The patient’s tongue can be seen incorrectly against her front teeth in the pics on the left compared to the pics on the right after she was asked to move her tongue to the back of her mouth. Habits must be considered as part of dental treatment.
I had lunch with a group of friends last month and I noticed a friend was missing a tooth! I asked him why and he said he was getting a bone graft and then a dental implant so his dentist and oral surgeon thought to leave him like that for the nearly twelve months the bone graft and then dental implant would take to heal. I told him to visit my office and I would give him a custom-shaded “fixed” temporary crown that is not removable. Total treatment time was less than one hour. Note this is NOT a flipper which is a “removable” temporary tooth. Avoid lazy dentists.
The Center for Special Dentistry® is a teaching dental practice. Dental students and young dentists from all over the world apply to our academic programs to study with us. In this photo students are learning about the cementation of Porcelain Veneers under the direction of Dr. Jeffrey Dorfman (foreground left) — and a Master Porcelain Ceramist (background center) who is personally present in case any modifications are needed. Note: all patients may opt for privacy but they rarely do because most are personally interested in learning. #PorcelainVeneers #MadisonAvenueDentistry #NYCosmeticDentist #dentalSchool #dentalInternship #dentalIntern
from The University of Pennsylvania School of Dental Medicine
“I personally recommend this course to all predental students.” — Dr. Jeffrey Dorfman
About the Course
In this course, you will learn basic dental anatomy, how to evaluate a patient and the causes and impact of oral diseases. We will use case examples and live demonstrations with patients.
The course will focus on four areas:
1 Review of modern aspects of dental medicine
2 Introduction of basic oral and dental anatomy and techniques of clinical examination of the oral and per-oral structures
3 Discussion of common disease processes affecting the oral cavity and peri-oral structures including a) dental and periodontal diseases, b) oral mucosal diseases, c) orofacial pain conditions
4 Demonstration of clinical cases, ranging from basic to complex, reflective of the common disease processes affecting the oral cavity and perioral structures
Eligible for Verified Certificate Statement of Accomplishment
7 weeks of study
WEEK ONE: Introduction to dental medicine including oral health related to general health, sources of infection, modern technology in dentistry and public health impact.
WEEK TWO: Basic dental anatomy including embryology of the oral cavity, oral functions, basic tooth structure and clinical implications of disease.
WEEK THREE: Comprehensive evaluation of the patient including medical history, with live demonstrations with patients.
WEEK FOUR: Dental and periodontal disease – their causes and contributing factors.
WEEK FIVE: Oral and mucosal disease focusing on anomalies, ulcers, cancer and other diseases.
WEEK SIX: Oral and facial pain from common conditions to rare ones including an exploration of psychological aspects of oral and facial pain.
WEEK SEVEN: Selected cases in dental medicine ranging from oral surgery to prosthetic reconstruction.
You will have the opportunity to learn from three of Penn’s respected dental medicine faculty. Each of the three professors will share his particular area of expertise. Live demonstrations with patients will help you see the techniques in practice.
HIPAA and the New York State Public Health Law require only that medical and dental records be destroyed in a secure manner, one of which is shredding or using a reputable shredding service to perform that function. Typically, the shredding company picks up the material at your office. However, it is permissible to deposit material in a secure receptacle that is not accessible to the general public, but only to the qualified shredding company personnel. You should have what is called a “HIPAA business associate contract” with the disposal company that spells out their responsibilities to maintain the security of the receptacles and the protection of the records from any disclosure prior to final destruction. You cannot just deposit records in a dumpster or a recycling box of some kind. You need to be confident that the particular company will keep the material secure and their deposit boxes are not accessible to any unauthorized persons. All of that should be in the HIPAA business associate contract. If they are familiar with HIPAA as they state, they should have a HIPAA business associate agreement on file that they can readily use. Otherwise, even if their box is secure, but somehow the records get out in the public view due to any negligence on their part, you will bear the entire burden for that event.
Acknowledgement: a very knowledgeable General Counsel friend
The most basic rule of tort law is that you are only responsible for that which you do personally and for what your employees do in the scope of their employment. Thus, if you put your name on something as an employee, but your employer alters it fraudulently without your knowledge, you are not responsible for that just because your name is on the item – but of course proving that you didn’t know about any change is not always easy (a good idea is to make a copy of the item before it leaves your hands and you never see it again until the authorities come calling). Where employer fraud is rampant, it sometimes becomes incredible for an employee to reasonably assert he or she was unaware of things in the absence of clear evidence otherwise. You can seek indemnification clauses in an employment contract so that an employer will have to pay for any damages, attorney fees, or civil penalties imposed on you as a result of the employer’s own actions – but few employers would agree to do that even if the employee insisted (who would want to start off on that foot with any employee paranoid over fraud?). Also, nothing can save anyone from government authorities who seek criminal fines or other criminal sanctions for something like Medicaid or insurance fraud. No indemnification or other contractual agreement will be enforced where it seeks to shield someone from criminal behavior. You are already shielded by the law from an employer committing fraud that you were completely unaware of and had no reason to be aware of. All you need to do is make sure that you can establish your unawareness credibly. Making copies of claims you sign is the easiest way. Randomly doing your own review of submitted claims is another way to monitor things. Carefully charting your work in the patient record is another check and even keeping your own separate claims ledger is an idea. Those things make it harder for an employer to take liberties by altering items because the back-up documentation clearly wouldn’t make it easy to argue pretend justifications for the alterations. But, and this is a matter of common sense, if you really think your employer is engaging in that kind of fraud, find another employer as quickly as possible.
Acknowledgement: a very knowledgeable General Counsel friend
Senior Associate Dean of The University of Pennsylvania School of Dental Medicine, Elizabeth Ketterlinus, visited The Center for Special Dentistry® today for lunch.
Dr. Kent is an Endodontist (Root Canal Specialist) at The Center for Special Dentistry® in NYC. He graduated NYU dental school in 1999 and completed his Specialty Certificate at Lutheran Medical Center. He has practiced Root Canal Therapy (Endodontics) with us in midtown Manhattan for nearly a decade.
Top 12 Ways People Can Become Educated Dental Consumers
by Dr. Jeffrey Dorfman*
People who visit a dentist should become educated about how to differentiate a good from bad dentist and how to differentiate good from bad dentistry. One can certainly search online for dentist reviews and/or learn about malpractice claims on various websites of dubious quality. People may also visit the dental office and read academic degrees and membership in professional organizations that are framed on the walls. This is totally inadequate. This article is an insiders view to dentistry written by a master clinician who has over 20 combined years of professorships at NYU and Columbia dental schools and who is also director of Advanced Dental Education at The Center for Special Dentistry® in NYC for almost 30 years. The dentistry he has personally seen and the stories he has personally heard from former students who are now in practice around the country is scary and sad.
One of the first questions a prospective dental patient should learn is how many years has the dentist been in practice? If the dentist is young is he/she working in an established practice with older more experienced dentists who appear to be interested in actual patient care? Or instead does the practice appear to be run by a non-dentist office manager that is owned by an absentee dentist? Is the office clean and do the treatment rooms appear to be sterile? Are instruments and dental drills removed from sealed clear plastic bags that have been subjected to real sterilization or does it appear that disinfection (not sterilization) is your best hope? Is fresh plastic wrapped around everything that might be touched? Do the dentist and staff wash their hands and put on fresh gloves, mask and eye protection before the procedure begins?
A good dentist is trustworthy, intelligent and knows his/her skill limitations. Trust implies that the dentist is looking out for the best interest of the patient instead of personal economic gain. Trust is something one feels intuitively, and given the lingering Great Recession, people should be even more aware that trust is something that should be earned before it is granted. Does the dentist photo document the work they plan to perform on you and if so are they willing to email those photos to you? Are x-rays taken every six or 12 months during teeth cleaning visits as allowed by your insurance plan? This is very common and is frequently performed much more often than necessary to help dentists recoup income lost by participation in managed care insurance plans. Are x-rays taken immediately by office staff – possibly under the direction of the office manager – instead of after careful consideration by the treating dentist?
Is significant treatment suddenly being suggested or even pushed? Is a thorough explanation offered for the need for such treatment? Do you think too many cavities are being discovered and that many of them need crowns instead of fillings? Is other possibly less lucrative treatment being ignored? For example, gum disease is commonly under diagnosed and under treated. Failure to diagnose and treat gum disease is a significant cause for malpractice claims. Don’t think you can drive to your dentist in your new Mercedes and talk about your family ski trip to Aspen and then expect him/her to be happy to accept your in-network managed care plan payments. Dentists and doctors are getting squeezed by the Affordable Care Act and many need alternative revenue streams while they also reduce costs. Consider participation in an out-of-network Fee For Service (FFS) plan rather than an in-network Preferred Provider Organization (PPO) plan if you can afford to do so. The significant difference in those fees is not made up by the insurance company but instead comes out solely from the dentist’s bottom line. That has to directly impact your treatment in terms of skills, materials and time.
An intelligent dentist need not be Ivy League educated. Instead he/she should possess the innate ability to make an accurate diagnosis and then, like a chess grandmaster, be able to see all possible treatment options before them. Surprisingly, the ability to properly diagnose a patient and see all subsequent treatment options can vary as widely as the skills one can notice watching 12 year olds playing Little League. Some kids can clearly play ball while others will probably give up at the end of the season; the majority of the Little Leaguers demonstrate middling skill. Dentistry is no different.
A good dentist should possess the communication skills to clearly articulate the diagnosis and also be willing to spend the time necessary to discuss treatment options. Treatment time, benefits and risks of treatment and cost should be discussed for all treatment options. Upon reaching a mutually agreed course of treatment a “treatment plan” should be written and signed. Ideally this should all be done with the treating dentist but it may not be possible in this age of managed care; frequently office staff are delegated this task. The question is then what is the qualification of the office staff to have this discussion and make appropriate treatment recommendations? It could be argued that anyone other than the dentist making treatment plan decisions with a patient is actually practicing dentistry without a license.
So let’s assume we have found the perfect honest and intelligent dentist who has a reasonable number of years experience and the office is spotless. The next question is do they have “hands?” Does the dentist possess the requisite eye-hand skills to carefully perform the dentistry desired by their own heart and mind? Let’s not forget the good student who becomes a dentist because it offers a wonderful lifestyle but they never considered the fact that they have difficulty replacing a light bulb at home. We all know those types of people and sadly many of them become dentists. Does the dentist discuss hobbies like playing a musical instrument, painting or sculpture, carpentry or playing sports at a higher level of skill? These hobbies are sought out by dental schools as one measure of an applicants potential eye-hand skills.
If we discover that this perfect dentist used to be a studio musician with Pearl Jam then the next question is time. Does the office schedule allow the dentist the necessary amount of time to carefully perform this dentistry or must they expeditiously run off to the next patient. Good dentistry requires time – and a little extra time if the initial work doesn’t turn out quite right and something needs to be redone. About 10% of my dentistry runs 50% longer than expected so I build that time into every appointment – just in case I need it. And while we are discussing time, consider this: the most common reason people don’t visit the dentist is because of fear. Novocaine takes time after the injection to get you numb. In my office I typically allow 15 minutes after the injection before I begin treatment in the lower jaw. Think of novocaine like a glass of wine. If you drink a glass of wine after work with your spouse you probably don’t immediately feel the relaxing effect immediately after the first few sips; it takes a few minutes.
Another question is whether an honest and intelligent dentist with good hands is capable of performing most specialty work himself/herself. In my opinion the answer is generally no. A skilled dentist may be reasonably skillful in one or several areas of specialty dentistry but a given specialist does nothing other than that specialty procedure all day long. How can you compare? The question then is the dentist willing to appropriately refer dentistry to specialists and thereby either lose, or have to share, the higher fee specialty dentistry? In many cases dentists perform their own specialty dentistry with results that are less than ideal for the patient.
So now you visit your perfect dentist who is sterile, honest, intelligent and has good hands. He photo documented all your treatment and appropriately referred you to, for a example, an endodontist (root canal specialist) before he proceeds to make your porcelain crown. All crowns are the same – aren’t they? Surprise, porcelain crowns can vary drastically in how they are made: the material composition, the skill and artistry of the individual porcelain ceramist, dental laboratory and even the country in which they are made. Many crowns made for patients in the USA are now made in China. Remember the problem with Chinese toothpaste and drywall a few years ago? Imagine that permanently cemented in your mouth. Then let’s hope it looks nice because it takes serious skill – and yes time – to make crowns fit well and look natural.
After 29 years of dental practice it still surprises me when potential patients call our office to ask the cost of a procedure as if showrooming via telephone is a good way to choose a doctor. “No, we are not a managed care dental office.”
*Dr. Jeffrey Dorfman is Director of The Center for Special Dentistry® in NYC and publisher of NYCdentist.com, a website containing over 4,400 pages of original free content.
This is an Example of Bad Dentistry
Was this the result of a dentist who was untrustworthy, unintelligent and who lacked “good hands” and the time to perform good dentistry?
Did this dentist perform the root canal specialty work himself/herself? Where were the crowns made?
1) There is a cavity under this crown. 2) There is a cavity under this adjacent crown. The root canal filling (arrows 3, 4 & 10) does not extend to the end of the tooth root (arrows 5, 6 & 11). 7) & 8) X-ray evidence of an active root canal infection in the jaw. Pain in this tooth was the reason for this new patient visit. He thought his dentist was his friend. 9) A poor-fitting prefabricated post. The molar tooth will likely need extraction and replacement with a dental implant and new crown. The premolar tooth will need root canal retreatment, a new post, possible gum surgery and a new crown.
I grew up as a dentist using EZ Dental and about ten years ago I moved on to Dentrix for the supposedly superior imaging. A few years ago Henry Schein, the corporate giant-owner of Dentrix, sold the imaging component to Danaher, the corporate giant-owner of Dexis. Now Dexis wants to resell me their updated imaging software that I thought I had already bought from Dentrix.
In January 2014 my local rep offered me this deal:
“The Dexis imaging integration would cost you half of the original price quoted. We would charge you our cost which is $3182 with tax the total would be $3452.47. I would then give you merchandise certificates totaling $952.47 which you would pay your regular Schein bill with. This would bring your cost down to $2,500.
The Dexis imaging package would include the bridges to Dentrix and ScanX as well as 4 hours of training. So you getting quite a bit more than just the imaging SW.”
I didn’t do it.
Today, Oct 6 2014, I was visited by both a Schein and Dexis rep. They gave me an upgrade price of $5,111.45 and said:
“..unfortunately we can no longer honor the offer that … had put together for you back in January as it was tied to your then level of merchandise spending with Henry Schein. We can however offer you the special discounted Dexis software bundle which will allow you to upgrade your current Dentrix Image software over to Dexis with full Dentrix Image conversion and on-site training. Please let us know if you’d like to proceed with this.”
I have dramatically reduced my overall spending with Henry Schein because they are no longer price-competitive. I will now look at different dental practice management software because this is horrible customer service. I wouldn’t recommend it to anyone.