the copy is written by someone other than who claims to have written it I won’t put it up.
  2. If you have a product you’d like dentists to know about but you’re only willing to share canned content I’m not going to let you guest blog.
  3. Buying ad space. At this point you can’t buy space at the Blogging Dentist. But if you have an interesting idea that you want to share in an amusing and engaging way…I’m happy to help!

If you’re interested on guest blogging about your product, service or idea feel free to email me at: alan@meadfamilydental.com. I’m happy to discuss it with you…as long as you’re willing to follow my rules!

magic impression goo

Let me start by saying I am not on the payroll of any dental company. It’s not like I object to it or anything. I’m sure that I could be bought. Probably cheaply. But I’ve never been paid for my opinion. Yet I still feel compelled to talk about this new stuff I’m using.

I’m a bread and butter dentist. Lots of fillings and crowns, some root canals and extractions and a few implants here and there. So we take lots of impressions. Over the years I’ve come to hate packing cord. It was a necessary evil to get a good impression. I’ve used electrosurgery before with mixed results. I’ve never used a soft tissue laser and I know some clinicians swear by them. The thing that all of these things require is anesthesia on (at least) the palatal or lingual for comfort. If you don’t have some solid gingival anesthesia, you’re cannot use cord, electrosurgery or a laser comfortably. In some cases, this gingival anesthesia is only necessary for tissue retraction. Usually, you can prepare a tooth without it. So, I’ve routinely used my paroject for profound gingival anesthesia and placed cord. Which is the most tedious job in dentistry, I think.

I don’t like placing cord, but I’m O.K. at it. When done well, you get great retraction. Often, it doesn’t do a red hot job with hemostasis without adding some kind of astringent. I’m a fan of Astringident X from Ultradent. I can still hear Dr. Fischer of Ultradent explain, “I could stop bleeding from the aorta with this stuff.” Anyhow, I hate cord. I’ll use it, but I hate it.

So then I hear about this stuff from 3M. The “retraction capsule.” I saw ads for it on DentalTown and thought it looked interesting. But it looked a lot like Expasyl, which I had tried and didn’t think that much of. It needed a special gun and was really tough to rinse off. So I was skeptical. Then a couple friends of mine on Facebook started raving about it and even putting up some case studies. So I thought I’d try it.

The “retraction capsule” fits in any standard composite compule gun. When you dispense the stuff, it comes out quickly. You don’t need to use a lot of pressure like with Expasyl. It doesn’t have a ton of body, but it seems to expand slightly after you dispense it. I think this is where you get the retraction. The tip of the capsule is very thin. Slightly thicker than a periodontal probe, but it slips under the gingiva quite easily. The instructions suggest letting it sit for a couple of minutes. After that, you rinse vigorously (and I mean vigorously). I go into the sulcus with an Ultradent Dento-Infusor tip on a small syringe of isopropyl alcohol for a vigorous rinse and removal of any handpiece oil, etc. What you end up with is a very clean and dry preparation with nicely retracted sulcus.

The impressions are good. Really good. I’m getting marginal flash in places where I never got it before. And better than that…no cord! I’ll place it when I need to, but so far I haven’t had to use it for the better part of a month. Which makes working more fun. Which is pretty much my main concern around here. 

My main problem with this product is the name. “3M retraction capsule” is clearly not sexy enough. I started calling it “paste” at first. Now I just ask for “magic impression goo” and Shelly gets it for me.

I won’t even charge 3M for the name if they want to use it.

Going Back to the Well

The best time to start a blog is five years ago.

I started writing my blog at meadfamilydental.com in 2008. Just about 5 years ago. I’ve got a couple hundred blog posts. I’m very proud of a lot of them. Some of them are just O.K. A few kind of suck. I’ve found something kind of cool about blogs, though. They can be recycled. Social media platforms like Facebook, Twitter and Google+ are uniquely designed to feature links.

I wrote a post on Mead Family Dental on October 12, 2012 called “Objections.” I was pretty proud of it. I think it was one of my better posts. It did not get a lot of traffic at the time. There were a total of 96 pageviews from October 12 to October 31. That’s O.K., but not great. I remember being disappointed that it didn’t get a little more notice, but hey…that’s how it goes.

I posted the same link on Facebook yesterday, June 6th, 2013. I’ve already had 105 pageviews in the last two days and a few Facebook friends “shared” the link on their pages. Why didn’t it get the attention the first time? I’m not sure. I do know that my posts only show up on a fraction of my Facebook friends’ pages when I post them. So it actually makes sense to link your blog posts on social media sites more than once. How many times? I’m not sure. I want them to seem fresh, so I don’t share the same link more than once every few months or so.

The point is this…if you’re not sure what you should post on an office’s Facebook page, why not use older posts from your blog?

Oh, that’s right. You don’t have an office blog. Or your office blog doesn’t have a lot of posts. Or your office blog posts aren’t original and authentic.

The best time to start writing an original and authentic office blog was 5 years ago. The second best time is right now!

Does My Dental Office Need a Blog?

To be honest…probably not. Let me explain.

Blogs are a pretty special kind of website. The defining property of a blog is the fact that it is updated “regularly.” Regularly means different things for different kind of blogs. Many news websites are blogs that are updated minute by minute. This blog is updated as regularly as I have ideas and time to write them down. How regularly depends on the goal of the blogger.

Because blogs are websites that are updated regularly, search engines like Google and Bing tend to notice them. These search engines are constantly sending out bots or crawlers to index the internet. Sites that have regular updates get more attention from these bots and often do well in search engine results.

Most dental office websites are relatively static. Their content doesn’t change very much. A website with static content has to rely on other ways for search engines to find them. There are lots of ways to optimize a website to be found by search engines, but updating content is a simple way for non programmers to compete.

So, back to the original question. Does my office need a blog? Well, it depends. Is your current website doing well with the search engines? Do you come up pretty high on the first page when people look for “dentist in your town” or any other keywords you’re trying to connect with? If you’re doing well here, you probably don’t need a blog. If you’re not doing so well with the search engines, a blog could probably help.

Here’s the part you’re going to hate. In order to be helpful, the blog needs to be pretty original. If you have a company that’s managing your social media presence and they include a blog, it’s probably not going to help much with the search engines. In fact, it could be hurting you. If they’re using a stock blog for many of their clients, Google knows this. Google could actually use duplicate content against you.

You should write your own blog. That’s the very best way to do it. It’s time consuming and you don’t have a lot of time. I get it. If that’s the case, just don’t do it.

People can tell when a blog is written by someone who cares about the content. It really shows. You don’t have to be a great writer to have a great blog. But, you do have to be honest and it helps if you write like real people talk.

Another cool thing about blogging is that it is a great way to share ideas. If you have an interesting take on a topic, a blog is a very easy way to get your message out. It’s really easy to amplify your message using social media like Facebook, Google+ or Twitter. All you have to do is copy your blog’s url and paste it into your Facebook status. You just shared your idea with a bunch of your Facebook friends. And if you use Facebook on a somewhat regular basis, your friends there are probably a great audience that may well enjoy your message and help you spread it!

So, does your dental office need a blog? It’s hard to say. Whatever you do, don’t have a blog just because someone selling you something tells you that you need one. A good rule of thumb is that if you won’t write it, at least most of the time, you probably shouldn’t have one.

But then again, what do I know?

Dr. Oz is wrong about amalgam fillings

MrWrong

Dr. Oz is wrong about amalgam fillings. He’s super wrong. He couldn’t be more wrong if his name was W. Wrong Wrongington. An episode of Dr. Oz recently aired where several “experts” weighed in on whether your amalgam fillings are poisoning you. That was the question that all the promos for the show asked: “are your mercury fillings poisoning you?” So I tuned in with bated breath to hear his answer.

His answer, of course, was that yes, they are poisoning you. Seriously, you knew that was the answer, right? If he’s said, “nope, they’re actually pretty safe” that would make the most boring television ever. And Dr. Oz is not about boring TV.

A couple of “experts” weighed in that the problem is the mercury vapor that comes off of silver fillings. According to the experts, any time you contact your teeth together, like chewing or heaven forbid grinding your teeth together, you’re emitting toxic gas into your mouth. That, my friends, is pretty scary stuff. But since you can’t see mercury vapor coming off of your teeth, Dr. Oz and another “expert” did a demonstration to measure how much mercury is released when you brush your teeth.

The demonstration consisted of a plastic model mouth with a bunch of silver fillings in the teeth. The model mouth was kept in a clear box that was ventilated. Dave Wentz, the guy doing the demonstration with Dr. Oz, let everyone know that they do the demonstration in a box so they don’t let any of the toxic mercury out. Which is interesting since it’s very likely that many people in the audience have silver fillings. If they’re that worried about the toxicity of silver filling, wouldn’t they screen the audience to not let folks with toxic fillings in the door? But I digress.

So, they do the demonstration. Dr. Oz puts his hands in the gloves in the clear box and scrubs these amalgam fillings like he’s cleaning the grout in the bathroom tiles. And, low and behold, they measure mercury gas coming off the fillings!

So Dr. Oz is scrubbing away at these silver fillings and asks:

“…at what point should I be concerned. At what [mercury vapor] level is it more than we’re supposed to have?”

Anything over zero is toxic. We’re at 61. 61 micrograms.”

Then Dr. Oz comes up with: “Now how can anyone dispute that there’s no mercury coming off of amalgams?”

And his guest expert Dave Wentz replies. “You can’t. You really can’t.”

If you aren’t careful or observant, this seems like a smoking gun. Amalgam fillings are dangerous and they are poisoning you. I ask you to step back.

The first thing that jumps out at me is the language that is used to frame the discussion. I typically refer to amalgam fillings as “silver fillings.” I never have thought of this as the element silver, but the color of the fillings, when polished is silvery. The Dr. Oz show refers to them as “mercury fillings.” Neither of these terms is probably adequate. Amalgam is a generic term for something that is mixed together. When the term is used in metallurgy it means: “an alloy made with Mercury.” So probably the most accurate term for these fillings would be “amalgam” and not “silver” or “mercury” fillings.

Language matters. When I use the term silver filling I’m indicating the color. When Dr. Oz uses the term mercury filling he’s pointing out the scary, toxic ingredient of the filling. That’s used to frame the discussion, so right away someone who isn’t thinking critically is thinking, “whoa, I didn’t know they placed mercury fillings!”

The next thing that jumps out at me is the way that they created and measured the mercury gas. It is assumed that the model that they offer (a plastic typodont with a ton of silver fillings in a plastic box) is an accurate representation of what’s going on in a human being’s mouth when they have silver fillings and they brush their teeth. I’m not sure it’s fair to assume that for the following reasons:

  • There was no moisture in this model mouth. A normal human being has saliva flow, which keeps the entire mouth moist and lubricated. Moisture on a surface could clearly affect the amount of vapor coming off the surface of a tooth.
  • We don’t know when these fillings were placed, if they were placed correctly, or if they were polished. All of those things can make a difference in the amount of vapor that might come off of these fillings. It wasn’t mentioned on Dr. Oz’s show.
  • We’ll also ignore the fact that the quadrant of fillings he scrubbed had anywhere between 4 and 7 surfaces of amalgam. I did my best to figure out how many surfaces the teeth had but they never showed the far side of the typodont. In any case, that’s quite a bit of amalgam…more than the average patient has for sure.
  • The model had no lips, tongue or cheeks and also wasn’t breathing. Wouldn’t a more accurate measure come from actual patients with actual fillings that were actually brushing their teeth?

They have measured the vapor that comes off of teeth in human models, and it is true that there is a measurable amount. In fact, there’s some question about the most accurate way to measure mercury vapor released from a silver filling. Is the vapor in someone’s breath the most important factor, or would absorbed levels of mercury in urine and blood be the most important measure? The Dr. Oz show wasn’t interested in an actual discussion. They went from “hey look, there’s mercury vapor in this model” to “your fillings are poisoning you.” No mention of actual outcomes based research. No mention of the millions and millions of teeth saved by the use of amalgam fillings with virtually no verifiable reports of bad health outcomes due to amalgam fillings. Clearly the most important message was that there is scary, poisonous vapor coming off of your silver fillings. Awesome.

The final thorn in my side was the statement made by the guest who was putting on the tooth brushing demonstration, Dave Wentz. He says, “anything over zero is toxic.”

Alternative medicine advocates aren’t known for their nuance. Poisons are dose dependent. In other words, something that is harmless in small doses can become harmful in larger doses. That is the case for most things that are known to be toxic to humans. So, how do we know if we’re getting a toxic dose of mercury vapor? Well, the World Health Organization describes a “tolerable intake” of elemental mercury vapor to be 2 micrograms/kg of weight per day. So if we take an average male of 150 lbs, they can tolerate a daily intake of around 136 micrograms of mercury per day. So, are our amalgams delivering that much? The short answer is no. Dr. Oz was able to generate an impressive 61 micrograms by scrubbing on some silver fillings in a box. However, actual measured amounts in human beings are more like 1-3 micrograms per day, depending on how many surfaces of amalgam a patient has.

There are reasons to dislike silver fillings. However, there is no credible evidence that they will cause anyone harm. The outcry by many poorly informed people has led to the outright ban of this material in some countries and the sharp reduction of it’s use here in the United States. Amalgam fillings are durable, long lasting and safe. That’s what credible evidence states. Until credible evidence says otherwise, I think Dr. Oz is wrong. Really wrong. Super duper wrong. His name should be W. Wrong Wrongington.

That last part is just my opinion, though. The rest of it is the truth as we know it.

 

 

 

 

 

eBay saved searches

I’m obsessed with dental microscopes. There. I said it. I’m still a beginner user even though I’ve had one for more than 2 years. I’ve been obsessed with the concept for probably 8 years or more. I do better dentistry because of magnification and the microscope is really the pinnacle. But that’s not what I want to talk about.

What I really want to talk about is a cool way to use eBay. I’ve been trying to find my “sweet spot” for my microscope’s objective lens (the distance from the bottom of the scope lens to the patient) and I didn’t want to pay thousands of dollars to figure it out. Global Surgical microscopes use an objective lens that’s pretty common amongst medical operating microscope manufacturers. And eBay has a ton of them. But let’s say you’ve got better things to do than search eBay every day for microscope objective lenses. What do you do? You make a “saved search.”

This feature may have been there forever, but I never noticed it. I think it’s particularly cool for dentists, though. Every dentist has that shelf in the strorage closet where the amazing and practice changing technologies they’ve purchased that didn’t work out sit. You can sell this stuff on eBay to dentists that could use it. And if there’s stuff you’re interested in, you can create a saved search so eBay will let you know when someone has something on their shelf that you might be interested in!

How does it work? After you enter a search for an item on eBay a button will appear on the right side of the search box that says “Save” and with a little star next to it. When you click on this button it defaults to “email me daily when new items match my search.” This means, it will send you an email when something that fits the search is listed on eBay. You can opt out of the email option, but you’ll still need to check eBay regularly.

So, give it a try! You might be helping some other poor dentist clear their “shelf of shame” of stuff that’s useful to you!

 

Meet the new guidelines. Same as the old guidelines.

Yesterday, the American Dental Association and the American Academy of Orthopedic Surgeons released new, evidence based guidelines regarding antibiotic prophylaxis before dental treatment in patients with joint replacements. The press release states that there is no evidence that dental procedures cause joint infections. Prior to this statement, we were to assume that a dental cleaning or placement of a filling had a special and dangerous power to seed the blood with frightening bacteria that somehow knew to go directly to the joint spaces of innocent artificial knees or hips with the malicious intent to infect.

For years I’ve been complaining to anyone who would listen about the joint replacement conundrum. Even though there was no evidence that premedicating patients was doing anyone any good, we did it. Because giving a patient a giant dose of antibiotics before having dental treatment is a much better option than having to treat or replace an infected joint, right? So just shut up and give them the antibiotics, Doc.

And that’s what we do. Each time I consult with a patient’s surgeon I get similarly frustrated. Some surgeons want premedication for the the rest of the patient’s life. Some surgeons want 6 months. Some want 2 years. Some think Amoxicillin is the way to go. Some say it’s Keflex or nothing. The one thing that all surgeons agree on is that they aren’t going to write the prescription for the antibiotics. That’s the job of the dentist. Which also means it’s the liability of the dentist. Let’s face it. Some patients can develop hypersensitivity to antibiotics and a huge dose of antibiotics could cause a reaction. Even a potentially severe reaction. And no one wants to be the one who wrote that script, right?

Let’s just get this out of the way. Most dentists don’t believe we’re doing a valuable service by premedicating our patients. Most of us know that eating a Dorito is at least as great of a risk as a dental cleaning for seeding the blood with oral bacteria. But we’re not rushing to premedicate patients prior to Dorito consumption. We’re doing it to cover our asses! We’ve been trained to cover our asses about this stuff since dental school. It has nothing to do with excellent patient care and everything to do with making sure we did everything right so that if some future joint infection or infective endocarditis event comes along we can prove that “it wasn’t us.” If it was really about excellent patient care, we’d have the ADA lobbying Frito Lay to bring out “Blazin’ Amoxicillin” Doritos.

I’m a dentist. My strength is treating dental disease. I’m a pretty smart guy, but frankly I’m not really up on the real risks of artificial joint infection or antibiotic allergies. How can I be expected to weigh the likelihood of two incredibly rare but very serious outcomes (joint infection vs. antibiotic reaction)? I don’t think it’s legitimate for the dentist to have their own policy. How about if the professional group that represents me, the American Dental Association, gives me some solid guidance so I don’t have to worry that I’ll be 1) harming my patients by not correctly weighing the risk factors and 2) you know…the lawyers.

But now, the evidence (or lack thereof) is in! We can stop worrying about the premedication for people with joint replacements because there’s no evidence of harm, right? 

Ummm. No.

What the joint ADA-AAOS actually gives us are 3 “guideline recommendations.”

But recommendations are good, right? After all, the American Heart Association passed down (many times!) their recommendations on stone tablets for all dentists to know and heed! And by following recommendations it means that the lawyers can’t get us! I mean, as long as we follow the recommendations!  

You’d think so. I mean, you’d think that having recommendations from the two big professional groups representing dentists and orthopedic surgeons would give us actual guidance on this issue. But it’s just not true.

The ADA-AAOS statement made me skeptical almost as soon as I started reading.

This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.

I read that and think, “these guidelines are perfectly fine, except you still have to evaluate patients on a case by case basis and if you get sued, we don’t have your back.”

I have to admit that I haven’t taken the time to read the full guideline, so my comments are based on the summary. The full guideline is somewhere around 100 pages and my own inability to concentrate for that length of time (thanks, internet!) has kept me from reading it. If someone does read it and find that I’m completely wrong, please let me know. I’d love to be wrong about this.

The recommendations strike me as incredibly watered down. They seem to be written as obliquely and indirectly as possible. Then each of them is given a “strength of recommendation” rating which means nothing to me. And they know this. So they give a definition about the strength of rating. Right after they give the strength of the rating. Honestly, it’s kind of bizarre.

The first recommendation addresses the use of prophylactic antibiotics:

The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

I might consider discontinuing antibiotics. Sure. I might. I might consider explaining my position to the patient, too. I mean they are the ones that are taking the very slight (but real!) risk here. But did I really need a recommendation from the ADA and the AAOS to tell me that I might think about it?

Further bolstering my opinion of this recommendation is the “strength of recommendation” score it’s given: “limited.”

A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

Recommendation 2 speaks to the use of preoperative topical oral antimicrobials:

We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.

So, they won’t say whether use of chlorhexidine prior to your filling is worth it or not. Great. Thanks for that. This strikes me as unnecessary because the risk profile of a swish of Peridex is a lot less than a megadose of Amoxicillin. In any case, they want us to know that we should feel “little contraint” in deciding whether to follow this recommendation. Gee, thanks.

Finally, the most bizarre recommendation.

In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Really? Was there a time when I was supposed to be telling joint replacement patients that the risk of joint infection was so great that the shouldn’t floss? Or am I to assume that the ADA and AAOS feel that maintaining oral hygiene is vital to the health of an artificial joint? Honestly, I don’t even know what they’re trying to say. But at least they all agree on it. They give this recommendation a strength of: “consensus.”

A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.

I had high hopes that the ADA would come through for us on this issue. I was hoping for an “AHA-like” guideline that would take the guessing out of this very common event for dental patients and dentists alike. It didn’t happen.

The most hopeful statement I got from the new guidelines is this:

Patient preference should have a substantial influencing role.

Although this statement was made specifically in reference to recommendation 2, I think it’s worth contemplating for the whole thing. Taking a large dose of antibiotics prior to dental appointments is not a risk-free event. I honestly don’t know if the data exists to weight the risk of taking antibiotics against the risk of joint infection at the dental office. I think patients can and should be part of the decision here.

The whole inconclusive data issue cuts both ways. Sure, there is no data to conclude that dental treatment causes joint infections. However, outside interests can just as easily claim that there isn’t data that dental treatment doesn’t cause infection in artificial joints. As a profession, we’re in the exact same spot that we were before these so called recommendations came out. We’re still going to cover our asses for the wrong reasons. It wasn’t good medicine before and it still isn’t.

What do I think should happen? I think the ADA and AAOS should sound off like they’ve got a pair. I think they should put a statement out that they’re going to help fund research on this topic to really answer the question and in the mean time they need to make a statement to dentists that “this is the recommendation and we’ve got your back if there’s a problem.” I think that the ADA should set aside a fund for the inevitable legal challenges that will come along to such a definitive statement and let member dentist’s know that they will be represented. It’s time to do the right thing for the right reason.

Am I right on the money? Am I completely dead wrong? I’d like to hear what you think. Feel free to leave a comment here or email me at alan@meadfamilydental.com.

 

 

 

 

 

Reasonable

I’d like to think I’m a pretty good dentist. I’ve developed my skills with practice and a constant drive to learn. I’ve hired and retained an office team that really goes the extra mile for patients. But above all, my goal has been to be reasonable person with an equally reasonable team. I think patients like dealing with an office full of reasonable people.

What do I mean by this? Well, if I put a filling in last year and a piece of it breaks off…I’m going to fix it for you and not charge you for it.

Could we charge for a new filling? Sure. Probably some would. Frankly, if a filling of mine comes out in a year, I can’t help but think that something went wrong with the placement of it. In most mouths, a filling should last awhile. How long? Well, that’s a complicated question. But let’s just say a year is usually too short of a lifespan for a filling.

Another example of reasonable. It’s the holidays and you’ve got a day off. This is your one day to knock out all the Christmas shopping. You remembered that you had an appointment with us when you woke up, but time just slipped away from you. You check your cell phone and realize that your appointment was an hour and a half ago and you completely missed it. You call in a panic and Kathy teases you and sets up a new appointment. Can we charge you a late fee? Absolutely. Will we? Probably not. Why not? Because we’re reasonable.

Being reasonable is one of the things that makes me enjoy being human. Sometimes all it takes to make someone’s day better is being a little flexible about expectations. Everyone has a occasional bad day. Sincere apologies are worth their weight in gold.

Of course this totally goes both ways. I like to brag about how my office runs on time. Often we run ahead of time. I only see one patient at a time, so the time that we reserve is actually reserved especially for you. Every once in awhile…I get behind. Usually it’s a procedure that went much longer than I expected or a dental emergency that just couldn’t wait. Every time this happens, it throws me off my game. I hate being behind. I almost always walk out into the waiting room to apologize and let the patient know what’s happening. I can’t remember a time when the patient gave me a hard time. It’s because most people are reasonable.

Very occasionally we run into patients who aren’t kind and understanding. In fact, they’re just unreasonable. I have quite a few stories of patients who’s expectations were unrealistic and they were happy to tell me about how I had failed them.

I’m not going to tell you those stories, though. Why? Because I’m a reasonable person and it doesn’t help to dwell on them.

Instead, I’m just going to ask myself a question. When I’m in a situation where I’m unhappy with the service I’m receiving…am I being reasonable?