Operative Dentistry

Future “drug” for dental phobics

April 12, 2013 By Trish Walraven 2 Comments

It looks like virtual reality may actually be almost Matrix-quality in a few short years, and our patients will be able to immerse themselves fully in another world while they’re getting their dental work done. But because there’s a lot more money to be made in gaming (and there’s a MUCH wider customer base) don’t expect that this technology will have a dental application any time soon. Here’s a decent introduction to the concept featuring Palmer Luckey, the originator of the Oculus Rift headset:

These sorts of glasses have been intriguing to me for years, but all the previous versions mentioned here on DentalBuzz basically make it seem like you’re watching a TV screen from a distance. Oculus Rift is different. Users have described the feeling as being totally disconnected from reality. And isn’t that what recreational drugs do? Isn’t that what dental sedatives do?

Imagine a dental appointment where a fearful patient is allowed to slip into a virtual playground where they don’t even need to move their head much in order to initiate the immersive feeling of being elsewhere while they hold their totally oblivious mouths open. Patients’ ears will hear the sounds of their “other world,” letting them slip away from their bodies for a little while so that you can manage all the dental unpleasantries for them.

Here’s another preview of Oculus Rift:

There are many software developers in dentistry that are in search of the next big thing. The 3-D milling technology is pretty awesome these days, but indirect dental software such as patient education, practice management and the like are also looking for the leg-up. Oculus Rift is looking for developers right now, and my guess is that they haven’t even imagined its application in dentistry.

But that’s because you haven’t yet picked up their development kit to make it happen.

Here ya go, and good luck:

Why your fingers shouldn’t be in the picture

March 15, 2013 By Trish Walraven 6 Comments

“Just this once; it’s okay.”

Does that sound like your practice? You know, you have a gaggy, bouncy kid who’s just about to tongue-thrust their way out of having those radiographs taken, but here comes Amazing Assistant to help you get a diagnostically acceptable image. SCORE!

The problem is that this never happens “just once.” I’ve seen the same person holding sensors in patients’ mouths dozens of times, and that’s when it becomes a problem. Yes, radiation is safer now that we’ve dialed it down and collimators make sure that there’s nothing scattering beyond the focused beam, but that doesn’t mean that we should be flippant about limiting exposure to our patients and most importantly, ourselves.

My best friend from high school could tell you not to hold those films in people’s mouths, too. She was a dental technician in the Navy and also worked for years in pediatric dental offices and orthodontics as an assistant, calming nervous children, helping them to have good dental experiences, and when she was exposing radiographs, sometimes she admits that she would make it easier on everyone if she would stay with the child while the x-rays were beaming through her hand.

She doesn’t have to tell you not to hold the films, though. She can just show you why you shouldn’t:

This is her right hand. Several years ago when she was doing laundry her finger caught on the dryer and “snapped.” This is important, sort of like when your patient tells you exactly what they were eating when their tooth broke – don’t you pay that the most attention of all? Because it was the darn dryer that was the problem….(!) Let’s be serious, though. Like you, her doctor really didn’t care what broke her finger, he wanted to know why it broke.

Turns out that she had developed a giant cell tumor in the first (proximal) phalange of her ring finger that had eaten everything except a small sliver of bone and that was what had snapped. These are very, very rare in small bones like those found in our fingers; most osteoclastomas happen in the larger bones like femurs and such. Hmmm.

Even though the tumor was benign, because of the damage done, the possibility of regrowth and other factors, the decision was made for my friend to have her ring finger amputated. I would have had her flip you the bird for effect but she no longer has a middle finger either…! (think about it…!)

So she was fortunate enough to stay in dentistry as a patient care coordinator for a few more years as she recovered but is now working towards her master’s degree for speech pathology. While she doesn’t seem totally convinced that excessive radiation exposure caused her to lose her finger, she doesn’t count it out for even a second.

And neither do I.

Losing a finger may be anecdotal evidence about the dangers of radiation, but it’s enough for me to feel like enforcing what we already know to be true.

Please share this story with those you care about, even if it makes you feel like the Radiation Nazi.

A plea to use DMG Icon infiltrant

February 22, 2013 By Trish Walraven 9 Comments

Don’t you think that this is the WORST part of orthodontia? You take off the brackets and voila! Straight teeth… with fugly white squares where acid beat the $#!† out your patients’ anteriors. And NOW you have to go drill on their teeth, destroying what you so carefully tried to perfect.

Once you’re here there’s no use in blaming the patient; it’s not like they’re going to get the brackets put back on to cover the white spots and then get more decalcification there. Yes, you should help them with their lifestyle choices (less energy drinks and voluntary mouth breathing, please) but at this point you have to do something to make them look better.

As a hygienist I’ve been totally itching for about the last four years to get the go-ahead to use a relatively new product called an infiltrant. There’s only one, it’s made by DMG and it’s called Icon. This infiltrant is placed on the tooth where it seeps into smooth-surface lesions that haven’t fully cavitated (although if you ask me the ones in the “Before” picture above look way gnarled out) and pretty much does a little remineralization voodoo.

I’d hoped that it would be classified as a sealant because Yay! I can do sealants. There’s no drilling done, right? There’s nothing taken away, right? There is, however, some irreversible improvement made to the tooth though and that (plus a significant etch time) means that when the CDT recognized that an infiltrant needed a code, where did that boom fall? Smack dab into Composite Land as a D2990. I know. The wording says “placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting progression of the lesion” and that SCREAMS prevention. Alas there’s the other word. Restoration.

Dangit.

Another problem is that this stuff is very expensive. See what it costs here for the mini kit for a maximum of six lesions?

That’s at best, $27 per tooth just for the kit (not including your other overhead or minusing the limited-time Amex card!). The suggested cost to a patient should be somewhere between your one surface composite fee and a sealant fee, and conservatively it takes at least 20 minutes of intense doctor time to place an infiltrant on a single tooth. Composites don’t cost that much or take that long to place so you know what that means, right? THE FEASIBILITY OF ICON SUCKS.

I really hope I’m wrong, but to most doctors, what’s a few millimeters of drilled-away tooth structure? Minimally invasive dentistry is for anal retentive freak dentists anyway. And every hygienist who has ever had a passion for preserving tooth structure, including me.

So yeah, this is bad news for Icon and for DMG, really. Sure, they got a CDT code this year but it’s not like anyone is going to use it. There’s like one dentist in a 5o mile radius that’s even ordered it around here. I know this because you can look on the DMG patient portal here and find a dentist that offers Icon in your area.

I have a challenge then. Actually two challenges – one for dentists, and the other for those who want to see this service added to the hygienist’s scope of practice in every state.

•If you’re a dentist and you love saving teeth, JUST DO THIS. Charge what you must, you’re not going to get rich, but you will have the warm fuzzy feeling that you’re doing the right thing by preserving tooth structure. We all know composites and amalgams eventually fail around their margins. There are no margins with an infiltration, just a lovely, arrested half-moon where an incipient lesion never progressed if you follow up with radiographs two decades from now (I may be exaggerating, but maybe not!). Go here, learn more, buy some.

•Those of you who are frustrated with dental hygienists wanting to become these mid-level providers that are supposed to help in low-access areas but will probably just come take your job away from you (I keed! I keed!) please support the use of infiltrants by hygienists. You will still need to diagnose that the treatment is needed but the service should be able to be delegated because of the very nature of the care being provided and the labor intensity needed for this smaller ROI.

As a realist, I don’t see squat happening as a result of this challenge. What can one blogger do? I have these silly dream glasses, when I put them on and see the future, well, there are no more cavities, on anyone, except arrested ones, and all the dentists are happy because all they have to do is play on the computer and nod their head every so often while their hygienists prevent all dental infirmities for ever and ever. Then I take them off again, and I see white spot lesions on teeth.

And I say…..dangit.

Thanks to Dental Products Report and The Catapult Group for this review of ICON from DMG America: http://www.dentalproductsreport.com/dental/article/review-catapult-group-delves-details-icon-dmg-america

Iraqi vets losing their teeth

February 12, 2013 By Trish Walraven Leave a Comment

Our local ABC affiliate ran an investigative story on TV today that made me think I was in the middle of a big CE lecture with blown-up pink on the edges and all white and brown in the centers. Dental closeups! Yeah, I should probably put a porn-type filter on my email box when those “identify this lesion” photos pop up because they are just so gross to look at when I’m not in my Dental Frame Of Mind.

I saw three severely decayed mouths in super-close detail on local television, and felt sorry for everyone eating lunch during their noon hour that caught the show, too.

The gist is that these men were serving in Iraq almost ten years ago and now all their teeth are rotting and breaking and hurting and the VA won’t pay to get them fixed up.

As much as you want to feel bad for these guys, and I do, there’s a big part of me wondering what questions aren’t being asked. They’ve never done meth, they don’t complain about severe dry mouth. That’s about all the evidence I heard. What about medications that may be causing an acid imbalance in their saliva? What are their soda habits? How well did they keep up with their dental care the first five years since Iraq?

Watch this video, or if you just want to get through this quickly and avoid an orthodontic commercial, go read the transcript here.

The station will be airing another segment tonight so I may post it online tomorrow that may answer some of these questions and get to the bottom of this Medical Mystery and our pathetic excuse of a government that lets this happen to innocent people (not necessarily my view, but possibly the witch that this investigative report is trying to hunt down).

I’d love to know your theories too, post them here, maybe we can all figure this out together with our Holmesian powers of deduction and ultimately solve this conundrum for these unfortunate men.

Update:

Here’s the second segment of this story (Go Dr. Beadle!) where stress is cited as a major factor in causing tooth loss. I guess it could, in a roundabout way. You’ll find the transcript of this story here, for those of you who aren’t in the mood for a movie.

Prosthetic joint wha-what?

December 19, 2012 By Trish Walraven Leave a Comment

Bendy fake joints may not be susceptible to the bacteria introduced during dental procedures after all.

According to a systematic review of the research involving prosthetic knees and hips conducted collaboratively by the American Dental Association and the American Academy of Orthopaedic Surgeons, it was announced yesterday that there was no increase in the odds of developing a prosthetic joint infection as a result of invasive dental procedures.

This means that the Antibiotic Prophylaxis Guidelines have been updated with some sort of vague blurburbmush gabble guhg that essentially states what I’ve been saying for YEARS! When patients ask why they have to choke down those four huge amoxicillin capsules an hour before their dental visit, my answer has been something along the lines of “because it protects the dentist against liability.” This has taken some tact, of course, with explanations of how open sores in the mouth allow bacteremias every time that a toothbrush pops open a pocket and causes untold blood-squirtage- these aren’t necessarily negotiated with daily doses of doxycycline. We’ve all realized it’s good homecare, not an antibiotic, that is the key to preventing oral bacteria from getting into the bloodstream and infecting artificial joints.

Thank you, ADA, for affirming the overkill of antibiotic prophylaxis.

For the rest of the story, here’s the link:

http://www.ada.org/news/8061.aspx

_________

Update 1/2/2015:

Antibiotic premedication for joints is still not recommended.This clarification was published by the ADA yesterday:

Background. A panel of experts (the 2014 Panel) convened by the American Dental Association Council on Scientific Affairs developed an evidence-based clinical practice guideline (CPG) on the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures. This CPG is intended to clarify the “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report,” which was developed and published by the American Academy of Orthopaedic Surgeons and the American Dental Association (the 2012 Panel).

Types of Studies Reviewed. The 2014 Panel based the current CPG on literature search results and direct evidence contained in the comprehensive systematic review published by the 2012 Panel, as well as the results from an updated literature search. The 2014 Panel identified 4 case-control studies.

Results. The 2014 Panel judged that the current best evidence failed to demonstrate an association between dental procedures and prosthetic joint infection (PJI). The 2014 Panel also presented information about antibiotic resistance, adverse drug reactions, and costs associated with prescribing antibiotics for PJI prophylaxis.

Practical Implications. The 2014 Panel made the following clinical recommendation: In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.

CONCLUSIONS

Evidence fails to demonstrate an association between dental procedures and PJI or any effectiveness for antibiotic prophylaxis. Given this information in conjunction with the potential harm from antibiotic use, using antibiotics before dental procedures is not recommended to prevent PJI. Additional case-control studies are needed to increase the level of certainty in the evidence to a level higher than moderate.

The entire content can be read here:

http://jada.ada.org/content/146/1/11.full

Update 1/2/2015:

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