Notorious press has given the papoose board a bad name. Granted, its utilization can be abused, especially as seen in the story that was profiled on ABC’s 20/20. General anesthesia isn’t without its opponents as well, especially when a child dies.

With that somber note hanging in the air, you may want to revisit David After Dentist and pick yourself up with a little sedation dentistry humor. Even if you don’t agree that his dad should have ever posted the video on YouTube, it’s still so freakin’ funny.

Children who can’t be cooperative still need a means of getting their dentistry done, so pedodontists must make choices that sometimes include the use of papoose boards or general anesthesia. For entertainment’s sake, let’s just call this polarizing dilemma by another name: Hugs vs. Drugs.

There have been accusations from both sides: allegations of “nest feathering” by morally outraged dental anesthesiologists, abuses of public funds to pay for unnecessary procedures, the ultimatums given that any child restraint is considered grounds for lawsuits, equating papoose boards with third-world dental care, or offering general anesthesia for simple extractions when a combination of restraint and other sedation would be less expensive and as effective.

As a dental professional, it is your responsibility to make well-informed choices about sedation and restraint methods. For instance, individuals with autism or cerebral palsy may find that restraints are not only necessary, but even welcomed when compared to the use of drugs that can do more harm than the good that the dentistry is trying to achieve. Restraints may not be a better choice for toddlers whose biggest problem is a helicopter parent or two who are freaked out about the psychological trauma of having an irreparable tooth pulled. If a parent freaks, most likely so will the child, so it may be your choice to pander to the whiny world of children who are more in charge than their parents. After all, it’s no big deal to go under GA for a five-minute ear tube procedure with the ENT, right? That’s expected.

No matter what you decide to do, as long as you’re doing it from a level of comfort with your ability, and most importantly, from a sense of compassion, you should be able to confidently make the call for each patient, no matter where it falls on this line.

But sometimes, you just want to throw up your hands and say “AHHHHH I QUIT!” because you don’t know how to manage a patient. That’s when it’s awesome to have someone in your contact list who you trust to make this call.

And then pass the buck to them, because referring out can be very, very gratifying at times.

Until yesterday. Instead of getting your soup in a bowl at the counter,  you complainers will be able to get it in a to-go container, from the “Concession Stand”:

Align Technology Eliminates Annual Case Requirement for Invisalign(R) Providers

SANTA CLARA, Calif., Apr 22, 2010 (GlobeNewswire via COMTEX News Network) — Align Technology, Inc. (Nasdaq:ALGN) today announced a strategic change to the Invisalign proficiency program the Company launched last June to help ensure Invisalign providers build a baseline of Invisalign product experience and knowledge through minimum annual case and continuing education (CE) goals. Effective immediately, doctors will no longer be required to start a minimum of ten shipped cases per year to maintain their active provider status. Doctors are still required to complete a minimum of ten Invisalign continuing education (CE) hours per year.

“Despite continued strong efforts by our customers to meet the annual proficiency requirements, many customers remain frustrated with the program, particularly the case requirement,” said Dan S. Ellis, vice president, North American Sales. “While we remain deeply committed to ensuring great treatment results for Invisalign doctors and patients, we are equally committed to listening to our customers and responding to their needs.”

Align will continue to emphasize the importance of Invisalign professional education in treatment success by maintaining the annual ten Invisalign CE hour requirements. In addition, Align will focus on continued product innovation and performance improvements and customer loyalty and rewards programs to help drive great treatment experiences and results. As part of this focus, Align will continue to promote the benefits of Invisalign Preferred Provider status for doctors who start ten or more cases each year.

Doctors who do not complete a minimum of ten Invisalign CE hours in a calendar year will have their Invisalign accounts temporarily suspended until they complete the minimum CE hours. With more than 200 hours of lecture-based and online learning opportunities, Align’s robust educational curriculum makes it convenient for doctors of every Invisalign experience level to stay current with product and clinical advancements.

Doctors whose customer accounts were deactivated or changed to limited status for failing to meet the 2009 proficiency requirements can reactivate their account and start using Invisalign again at any time by completing a Clear Essentials I or Clear Principles training course and thereafter meeting the annual ten CE hour requirement. More information on the proficiency program and related changes are available at http://vip.invisalign.com/proficiency.

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Also worthy of reading are the frustrations aired at Jim DuMolin’s great website: http://www.thewealthydentist.com/SurveyResults/162-Invisalign-Dentists.htm.

Just so we have this straight: lasers are okay, but needles? Not so much. Texas is a bit behind the times regarding local anesthesia. But the great news is that their state board just recently issued a statement that affirms the legality of laser use by formally trained hygienists for treating periodontal disease that is not responding to traditional therapy.  Here it is in the Board’s own words:

Texas State Board of Dental Examiners’ Position Statement on the Use of Lasers by Dental Hygienists

The Texas State Board of Dental Examiners is aware that lasers can be used to replace or supplement traditional dental instruments such as handpieces, scalpels, curing lights, and the explorer.

It is the position of the Board that licensed dental hygienists may use lasers that are not capable of cutting or removing hard tissue, soft tissue, or tooth structure to perform clinical tasks that are otherwise within the hygienist’s scope of practice. Dental hygienists must perform intraoral procedures involving a laser under the general supervision of a licensed dentist.**

Whenever a new treatment modality is brought forward, it is the Board’s policy that the licensee must have proficiency and training in the use of the technology for the procedure performed. Licensees utilizing new technology must maintain documentation of the satisfactory completion of formal continuing education or training using the technology for the procedures performed. The particular technology utilized performing any particular clinical task does not alter the requirement that a dentist is ultimately responsible for any procedure delegated to an auxiliary and the auxiliary performing the procedure remains responsible for performing the task within the standard of care.

** “General supervision” means that the dentist employs or is in charge of the dental hygienist and is responsible for supervising the services performed by the dental hygienist. The dentist may or may not be present on the premises when the dental hygienist performs the procedures.

We were impressed that when put on the spot between inaugural balls today, President Barack Obama was able to outline his plan to give all people in the United States of America the right to a beautiful, healthy smile. The big question is: just

Obama’s Mastication Initiative for America (MIA)

The people of the United States should realize that teeth are a quality of life issue. The government cannot force a citizen to take care of his or her body, nor should a person be penalized for issues that are beyond their control. We have seen the insurance industry take hold of healthcare and overvalue its services. Furthermore, dentists throughout our great nation have resisted the tide of managed medicine and are now capable of not only improving the quality of their patients’ lives, but even the very length of the average American lifespan.

When we look at the technological advances that have been made in dentistry, we know that now is the time for change. It is this administration’s hope that by combining personal responsibility with expert guidance, my Mastication Initiative for America will fulfill the needs of all Americans, not just the ones barely getting by; not just the wealthy, but every one of us.

The details will be forthcoming when I have more than a few breaths of air between dipping my wife on dance floors, but here is a brief outline of the plan:

1. Participation in the plan is voluntary, both for dental providers and for patients.

2. Payments will be made directly to patients on a yearly basis, with the exception of the Lump Sum plan that is described in line 6.

3. All participating dental practices will engage the use of a government-approved method of data gathering and reporting, to be agreed upon in the future, but possibly a special watermarked panoramic digital image that can be submitted to the Department of Health and Human Resources. This will significantly decrease the ability for fraudulent reporting on patient status.

4. Each person under the age of 30 will be required to have yearly dental images submitted on their behalf for reimbursement by the federal government. There will be a fixed amount allowed per person, regardless of actual care rendered. i.e. $500 per year per person under 30. Under no circumstances will any funds be reimbursed if basic preventive measures were not pursued by the patient or their family.

5. Third Molar Extraction will be considered a medical expense, as will any congenital deformity that is currently considered the arena of oral maxillofacial surgeons, so is excluded from the MIA plan.

6. At the age of 30, regardless of previous dental history, all citizens will be eligible for Dental Implant Screening (DIS). Because of the excellent properties of implants versus natural teeth regarding the elimination of the periodontium and thus the link to systemic disease, it is the MIA’s recommendation for DIS to be implemented before dental disease is likely to permanently affect a person’s whole health. Those who are at risk for losing their teeth, who have already lost teeth, or who simply make the choice of not wanting to maintain their teeth will, at this time in their lives, be given the opportunity to have all their teeth removed and have dental implants placed instead. This is a Lump Sum, and will include a preventive appliance to be worn at night. Any person who has implants with DIS will not be able to participate in the MIA after having implants placed.

7. DIS practitioners will work directly for the government, be well-trained, and well-compensated for their expertise.

8. From the age of 30 onward, payments from the MIA will be based on the number of healthy, maintained teeth that a patient displays in the accepted yearly imaging submitted. Included as healthy teeth: those with no restorations, restored teeth with no active defects, teeth with successful root canal therapy, periodontally involved teeth with no bone loss noted within the past year, and dental implants. Teeth that would not be counted for MIA payments: Broken teeth, retained root tips, teeth with active decay, and teeth showing periodontal involvement that has progressed since the previous submitted image.

This is the plan that will ensure that all Americans will be able to smile proudly, whether it is a God-given smile or one granted to them by choice, and no longer will we as a nation be faced with lost work time, emergency room visits, and other troubles caused by bad teeth. After all, this is the very soil where the “Hollywood Smile” was born, and so I ask you to consider what is best for our country, for our children, and for dentistry in the new economy to come.

This is about dental pollution, people. It may be ignored by mainstream science, but this problem is real enough to sell newspapers, magazines, and make you read online articles.

What I’ve Heard About Dental Pollution

Everywhere I go I hear about how it’s not fair that the citizens of cities have no choice about the fluoride in their drinking water. Sure, it makes teeth stronger, but there’s a conspiracy of pollution! And it’s the people who are so poor that they can’t even afford cups, they have to tilt their heads sideways to drink under the sink faucet, they are the ones who get the most fluoride in their bodies.

Does fluoride save lives like chlorine does? Wait, I didn’t say that, because it’s going to sound like I am in favor of putting poisons in the water.

You dentists also are protecting the right to fix the holes in people’s mouths with evil substances. If you drill a tooth and put in a silver filling, you have to make the filling soft with toxic mercury. Why can’t you just heat up the silver and pour it in the cavity?

The high road dentists are no better, with their lady-man BPA-leaching plastic composites. I’d rather gnaw on a Nalgene bottle and take my chances with it than have an oil-slick wedged between my teeth 24/7.  The recent petroleum price increases are nothing compared to the cost in human lives.

The other thing that’s polluting our mouths is lead. There’s been lead found in ceramic/metal crowns. They say these crowns come from China. We like to blame everything on China.  But the real reason that there’s lead coming from the dental labs is because the cheap dentists have forced lab technicians to scavenge for scrap metal by secretly dumpster-diving for X-ray film packets.

My shaman tells me that all the metal he sees in people’s mouths is creating imbalance in their meridians. This pollution is caused by all the various metals sending out galvanic currents, which turns our mouths into electrolyte-driven batteries. It scares me even today when I see that trick with the guy who sticks the end of a lightbulb in his mouth and it turns on. I know he’s dying from galvanic currents just for a laugh.

One more pollutant that is caused by the well-meaning but unenlightened dentists of the world is when they leave a dead tooth in a living mouth. Would you leave a cadaver just laying around with living people? Well, this is just what is done when a dentist fills the root canal of a tooth and just leaves the dead shell of a tooth in place.

I’m no Navajo with my sand art, but I sketched out this modern flow chart to help us understand where all this pollution is leading:

The pollutants are circled in red. Only one treatment is circled in green because it doesn’t involve dental pollution.

With only two choices in life if we find that we need a dentist – a polluted mouth or the totally toothless gums of a baby – all we can do is pray to our ancestors to give us naturally strong, healthy teeth.

My life has been one of ignorance until now. I have been going to the dentist regularly, and have had various pollutants placed in my mouth. I still have all of my teeth and have no ill symptoms from the poisons. Should I be grateful, or should I be worried? Are teeth worth it, in the end?

Six Degrees Of Dental Pollution

Here are various tests that you can either do in your office or send home with patients to make sure that you aren’t polluting their mouths:

Fluoride: http://www.hach.com

Bisphenol-A: http://www.biosense.com

Mercury: http://www.heavymetalstest.com/_hgkit.php

Lead: http://www.zefon.com/store/leadcheck-swabs.html

Galvanic Currents: http://www.biomeridian.com/devices.htm

Root Canal Therapy: http://www.holisticdentist.com/articles/root-canal-treatment.html

I know that this isn’t Keep America Beautiful or any other grand public service announcement, but it’s important for dentists to understand the consequences of their actions. And sorry about the waterworks; you know how pollution is a touchy subject for me.

Unbiased reporting about the consumers themselves.

It may be hard to believe, but patients all over the country are complaining that dentists aren’t asking them to pay their bills anymore.

For many years, consumers have taken advantage of dental practices’ good will by just “paying when they could” for their dental care. Unfortunately for many offices, this resulted in the expenses of staff time, mailing repeated statements, and simply writing off debts that were never paid.

Now that healthcare financing has come to the market, Consumer Reports (July 2008 issue) is pointing fingers at CareCredit, the Citi Health Card, Chase HealthAdvance, CapitalOne Healthcare Finance, and the dental providers themselves for allegedly taking advantage of the doctor-patient relationship.

There is no excuse for dentists who purportedly sign patients up for these programs while sedated, or otherwise abuse their patient’s credit for personal gain. Consumer Reports makes it seem like the American Dental Association itself condones this type of behavior. The purpose of healthcare financing is to benefit patients, dentists, and the participating banks. The article even affirms that the lenders take anywhere from 4.5% to 13.9% of the fees that are financed through their credit cards, which is much, much higher than traditional credit cards. Dentists pay these fees in order to give patients access to interest-free payments.

Most patients do pay off their balances within the interest-free period. Those 20 percent who do not were originally the kind that were most likely to show up in the dentists’ accounts-receivable column at the end of the year. Only now it is the banks who have accepted the burden, and because contracts are involved, so are consequences.

Is it really the dental equivalent of subprime mortgages?

Consumer Reports seems to think so. While not exactly an adjustable-rate mortgage, the default retroactive APR of 22.9% when a balance isn’t paid in full after 24 months is not news to anyone who reads the fine print on any typical credit card statement. The only money crisis in healthcare lending is that consumers are now being held accountable for their actions.

It is our culture that breeds the opinion that consumers deserve what they want, exactly when they want it, and it is this belief that is the underpinning of excessive consumer debt. Most patients want a perfect smile, but only the ones who don’t have the self-discipline to know whether or not they can even afford the payments are the ones getting snagged by the banks.

In defense of Consumer Reports, however, it does appear that some of the terms of the loan agreements are difficult to stomach, and it is agreed that some reform here would be beneficial to everyone involved.

Many consumers believe that teeth are more of a luxury than a life-and-death issue. Affirming this is the prosperity of quality dental practices which do not rely on insurance payments for their livelihood. And the bottom-line truth is that edentulism is not a risk factor for any other diseases, so it is not a liability to the overall health of a patient.

Dental insurance is a form of consumer entitlement, and healthcare financing is one strong step away from this dependency and expectation. Insurance justifies the acceptability of mediocre dentistry to the consumer. Perhaps the reality is that every dentist should move towards the model of providing excellent dental care at fees that will keep them in business, without taking advantage of those patients who need much more than just a good set of chompers in their lives.

What’s next?

Our prediction: haircare financing.

In our last episode, we left as the two camps bickered over what they were going to do once they had actually tracked down the elusive Maxillus mandibularis. The leader of Camp NeuroMuscular had leaned toward the fire, cradling the bowl of his pipe in his fingers and clenching its stem in his teeth like an NTI device. Removing the pipe, he suggested that the solution was to deprogram this infernal beast. 

“Nonsense!” replied Sir Centric Relation from under his handlebar moustache. “Everyone knows that you must guide the cuspid. It is the only way to stop the nightly rampage.”

As we return to the scene, Sir Centric stands up and peers into the encroaching darkness.

“But ho, what is this?” Out of the shadows steps a keen-eyed gentleman in a light blue seersucker suit and an obvious combover.

The man approaches the fire and begins his spiel. “You know what is the real problem, right? You just want to keep the Maxillus mandibularis from crashing in here and destroying everything. Do you think all those villagers care about why? They want this problem fixed, and they want it fixed today.”

The gentleman swiftly rolls out a sheet of something, squishes it around the beast’s water-hole, and waits for it to harden.

“There ya go. Problem solved. And it’ll cost you less than having those timberlogs dragged in from the forest. Besides, who has two weeks?”

“Certainly that shouldn’t be a problem. The villagers have been living with this for years.” says the leader of Camp Neuromuscular.

“Yes, but they came to you today for an immediate solution.”

“It’s only a stopgap. It doesn’t correct the underlying problem. And eventually the barrier will fail,” chime in the leaders of both camps.

The gentleman brings his fist up to his chin in thought. “Well, even if you can kill the beast, you do realize that it’s a protected species.”

“But no way is it in danger of going extinct. It must be laid to rest!”

“Yet, still so hard to kill quickly. Goodnight gentlemen. If you change your mind, just ask around. Everyone in these parts knows where to find me.”

The man in the suit slinks back off into the darkness, leaving the two leaders alone in silence, once again glaring at each other from across the campfire.

*********

When it comes to parafunction that eventually will whittle your patients’ teeth down to stumps at night, it only makes sense to fabricate some sort of cushion to soften the blow. Dentsply-Caulk has recently been advertising the inTerra iNoffice Nightguard. This product appears to break down some of the obstacles that come up as the dental profession seeks to eradicate bruxing from the planet.

The iNterra Nightguard’s VLC (visible light cure) material is packaged in three arch sizes. This soft tray is formed directly on the patient’s teeth while in the chair, tack cured in the mouth for a few minutes, and then completed in the lab in another 20 minutes, which makes same-day delivery a snap.

With an existing light-curing oven in your lab, the cost to begin fabricating nightguards in-office makes the iNterra system a decent value, cutting the usual lab fees for nightguards at least in half. Otherwise, be prepared to spend a few thousand dollars on a curing unit before you insert your first case.

Look at the iNterra Nightguard from an efficiency standpoint. Single appointment, no lab transportation issues, minimal doctor chairtime. You may also be able to improve case acceptance when passing on the reduced overhead costs to patients.

Is it the best way to prevent occlusal wear? Who’s to say? But the inTerra Nightguard is much better than doing nothing about parafunction.