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here Are The Doctors?
by Dr. Jeffrey Dorfman
(Published in Dentist Quarterly - The official publication of the New York County Dental Society - March 2000)

I attended the Bear Stearns 12th Annual Health Care Conference that was scheduled to run from September 15-17, 1999 at the Waldorf-Astoria Hotel in New York City. There were over 1200 registered attendees and over 150 speakers representing all kinds of healthcare companies. I was one of very few doctors who was invited to attend. I was asked to leave.

I was asked to leave because I asked two questions. Will insurance companies like Aetna and Wellpoint respect the request of the American Dental Association and stop using ‘usual, customary and reasonable (ucr)’ terminology in dealing with patients and instead use ‘maximum plan allowance.’ The reason for this request is that there is no such thing as a usual, customary and reasonable fee; there is tremendous variation of reimbursements for a given procedure even within the same insurance company based upon the specific policy purchased and premiums paid. To use such terminology raises distrust in the mind of the patient regarding their doctors fees.

…

These are legitimate questions that must be answered if doctors are to become involved in the evolution of healthcare delivery in our country. Investment bankers and their investors should not consider doctors merely a variable cost in healthcare and in need of paternalistic employment. We should be considered equal partners and invited to attend these conferences. Healthcare is much more than the pathetic representation of revenues and income growth as shown at this conference.

The author’s complete article may be found at: http://nycdentist.com/phpBB2/viewtopic.php?t=97#top

Read The Wall Street Journal article.

“As recently as September, Oracle Chief Executive Larry Ellison declared that online software companies “haven’t figured out how to make money.”"

–There is a way for software companies to make money offering online software and that is through bundling it with other more profitable revenue streams.

“Oracle currently has a net profit margin of 24.6%. In contrast, online software company Salesforce.com Inc. has a net margin of just 4.4%, though it spends a higher percentage of revenue on sales and marketing.”

–An online software company that offers a competitive product at a great price and that dominates all related worldwide urls in a category could inexpensively market itself online with a skeleton ‘sales and marketing’ budget.

“Overall, online software is estimated to account for just $9.5 billion of the $284 billion businesses will spend on software this year, according to research company IDC. But online-software sales are rising more than 40% a year compared with 3.4% for software overall.”

–Imagine combining free online software (charging only an inexpensive connection fee and optional support), EMR (electronic medical records) and vertical integration to improve the delivery of healthcare. It is being created and will have a competitive advantage.

Read The Wall Street Journal article.

“Consolidation in the online health world has become more common in recent months as sites fight for scarce advertising dollars.”

Relying on scare advertising dollars is only one business model for online health information websites to offer free information. www.1dentist.com and it’s 500 affiliated dentistry urls has profitably followed a free content model that hasn’t relied on advertising for over a decade. We believe vertical integration in free online health care is the future and that is how we are growing: bricks & mortar practices, in-house web content creation, in-house SEO, in-house clinical education and free 1dentist cloud software for EMR.

Read The Wall Street Journal article.

Today I observed an orthodontic braces consult with a teenage tv celebrity. He had orthodontic treatment previously but #10 had relapsed to its original position because of failure to wear his retainer. The patient had also developed a crossbite in both canine areas.

Normally, for a patient who has not complied with previous treatment an orthodontist would opt for fixed braces, however this patient presented a unique case. Being a singer and celebrity, the patient needed something that would be esthetic for performances and television time. In dental school we are taught about creating an “ideal” treatment plan, and then alternatives if the patient cannot choose the ideal plan for whatever reason (cost, esthetic issues, etc). The ideal treatment plan is generally created on scientific foundations. However this case shows us that this plan cannot be created just on science alone.

If we don’t have compliance, science can be thrown out the window. Fixed appliances are definitely the best scientifically, and best for the orthodontist because they can be assured of usage. But it would not allow this patient to continue his life normally, since he is a celebrity. The dentist has to treat the person, not just the teeth! In this case, the challenge was not moving #10 back, but doing so without affecting the patient’s career activities.

Clearly with this patient it would not be possible to put anything fixed onto the buccal surfaces of his maxillary teeth. That really left two options, a spring aligner or Triple Star trays. Once the treatment objective was attained, a bonded lingual retainer would be placed from #7-10.

How to treat the mandibular teeth, in particular the anterior crowding, became a topic of debate. When on stage, the patient’s mandibular teeth would not really be seen, usually only the incisal thirds of the teeth, so a wire could be placed without being seen during singing or other activities. The patient was apprehensive, but made the decision with his father to go through with it, because he understood realistically he would need a fixed appliance for the mandible. He was informed that it was better to do it now, rather than when he would be older, and the teeth could have move even further from ideal positioning.

Also Dr. Dorfman explained to him that at any point in his treatment he could opt for one of the alternative treatments. Nothing was irreversible, appliances could be taken off, and this went a long way to reassuring him that his singing and acting activities would be able to go ahead as planned. Also Dr. Dorfman examined his bite once again and found that the lower anteriors would need to be sculpted in order to place the lingual retainer from #7-10.

So the final treatment planned that both father and son agreed to was:

Maxillary arch- a spring aligner or Triple Star trays to align #10 followed by fixed bonded lingual retainer (#7-10)

Mandibular arch- fixed appliance to align lower anteriors with sculpting followed by bonded retainer

It is important to note that the treatment plan was signed by the father today. The patient often comes here without his father, and usually with someone else, such as an assistant. So it was very important to get the father’s consent before starting any of the work. Finally at the end of the visit, alginate impressions were taken, and the patient was told he would need to return to have some sealants placed and begin the orthodontic treatment.

Interestingly at the end of the appointment, when the patient was about to leave, he mentioned that he had problems with his jaw locking on opening. There are many possible causes to his locking. Being young and still growing can contribute to jaw locking by abnormal growth patterns. Chewing gum can definitely cause TMJ issues, and of course being a singer extra care must be taken with his TMJ health. So on his next visit, he will get an oral surgery consult in addition to having sealants placed and a PAN taken.

R.A., Columbia University School of Dental Medicine

This afternoon I observed an orthognathic surgery consult in a high end practice. I was familiar with orthognathic surgery from Columbia’s emphasis on medicine and high reputation in oral and maxillofacial surgery. However this was the first time I had really witnessed a consultation for orthognathic surgery in a very practical setting.

A 28 year old female patient presented to the clinic because she was unhappy with her facial proportions. She had orthodontic treatment for 2 years prior, but was unhappy with her prominent upper lip, retruded lower lip, and also mentioned that she was unhappy with her nose being too wide (despite having a previous rhinoplasty).

Seeing this patient reinforced how important it is to take a good history of the patient. This patient in particular had a history of plastic surgery, included the rhinoplasty, so right away one has to be aware that she is going to be very particular about the results. Often patients like these change their minds, so even if the surgery gives her what she wants, she may be unhappy with it at a later point in time. It is important for the surgeon not to make guarantees, and to thoroughly advise the patient on their options.

The consulting surgeon was simply brilliant in the manner he conducted his consult. This oral surgeon is an attending at Columbia and I have met him before. However this was the first time I got to see the wealth of his knowledge in full action. He is a very powerful presence but he listened to the patient and all her needs and concerns. He then advised her on the possible options, however the patient was still adamant that she wanted to have her maxilla retruded. The oral surgeon was very honest with her and explained that women pay thousands of dollars to have her full look. He pointed out that if you retract the maxilla, the soft tissues will fall back as well, and she would lose that youthful look that she naturally has.

One of the most impressive parts of his consultation was that he was still very knowledgeable about general dentistry. He took two sets of impressions and was very proficient at taking them for an oral surgeon!

He found two issues from his exam and consult:

1. Deficient mandible/class II skeletal discrepancy

2. Wide alar base

His best treatment plan at this point was mandibular advancement via BSSO (bilateral saggital split osteotomy) along with an alar cinch to address the patient’s issue with the width of her nose. The alar cinch procedure was an intriguing option and gave the patient an alternative to getting another rhinoplasty. He  explained to the patient that an oral surgeon can go intra-orally with the alar cinch procedure which is more effective and does not produce the scarring that is possible from a rhinoplasty performed by a plastic surgeon. He explained that plastic surgeons are limited in what they can do because they cannot work intra-orally.

The patient finally became convinced that it was not a good idea to touch the maxilla, and mandibular advancement was the best solution. The oral surgeon didn’t shoot her down right away, and he advised her to choose between the given choices. However he took it step by step, until the patient saw the benefits of a less invasive approach.

The patient would also have a consult with the orthodontist because she would probably need brief orthodontic treatment after the surgery to adjust the bite so it is properly aligned.

R.A., Columbia University School of Dental Medicine

I have seen a significant switch from patient payments using Amex to VIsa/Mastercard as their cash back programs expanded. I would have suggested to Yahoo to use a cash back model for purchases for a lot less than the $72 million they wasted on advisors when they rejected Microsoft’s offer last year.

Read the Wall Street Journal article.

Netbooks are the key to Electronic Medical Records. We are working on it.

Read the Wall Street Journal article.

Periodontal disease is a multifactoral problem, and cannot always be answered by the traditional methods of mechanical debridement (scaling and root planing) and periodontal surgery. Although in most cases,  debridement and improvement of oral hygiene can do wonders, unique cases always arise which leave periodontists baffled.  What happens when you have a 30 year old patient, with no radiographic calculus or significant plaque buildup but has severe bone loss and 8mm pockets? Clearly debridement of the pockets isn’t going to work. Understanding the microbiology of periodontal disease is of increasing importance to the general dentist and working with specialized labs is vital to the successful treatment of the disease.

The Oral Microbiology Testing Service (OMTS) at Temple University School of Dentistry was designed specifically to assist dentists with identifying and treating difficult cases of periodontal disease. It is one of only 4 state and federally-licensed clinical periodontal microbiology reference laboratories in the United States.

The process:

How do you get the culture?
The dentist should first use college pliers and a cotton pellet to wipe away supragingival plaque. Then a medium cotton point should be placed into about six different sites with the deepest periodontal probing depths. The cotton point should be left in for 5 to 10 seconds and then quickly placed in the culture medium, which is then sent to the lab.

Once the lab has the culture, they incubate and culture it. This is done in a one to two week period in a special chamber that replicates the conditions of the area of the mouth in which the bacteria grows.

After the culture is grown , it is examined by microbiologists and  the types of bacteria are identified. Then an antibiotic sensitivity test is performed on all the species of bacteria that were found. The pathogens were divided into groups depending on their known associations with periodontal disease. An acceptable critical % threshold level was given for each species of bacteria. The % of cultivable microbiota for each species from the sample was then compared against the given markers. For example if the acceptable threshold level for a certain species was 2.5% but the level found in this sample was 5.6% then the conclusion would be that there were elevated proportions of that species.

Antibiotic sensitivity tests were performed for 4 major antibiotics commonly used to treat periodontal pathogens. This bodes well for the patient because specific antibiotic therapy can be given to the patient in addition to dental treatment.

Clinical Scenario:
A patient presented to Dr. Dorfman’s office recently with severe periodontal disease and acute necrotizing ulcerative gingivitis (ANUG) on the lingual aspect of #27,28. The patient was treatment planned for 4 quadrant scaling and root planning,

The patient was previously treated with amoxicillin and metrodiazanole, two commonly prescribed antibiotics for periodontal pathogens. However, the lab results showed that many of the periodontal pathogens found were resistant to both antibiotics. The head of the lab at the OMTS suggested the use of Cipro to target the gram-negative bacteria that were found to be in significantly higher levels than expected.

R.A., Columbia University School of Dental Medicine