Why live-patient courses are essential

Why live-patient courses are essential

By Helaine Smith, DMD, MBA

December 30, 2008 -- Editor's note: Helaine Smith's column, The Mouth Physician, appears regularly on theDrBicuspid.com advice and opinion page, Second Opinion.

"A Bridgeport jury has awarded more than $198,000 to a woman who claims her dentist promised her a celebrity smile, but gave her what her attorney called 'horse teeth.' " -- The Associated Press

The media loves stories like this one, which has caught the attention of many people. Although the public is more informed than ever concerning cosmetics, many patients still trust their dentist to deliver quality work.

I do not know any details about this case other than what I read. I do not want to speak out of turn about the named dentist. Instead, I want to use this case as an example to illustrate that you must take proper live-patient courses in order to do cosmetic dentistry successfully.

There are many ingredients to a cosmetic practice, but skill is the most important one. Using a trained ceramist in cosmetics is the second most important.

During the initial cosmetic consult, my trained eye is evaluating the face shape and teeth shape and visualizing what smile design would best enhance the patient. I am also actively listening to what the patient wants, and a "Hollywood smile" is not enough detail for me. What does that mean to the patient? Does it mean what I think it does?

All of this must be understood in order to tell the ceramists what the smile design will be. Study models are examined, and a diagnostic wax-up to proper golden proportion is preformed. If I sense any hesitation from the patient, a simple way to show the patient the final results is accomplished by laying over their existing teeth acrylic from a stent of the wax-up. This will show them what the teeth will be like in their mouth. Before I pick up my headpiece, I know where I am going with the case. It is not guess work.

Cosmetics is more than prepping teeth and bonding veneers. Here again, the expression "You do not know what you do not know" applies. I urge you to learn more and take a comprehensive cosmetic course at one of the leading institutions in the country. To be the best, you need to learn from the best, with a live-patient hands-on course.

The Las Vegas Institute for Advanced Dental Studies and the Rosenthal Institute offer curriculums like this. It is a big commitment of time and money to travel to one of these places, but you owe it to your patients if you claim you are proficient in cosmetics.

Patients are very educated today, thanks to the Internet, and in order to have a competitive advantage, you need be well-trained. I encourage all dentists in the new year to make a commitment to being better at what they do, whether it is general dentistry, a specialty, or cosmetics. Please be the best and strive to be a mouth physician at all times.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

Copyright © 2008 DrBicuspid.com

Electronic health records: Part I -- Boon or boondoggle?

Electronic health records: Part I -- Boon or boondoggle?

By Kathy Kincade, Editor in Chief

December 31, 2008 -- Valerie Powell, Ph.D., is on a mission.

The 70-year-old professor of computer science at Robert Morris University in Pittsburgh says the creation of an electronic health record (EHR) that combines both medical and dental data cannot wait until 2015.

That is when the U.S. National Health Information Infrastructure (NHII) is slated to be up and running, and doctors and dentists are expected to be in compliance with federal mandates regarding the adoption of EHRs.

“Our nation needs excellent chronic care, and to make this happen means ensuring that the dentists and physicians can communicate.”
— Valerie Powell, Ph.D.

A new study shows that dentists aren't moving fast enough to meet these requirements, and that usability of existing software products is the problem. Others argue that patient privacy and implementation costs are the real issues.

Either way, Powell -- who recently hosted a teleconference with dental and medical experts that resulted in a 40-page report on EHRs that is being submitted to Tom Daschle, the nominee for secretary of the U.S. Department of Health and Human Services -- is adamant that EHRs must be adopted ASAP. There are too many chronically ill people who need dentists and physicians to start communicating now, she says.

Foremost among these patients are diabetics, a population she became very familiar with in her second career as a radiology technician. In fact, the correlation between periodontitis and diabetes is a prime example of why physicians and dentists should be sharing information sooner rather than later, argues Powell, who serves on a Pennsylvania task force that deals with the problem.

"Our nation needs excellent chronic care, and to make this happen means ensuring that the dentists and physicians can communicate," she said. "People are dying. This is urgent now."

Practitioners balk

The merits of transitioning to a paperless medical and dental office have been touted for years: increased efficiency, better care, fewer mistakes, the ability to track a condition over time or access patient information anytime, anyplace, anywhere -- the list goes on and on.

And once the NHII is in place, its designers and developers envision "regional collaborations among healthcare entities, including dentists and other healthcare practitioners, so that a patient's information can be securely stored in the local community and made electronically accessible to all healthcare providers involved in treatment of a particular patient," according to the ADA Web site.

And yet, adoption among the medical and dental communities remains low. According to a study published last month in the Journal of the American Dental Association, "In both medicine and dentistry, practitioners in solo and small-group practices have been slow to adopt CPRs (computer-based patient records). ... In dentistry, 25 percent of all general practitioners in the United States used a computer in at least one of their operatories in 2005. ... However, as of 2005, only 1.8 percent of general dental offices maintained patient records almost completely on the computer, suggesting a low adoption rate of CPRs" (JADA, December 2008, Vol. 139:12, pp. 1632-1642).

Building from previous research that suggested usability might be the issue, researchers from the University of Pittsburgh Center for Dental Informatics and New York University College of Dentistry evaluated four commercial practice management software products -- Dentrix (Henry Schein), EagleSoft (Patterson Dental), Kodak SoftDent (Carestream Health), and Kodak PracticeWorks (Carestream Health/PracticeWorks) -- to assess the ease of usability of their charting interfaces.

Working with four full-time dental faculty members, eight practicing dentists, and eight senior dental students from the university who all had computer (Windows) experience but no dental CPR familiarity, the researchers concluded that all four systems have "significant usability problems for novice users, resulting in a steep learning curve and potentially reduced system adoption."

The authors noted that "several lessons for the future design and redesign of dental CPR systems emerged from our analysis of design features responsible for usability problems." For example, task flow and models in the CPR systems "should be aligned more closely with common practice," and data entry and retrieval controls "should correspond with the tasks to be completed, while unrelated or extraneous controls should not be shown."

Two of the vendors whose products were part of the study -- Patterson and PracticeWorks, a subsidiary of Carestream Health -- took some exception to the findings (Henry Schein did not respond to our requests for comment). In particular, they noted that the study was done in a laboratory setting without the subjects receiving any training.

"Because our software is so robust and has to be able to accommodate the functionality of many different offices, part of our training is not just teaching users how to use the software but seeing how each office functions and setting up the software so it flows naturally for them," said Jana Berghoff, corporate technology manager at Patterson. "If you just sit down [at the computer] without a trainer, it might not feel so intuitive."

PracticeWorks U.S. CEO Patrik Eriksson agreed. "The research did not have a training component to it, so there is a difference between what was researched and what a normal customer would experience," he said, adding that the company is taking the study's findings "to heart" and that it is time to "redesign the way that software works."

In addition, the company has released two versions of PracticeWorks since the study was conducted, noted Larry Greenspan, vice president of development at PracticeWorks.

"There have been 572 enhancements to our products this year, and these are all customer-requested enhancements," he said.

One vendor that was not part of the study believes the JADA study is not so much about the software but about the users of clinical records.

"I think the most important aspect of this article is that there is a need to standardize clinical data so it can be exchanged between all offices," said Mark Hollis, president of MacPractice, the only Mac-based practice management and EHR system on the market. "Our highest priorities in product design have to do with flexibility and customizability. This allows us to recreate the model and the forms an office is accustomed to. You have to get people to buy into wanting to change, so the more your electronic system reflects what they are familiar with in a paper system, the easier the transition."

Tom Cockerell, D.D.S., agrees.

"In my opinion, the conclusions the researchers draw are not really that important in the clinical setting. From a pure research point of view, where data accumulates beginning with the ground floor, it is good to have this information," said Dr. Cockerell, a practicing dentist in Fort Worth, TX, and founder of an Internet-based patient record system company called Dental Symphony. "But it doesn't provide much value in answering the overriding question: why, after 30 years of computer records being available, do only 2% of dentists use them to manage patient care? Their conclusion is that usability is keeping dentists from adopting electronic records to manage patients, but there are bigger overriding issues."

In part II of this series, we look at how patient privacy, legacy software, and a lack of return on investment are also impeding adoption of electronic health records.

Study: Oral bisphosphonate risks higher than reported

Study: Oral bisphosphonate risks higher than reported

By Rabia Mughal, Contributing Editor

January 2, 2009 -- A University of Southern California (USC) study published in this month's Journal of the American Dental Association has found that the risk of osteonecrosis of the jaw (ONJ) in patients who have undergone oral bisphosphonate therapy could be higher than currently believed. Even short-term use can leave some patients vulnerable, according to the researchers.

“These results make a significant difference in the counseling and management of
patients on oral bisphosphonates.”
— Peter L. Jacobsen, Ph.D., D.D.S.

Most journals say the risk of osteonecrosis is negligible with oral bisphosphonates, but there is not enough data to back up this claim, said Parish Sedghizadeh, D.D.S., the director of the USC Center for Biofilms and one of the study authors, in a DrBicuspid.com interview.

"We found that approximately 4% of the patients who had a history of alendronate use developed osteonecrosis of the jaw," he said.

"These results make a significant difference in the counseling and management of patients on oral bisphosphonates," said Peter L. Jacobsen, Ph.D., D.D.S., the vice chairman of the ADA Council on Scientific Affairs. "The risk shown by this article is about two orders of magnitude higher than found in prior studies."

All healthcare providers and susceptible patients need to be made aware of the risks, he added.

But Merck, the maker of the oral bisphosphonate drug Fosamax, said in a written statement to DrBicuspid.com that the study is flawed, limited, and not a reliable source for valid scientific conclusions.

"Data from randomized, prospective clinical trials are the gold standard and are more reliable than data from studies like the one published in JADA," the company stated. "In controlled clinical trials involving more than 17,000 patients, contributing as much as 10 years' data with alendronate, there have been no reports of ONJ. This includes approximately 3,000 osteoporosis patients taking alendronate for 3 to 5 years and approximately 800 patients taking alendronate for 8 to 10 years."

The initial correlation between the use of oral alendronate and ONJ was not considered statistically significant by an expert panel appointed by the ADA Council on Scientific Affairs in 2006. The panel suggested then that routine dental treatment generally should not be modified solely on the basis of oral bisphosphonate therapy, the USC study authors noted.

Their recommendation was reaffirmed in 2008.

"We conducted a study to address the finding that in a patient population at the University of Southern California in Los Angeles, ONJ secondary to alendronate therapy is more common than suggested by the manufacturer and the ADA's expert panel," the authors wrote.

The study, which appears in the January issue of the Journal of the American Dental Association (January 2009, Vol. 140:1, pp. 61-66), was conducted at the USC School of Dentistry. It included 208 patients with a history of alendronate use, nine of whom had active ONJ and were being treated in USC clinics.

None of the patients was referred for evaluation or treatment of ONJ, excluding the possibility of referral bias, the authors noted.

Of the 208 patients, 66 underwent simple dental extraction without treatment modifications or preventive measures, and four developed ONJ at the extraction site postoperatively. Another five developed ONJ after denture-related mucosal ulceration.

The patients who developed bisphosphonate-associated osteonecrosis were all women between the ages of 63 to 80 who had received alendronate for osteoporosis for 12 months or longer.

Osteoporosis affects more than 10 million Americans, and alendronate is the most widely prescribed oral drug; it was the 21st most prescribed drug on the market in 2006, the authors noted. Despite these numbers, there are no epidemiologic data or research to support the risk of developing ONJ after its use, they added.

"Our data suggest that the risk of developing ONJ is much higher than initially reported," the authors noted.

This is not the first study of risk/incidence of ONJ in patients taking oral bisphosphonates, but it is the first to measure patients directly, explained Dr. Jacobsen.

The other studies estimated the risk from physicians voluntary reporting in the U.S. (which has a high risk of underreporting), physicians reporting in Australia (where such reporting is required, rather than voluntary, so the numbers are considered more accurate), or computerized analysis of insurance claims data with no patients or physician involvement, he added.

"If the current study holds up and future studies in other centers document its accuracy, then the prior study methods have appreciably underestimated the risk," Dr. Jacobsen emphasized.

Dental treatment implications

These findings clearly have implications for dentists working with patients who have a history of oral bisphosphonate use.

Alternate treatment options may be considered for unnecessary extractions, and good oral hygiene should be achieved before necessary extractions to minimize microbial load, according to the study authors.

They also recommend more routine and vigilant follow-up and use of chlorhexidine rinse preoperatively and postoperatively.

"Patients should get a dental consult before starting oral bisphosphonate therapy," Dr. Sedghizadeh said. "There should be comanagement of such patients by dentist and physicians, and it is important that they are involved in the informed consent process."

It is also important to identify patients who are at risk and focus on risk assessment and prevention protocols, he added.

"Most of the patients receiving alendronate at USC who developed ONJ did so after routine tooth extraction, suggesting that perhaps these patients should be identified as an at-risk population and preventive measures should be taken," the study authors noted.

There is a need for more studies in this area, Dr. Sedghizadeh said. People will say the risk may not be negligible if more studies like this come out, he added.

More science is needed to better understand why some patients get ONJ and others do not -- as well as what can be done to minimize the likelihood of this serious condition among susceptible patients, Dr. Jacobsen noted. This kind of patient-based data is what the ADA has said is needed all along, he emphasized.

Additional studies will be needed to better delineate the risk across the entire population of alendronate users, he concluded.