SEPTEMBER 2016
Pulp
Fiction
Top Ten Myths of the Primary Dental Pulp.
Tips
MEDICAL
on restoring badly broken-down anterior teeth
EMERGENCIES Sedation and Medical Emergencies in the Pediatric Patient.
Improve your technique while learning some yiddish vocabulary.
more on Page 32
10
ESSENTIALS
For a dynamic, successful pediatric practice. more on Page 40
You're covered A Q&A with Industry Experts on Expanding Insurance Coverage for Prefabricated Zirconia Crowns. Page 28
PROGRAM DESTINATIONS FOR 2017
DALLAS 1/27
DENVER 2/24
ATLANTA 3/31
LAS VEGAS 4/21
CHICAGO 5/12
EZPU EZPEDO UNIVERSITY
2017
HONOLULU 6/23
PHILADELPHIA 8/4
SAN FRANCISCO 11/3
SCOTTSDALE 12/8
EZP ED O M ag azi ne / S e pt e m be r 2016
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Table of Contents
50 I N F LUENC E How I found my unique
40
humanitarian role in story telling.
10 ESSEN TIA LS For a dynamic, successful pediatric practice.
28 YOU ’RE C OV ER ED A Q&A with industry experts on expanding insurance coverage for prefabricated Zirconia crowns.
20 P ULP F IC T ION Top ten myths of the primary dental pulp.
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TABLE OF CONTENTS
58
—
Pages 15–17 W H AT PA R E N T S A R E LO O K I N G F O R
TIPS ON RESTORING BADLY BROKEN-DOWN ANTERIOR TEETH
BY KARALEE – KARI'S MOM One mom's experience finding a dentist for her kids.
Improve your technique while
Page 18
learning some Yiddish vocabulary.
HELPFUL HINTS BY SARAH JOHNSON What an assistant tries and do for her doctor to make things go just a little smoother.
Pages 20–27 PULP FICTION BY JAROD JOHNSON, DDS Top ten myths of the primary dental pulp.
Pages 28–31 YO U ' R E CO V E R E D EZPEDO INTERVIEWS INDUSTRY EXPERTS A Q&A with industry experts on expanding insurance
32 MEDIC A L EMERG ENC I ES Sedation and medical emergencies in the pediatric patient.
coverage for prefabricated Zirconia crowns.
Pages 32–39 MEDICAL EMERGENCIES B Y D AV I D R OT H M A N , D D S Sedation and medical emergencies in the pediatric patient.
Pages 40–47 10 ESSENTIALS B Y C AT H Y J A M E S O N , P h D For a dynamic, successful pediatric practice.
Pages 50–57 I N F LU E N C E B Y D A N I E L VA K A R Y U K How I found my unique humanitarian role in story telling.
Pages 58–59 T I P S O N R E S T O R I N G B A D LY B R O K E N - D O W N ANTERIOR TEETH B Y L E V I PA L M E R , D D S Improve your technique while learning some Yiddish vocabulary.
15 WHAT PA R E NTS ARE LO OK ING F OR One mom's experience finding a dentist for her kids.
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EZPEDO
EZPEDO KNOWS PEDIATRIC ZIRCONIA CROWNS BETTER THAN ANYONE.
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EZPEDO
EZPEDO IS HELPING AN INDUSTRY TRANSFORM FROM LEGACY TO NEXT GENERATION TECHNOLOGY.
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Contributors Jarod Johnson, DDS
Aubrey Gooden is a communications professional based in Boston. She is a graduate of Oklahoma State University and earned her master’s degree from New York University. Currently she is a senior director at Gooden Group.
David Rothman, DDS
Sarah Johnson
David Rothman, DDS, is a board certified pediatric dentist in practce in San Francisco and associate clinical professor at CWRU. He completed GPR and anesthesia residencies prior to his specialty training. He is past chair of pediatric dentistry at UOP and active in organized dentistry. He is a member of OKU, Pierre Fauchard, ICD and ACD. He speaks on pediatric dentistry, anesthesia and sedation.
Daniel Vakaryuk Daniel Vakaryuk born in the small European country of Moldova, now resides in Loomis, California, where he works for EZPEDO as a digital media specialist. Prior to joining the EZPEDO team, he worked as a freelance storyteller. Whether doing videography or photography, his passion has always been behind the camera, sharing the unique stories of people from all different regions of the world.
Cathy Jameson, PhD Cathy Jameson, PhD, is founder of Jameson Management, a management, marketing and hygiene coaching firm, helping dentists and teams increase productivity and profitability. As a speaker, she delivers entertaining and educational programs to audiences worldwide. Cathy is a best-selling author. Her most recent title is Creating a Healthy Work Environment.
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Aubrey Gooden, MS
Jarod Johnson, DDS, earned his Bachelor of Science in biomedical engineering and Doctor of Dental Surgery from the University of Iowa. He recently completed a certificate in pediatric dentistry at The University of Nevada, Las Vegas, School of Dental Medicine. He is currently working in private practice in Muscatine, Iowa.
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Sarah Johnson works as a dental assistant with Dr. Joelle Speed at the Smile Gallery in Roseville, California. She has enjoyed working chair side with children for the last 15 years. Sarah and her teenage daughter love the outdoors and share an active lifestyle.
Karalee – Kari's mom Karalee wrote “What Parents Are Looking For” to share her personal experience in finding a dentist for her kids and her perspective on what a parent looks for when searching for a dentist.
Levi Palmer, DDS Dr. Levi Palmer, DDS, acquired a degree in nutrition from UC Davis. After two years of surgical research at the UC Davis Medical Center, he completed his dental degree at USC School of Dentistry. He took his pediatric dentistry residency at the University of Colorado Children’s Hospital. Dr. Palmer practices in Chico, California, where he lives with his wife and two children.
Keeping Your Eyes Open LIFELONG LEARNING THROUGH CONTINUING EDUCATION
Have you ever thought to yourself how amazing it would be if you could actually remember everything you have ever learned over your lifetime? The reality for most of us is that if we don’t use it ... we tend to lose it. This is one of the main reasons those of us in healthcare professions are required to take continuing education courses. In practice, we tend to get really good at the things we do every day. It may be the way our front office operates when interacting with patients, their parents, or third-party insurance carriers. Or it may involve a particular procedure or technique that we do on a daily basis. We become so accustomed to our routine, that, as the saying goes, “we could do it with our eyes closed.” This day-in and day-out, “eyes-closed” repetition, although for the most part helpful, may prevent us from mentally focusing on those areas of our practices which might potentially benefit from further growth. As you’re scanning the pages of this EZPEDO Magazine, take note of a variety of topics that may help you “open your eyes” and improve your practice. Check out our cover story on insurance coverage for pediatric Zirconia crowns (pg 26) or Cathy Jameson’s article dealing with 10 essential strategies designed to create a dynamic, successful practice (pg. 38). David Rothman reminds us all of the safety our patients deserve and highlights strategies for handling common in-office emergencies (pg 30). Jarod Johnson discusses common myths associated with treating the pulp in primary teeth and the science that addresses these beliefs (pg. 18). Finally, Levi Palmer shares some practical insight on dealing with advanced cases of early childhood decay (pg. 54). The goal of this publication is to bring topics of relevance and importance to practicing dentists who treat pediatric patients. More than ever before, our patients’ parents are educating themselves on techniques and current treatment options available for their children. Continuing education is important to all of us, forcing us to keep our eyes open—a crucial step in staying abreast of the latest advances in science and clinical technique that will enable us to provide the very best possible treatment for our patients.
CONTACT US EZPEDO MAGAZINE Vol. 2 No. 2 | September 2016
PUBLISHER EZPEDO, Inc.
A:
6140 Horseshoe Bar Road, Suite L
Loomis, CA 95650
P:
+1 (888) 539 7336
INT:
+1 (916) 677 1447
E:
info@ezpedo.com
W:
www.ezpedo.com
M A G A Z I N E S TA F F JEFFREY FISHER, DDS Editor-in-Chief JAMES FISHER, MSPH, PhD Senior Consulting Editor ANN FISHER Copy Editor D A N N Y VA K A R Y U K Art Director T I M OT H Y S H A M B R A Senior Designer
C O N T R I B U TO R S
Aubrey Gooden, MS Cathy Jameson, PhD Daniel Vakaryuk David Rothman, DDS Jarod Johnson, DDS Jeffrey Fisher, DDS Karalee – Kari's Mom Levi Palmer, DDS Sarah Johnson
If you have any comments about our current issue or suggestions for topics to include in future issues, please send them to me at editor@ezpedo.com. I’d love to hear from you.
D I G I TA L E D I T I O N www.ezpedo.com/publications
For new subscriptions, subscribe at ezpedo.com. For all other reader services, including letters to
Jeffrey P. Fisher, DDS Editor-in-Chief
the editor, write to editor@ezpedo.com.
EZP ED O M ag azi ne / Se pt e m be r 2016
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S O C I A L NETWORK
PEOPLE, PLACES, AND PARTIES
AAPD
John Hansen conducting a mini-EZPU course Lindsey Robinson, Jeffrey Fisher
Parker White
Jeffrey Fisher, Andrew Shannon, Daniel Vakaryuk (right)
Cynthia Cacho, Christel Haberland (right)
A future member of AAPD with her mom
GOOD TIMES
This year’s AAPD and EAPD annual meetings were held in San Antonio, Texas, and Belgrade, Serbia. These events were a lot of fun and a great opportunity to connect with friends.
Katie Woehling, Jovas Booker
Brenda Hansen
Alfred Burns with his son, and Vladimir Shcherbak
EAPD
Vladimir Shcherbak, Brenda Hansen, Carly Harrison
Mark Foster, Yakim Lahai, Oksana Oksenyuk, Natalia Popova, Alina Sitdikova
Arne Jacobsen and Brenda Hansen
SPECIAL MOMENTS
It was an absolute joy to spend quality time with a sizeable number of pediatric dentists. You are a loving, caring group of human beings, and we at EZPEDO highly value the care you are providing for our next generation of pediatric patients.
Serena Lopez Cazaux, Paloma Prieto and Gordana Brostovski
Brenda Hansen, Natalia Popova, Veronika Marie Vilimek
A children's choir entertaining guests at the Belgrade City Hall
E V E N T S 2016
DOCTOR TO DOCTOR A dedicated husband and proud father of four beautiful children, Dr. Cameron Quayle is a pediatric dentist with private practices in both Farmington and Pleasant View, Utah, and a proud user of EZPEDO pediatric Zirconia crowns.
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“When I began using EZPEDO crowns, I realized I could look parents in the eye and tell them, These crowns will look amazing.’” ’
CAMERON QUAYLE, DDS
Mountain View Pediatric Dentistry 2719 N. Highway 89, Suite 200 Pleasant View, Utah 84414 801.737.5437
991 Shepard Ln #100 Farmington, Utah 84414 801.447.5437
themoosedentist.com
EZP ED O M ag azi ne / S ept e m be r 2016
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EZPU 2017 Destinations.
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KNOWN GLOBALLY. LOVED LOCALLY. Instruction and inspiration for pediatric dental professionals from the pioneers of pediatric Zirconia crowns and the innovative leaders forging tomorrow's New Generation Technology. Learn more about our proven innovation, and discover how to use EZPEDO crowns to help grow your practice.
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Atlanta
Karalee, with her children.
What Parents Are Looking For
One Mom’s Experience Finding a Dentist for Her Kids. BY KARALEE – KARI'S MOM
K
ari is a girl featured recently in an EZPEDO Magazine ad, and Karalee is her mom. During a recent visit, we asked Karalee a number of questions to get her perspective on what a parent looks for when searching for a dentist. Her responses were so insightful we felt obligated to share her thoughts with you.
Which dentist do you take your kids to? This is the question every parent asks, or is asked, at some point. Providing a response should be so simple, but I have learned after my experience with three kids, it most certainly is not. Searching for a dentist that is the right fit for your family definitely takes some time and thought. When I was little, we all just went to the family dentist that our parents went to. Now, it's a whole different story. One change is that we now have so many pediatric dentist offices to choose from. Some offices have video games; others have playrooms. Some have large rooms with multiple chairs for the hygienists; others provide movies, toys—you name it! In this environment, making a choice can be quite the experience.
So how does a parent decide? For me, I felt asking trusted friends and neighbors was a great way to start. Some may find consulting social media to be a good source of suggestions and reviews. For the most part, the feedback is generally positive and helpful. But narrowing down choices can still be difficult, because everybody's experience is unique and different, and there are plenty of opinions out there. A third option is to just try out an office and see for yourself.
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What was your own experience choosing a dentist? What I discovered for myself personally is that there is no one-size-fits-all with dentistry. I looked for an office and atmosphere that matched my child’s personality. With my first child, the videos and stimulation at the pediatric office were really overwhelming for him, and it just made things more difficult. We ended up going the small family practice route, and it worked really well for him. My younger two are a different story. The girls love the kid-friendly nature of the pediatric office. They love having toys to play with while waiting, the movies, and all the action! And now that my son is older, he's fine with that as well. Good relations with the front-office staff are absolutely important. First impressions are so important. They may not always be accurate, but sometimes that's all it takes to make or break the experience. You start with them and you finish with them. As a parent, I want to go in feeling comfortable and walk out content! The most important thing for me is having confidence in the dentist. I have learned that trusting my gut is the best answer. Using this tactic, something nearly universal in parenting, is probably the most important factor, one I think we often overlook. When it feels right, and it's a good fit, I have confidence. My kids feel that, and have an overall sense of security. That, for me, is key.
Your current dentist wasn’t the first one you went to. How did you end up with your current dentist? So, when my son Seth was around 18 months old, I took him in for a cleaning. We went to the office I described earlier, the one with all the video games, climby things, etc. It was also where they had a room with 10 or 12 hygienist chairs. The whole situation was really overwhelming for my son. They attempted to do a cleaning (which wasn't even as thorough as the teeth brushing that I was doing), and by the time they were done with that, the dentist barely took a look in his mouth. To add insult to injury, I had to write a $275 check for a cleaning and check-up. A year later, when I went back, I specifically asked if the dentist could look at his teeth first, because I felt like Seth never even got a thorough check-up the first time. I didn't want to spend my money again on something that didn't happen. Then I asked if maybe we could perform the check-up in a private room, because I felt like Seth was really overwhelmed in the big room with all the other hygienists. I was given one excuse after another why this wasn't usual. Finally, they suggested maybe he would do better in their "teen room" where there was less going on. Next, they suggested I go around the corner and act like I'm just stepping away for a minute, because he might do better if I wasn't there. I obliged. I wasn't comfortable doing this, and I don't think Seth was either, but I trusted them. As I was standing around the corner, I overheard
the hygienist, in a very harsh tone, tell him, “Your mom isn't going to come back until you let us do what we need to do.” It was at this point I came back, took his hand, and left, after calmly taking the dentist aside and giving her a piece of my mind. To be honest, it was such a bad experience that I didn't go back to any dentist for six years. When I did, we had two more rather upsetting experiences with two other dentists. So I took another two-year break until all the trouble with my daughter Kari's teeth got too bad to ignore. That’s when I met Dr. Vicki. Things went well, but then for financial reasons, we made another change which led to another really bad experience. So I finally concluded that, regardless of cost, I was going to follow my gut. We went back to Dr. Vicki, and we’re staying with her. I trust her, and her office is the only one where I have felt at peace.
What are some of the things you like about Dr. Vicki’s office? I think my favorite is the up-to-date, latest technology. I can't tell you what a difference it made. For example, with X-rays, Kari would have nothing to do with the sharp plastic object being shoved between her teeth. She absolutely flipped out. Magic Smiles used a tiny little camera that she was not only intrigued by, but was also absolutely cooperative with. The same thing with nitrous. Having a little colored and scented disposable mask (not sure what they're called!) is far less intimidating than a big gray one with tubes attached to a huge machine. These things might not matter to all kids, but they made all the difference in the world to mine.
Is there anything you don’t like about the visits? I guess there were two things that put me off about my particular experience at Magic Smiles. First, I felt uncomfortable when we talked about the wording on the anesthesia form. Mostly because I was already struggling with the reality of the situation, and I felt like the decision for her to have anesthesia was based simply on the reasonable fear a 4-year-old would be feeling. So when I read on the form, "Your child may need anesthesia because they are not cooperative," it just put me off a little. The other difficult thing is accepting the board they strap the little ones to. That always puts me off, but that's just a personal issue for me. I realize some parents don't want to spend the money or take the risk of sedation, so using this device may be their only answer. But, as I mentioned before, the most important thing for me is having confidence in the dentist. I trust Dr. Vicki and her staff. I feel comfortable and valued there. My kids feel that confidence, too, and have an overall sense of security. That, for me, is key and explains why we won’t go anywhere else.
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Work HELPFUL HINTS
THINGS THAT SHOW ASSISTANTS CARE
1. THINK AHEAD
by Sarah Johnson
OFTEN IT IS TRUE IN LIFE THAT THE LITTLE THINGS TEND TO GO UNNOTICED. READ WHAT A FEW RDA’S TRY AND DO FOR THEIR DOCTOR EACH DAY TO MAKE THINGS GO JUST A LITTLE SMOOTHER.
Anticipate your doctor’s next two moves.
2. LISTEN AND REMEMBER Communication is key. If you're working as a new assistant or working with a new doctor, ask questions to find out what they prefer. You might find they have different expectations from what you're used to.
3 . PLAN FOR EFFICIENCY Be prepared. The appointment starts with you. Make sure your room is set up and know who your patient is – their fears, and how their visit went before. Your doctor is only as prepared as you are.
4. CONTROL THE APPOINTMENT Especially in pediatrics, it's easy for parents to try and take over the appointment, sometimes without you even knowing it. Set your expectations with the parent in the beginning, so they can be prepared. It sets the tone for the visit.
5. MANAGE TIME WISELY One of my essential tasks is to keep my doctor on time. It also shows the parent/patient you respect their time. Always know how much time you have for each procedure.
6. RESEARCH NEW PRODUCTS One of the things our office prides itself in is new technology. I try to keep up with research about new products to help our team be more efficient. It's important to stay relevant.
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WE’D LOVE TO CONNECT WITH YOU.
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FACEBOOK.COM/EZPEDO
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(888) 539.7336
EZPEDO EZP ED O M ag azi ne / S e pt e m be r 2016
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In the ever-changing world of dentistry, we are constantly being faced with the decision to stay with the status quo or try and navigate the waters of innovation and change. This article discusses some of the questions surrounding pulpal treatment in the pediatric dental patient.
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Pulp Fiction Top Ten Myths of the Primary Dental Pulp. By Jarod Johnson, DDS The primary dental pulp is challenged mostly by trauma or carious insult. Historically, the vital primary pulp has been treated with a Formocresol pulpotomy, and the vital permanent pulp with calcium hydroxide in the form of a direct pulp cap to avoid root-canal therapy.1,2 Recently in the last two decades, developments in materials, led by mineral trioxide aggregate, have forced providers to reconsider materials used in vital pulp therapy.3 As pediatric dentists and general practitioners, we continually seek to improve our clinical success by using new materials and techniques as they are developed. To do this, we must constantly be evaluating our treatment outcomes and stay up-to-date with the current best evidence available in the pediatric dental field. The purpose of this article is to review common misconceptions about the primary dental pulp as it relates to carious lesions and traumatic dental injuries.
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Ten Myths about the Pulp
*May be true
1.
2.
An asymptomatic pulp is a healthy pulp.
Some of the most difficult pulpal challenges we face as dentists treating children are the symptoms that patients experience while bacterial infection progresses. This pulpal response occurs with varying clinical manifestations. The American Academy of Endodontists has two classifications of irreversible pulpitis4— asymptomatic and symptomatic—making diagnosis of asymptomatic pulps challenging. Diagnosing irreversible pulpitis in children is further complicated by the fact that pulp testing in primary teeth is unreliable, and children and parents may be poor historians of symptoms.5 A recent study with permanent teeth correlated clinical diagnosis with histological diagnosis. For reversible pulpitis, histologic and clinical diagnosis matched 96 percent of the time; for irreversible pulpitis, the results matched only 84 percent of the time.6 Pulpal necrosis can also occur after symptoms have vanished, further leading to a possibility of incorrect diagnosis. While our preoperative diagnosis will match reality a majority of the time, even asymptomatic pulps may still mask unhealthy conditions. Correct clinical diagnosis may also change over time for primary teeth due to the difficulties previously mentioned. To further compound the task of making a correct diagnosis, a recent study found that young permanent teeth diagnosed with irreversible pulpitis were actually capable of healing.7 By definition, irreversible pulpitis means a pulp that is incapable of healing. So how can this be possible? To gain a better understanding, we must evaluate the histological response of the pulp to dental caries. The understanding of caries progression and the reaction of the dental pulp is a well-understood phenomenon. As caries progress, the pulp begins to undergo changes in response to bacterial infection. As lesions appear in enamel, changes in the odontoblast layer occur first, where it becomes less cellular and more disorganized. As the carious lesion continues to grow three-quarters of the way into dentin, reparative dentin becomes evident. The odontoblast layer is reduced, and vascularity increases in the pulp. Finally, once bacteria have infected the pulp, coagulative necrosis occurs, and the body elicits a response to the bacterial infection. Lymphocytes, macrophages, and polymorphic neutrophils proliferate adjacent to the necrosis. Deeper in the pulp, the response is similar to that occurring in the dentin. Interestingly, the radicular pulp remains normal in some instances.8 The key evidence that allows for our pulp treatment to be successful is the presence of healthy pulp tissue in the radicular pulp; this is the basis for pulpotomies in the primary and permanent dentition. If one is in doubt of the pulpal status in a child, caries removal and evaluation of the pulp tissue should be performed.
Formocresol is superior to other medicaments for pulpal therapy in primary teeth.
Formocresol Formocresol has been considered the gold standard for primary teeth pulpotomies for many years.9 Formocresol works by mummifying the pulp stumps, causing pulp necrosis with hopes of leaving a small amount of vital tissue in the root apex.10 Studies have associated teeth treated with Formocresol pulpotomies with expedited exfoliation and internal resorption.11 Critics have also cited carcinogenicity and mutagenicity as concerns associated with its use, while proponents have maintained it is safe to use until viable alternatives exist.12,13 Multiple studies have shown other materials perform just as well as Formocresol. The Handbook of the American Academy of Pediatric Dentistry notes that ferric sulfate, mineral trioxide aggregate (MTA), sodium hypochlorite, and laser treatment all have equivalent results when compared to Formocresol.11 More studies are needed to determine if some of these materials may be superior to Formocresol. Mineral trioxide aggregate has been shown to have promising results.14 ProRoot MTA Within the last few years, many bioceramics have entered the market led by the development of ProRoot MTA.3 ProRoot MTA is by far one of the most studied materials in the class. MTA is similar in composition to Portland Cement and contains tricalcium silicate and dicalcium silicate. Its mechanism of action is the release of calcium ions which combine with phosphate ions in the blood stream to form hydroxyapatite. It is biocompatible, has a high pH which provides a supportive environment for dentin formation and a negative environment for bacterial growth. The material sets with hydration from water (four hours), and has been known to cause a grey discoloration of teeth.14,15 MTA has demonstrated a high success rate in pulpotomies. A recent study which compared groups treated with Formocresol and MTA, reported clinical success and radiographic success of 96.9 percent / 84.4 percent respectively for Formocresol and 100 percent / 93.9 percent respectively for MTA at two years. No statistical difference was found between all the groups compared in the study.16 A second study found MTA to perform better than Formocresol at two years (97 percent clinical success verses 85 percent). In the same study, MTA had even better radiographical results with 88.6 percent success verses 54.5 percent for Formocresol.17 Numerous other MTA products have entered the market; however, there
IRM
IRM
MTA
Carious Lesion Tertiary Dentin Infected Pulp
Coagulation Necrosis
Dentin Bridge
Fixated Pulp
Vital Pulp
Affected Pulp
Vital Pulp MTA Pulpotomy
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Formocresol Pulpotomy
may be changes in composition, which may make them perform differently than MTA. Aside from pulpotomies in primary teeth, MTA can be used in multiple dental applications. It can be used in teeth for direct pulp caps, partial pulpotomies, pulpotomies, apexification, perforation repair, obturation, retrograde endodontic fillings, and regenerative endodontics. The diverse number of uses and the clinical track record make it a valuable material to have in the dental office.3,15 Biodentine Biodentine is a tricalcium silicate with a calcium chloride solution. It forms a putty-like substance which is considered by some clinicians easier to place. The setting time is 10 minutes compared to four hours for MTA.18,14 It comes in a form which is titrated to mix, which may provide a more consistent mix than MTA. Biodentine has been studied clinically in both animals and humans. It has been shown in one study to form dentin bridges which are thicker than those of MTA. A group of 28 premolars planned for extraction underwent non-carious pulp exposures and pulp capping with Biodentine and MTA. The teeth were extracted and evaluated histologically. Both groups showed clinical and histological success, and no statistical difference was found between the two groups.19 In pulpotomies, Biodentine has recently shown similar results to MTA at 18 months; clinical success was 95.24 percent and 100 percent respectively.20 A six-month study comparing Formocresol and Biodentine showed no difference in 56 pairs of teeth.21 One factor to consider is that cost may be prohibitive in the primary dentition as the auto-mix capsules cannot be dosed for multiple uses. Currently, Biodentine shows promise given the limited clinical follow-up required and is a viable alternative to Formocresol and MTA. However, more research is warranted with pulpotomies in the primary dentition. TheraCal LC TheraCal LC is a resin-based product that contains calcium silicates. It currently is not FDA approved for pulpotomies, but has been used off-label.22 TheraCal DC is another calcium silicate product that was recently discussed at the American Academy of Pediatric Dentistry annual session.23 Both of these materials lack long-term evaluation in a clinical setting. Specifically, TheraCal LC’s depth of cure is 1.7 mm and reaches a physiologic pH after seven days.24 It has been shown to release calcium ions, and it exhibits higher cytotoxicity to pulp cells in vitro, approximately 10 percent cell viability compared to 70 percent for MTA.25 TheraCal LC currently has not been studied in any long-term clinical trials, but has been shown to create dentin bridges at 28 days in primates.26 Resin products have been shown to have cytotoxicity that provides low-grade tissue irritation, but they allow for pulpal healing in the absence of bacteria and adequate coronal seal as discussed previously.27 The author’s opinion is that, due to a number of concerns, TheraCal LC should be limited to use in indirect and direct pulp therapy, as other viable and cost-effective medicaments exist. The author’s concerns are related to the following items: 1) cytotoxicity, 2) ability of a resin product to create an adequate coronal seal, 3) the recommendations of the manufacturer, and 4) the lack of clinical studies involving the primary dental pulp.
3.
A tooth treated with a crown requires a pulpotomy.
It is a misconception that primary teeth treated with Zirconia or stainless steel crowns need to have pulpal therapy. Some believe that the amount of reduction required to seat a Zirconia crown would cause an iatrogenic pulp exposure. This belief is not true. The amount of reduction required for an EZPEDO crown is approximately 2 mm; this is the same ideal depth a provider would prepare when restoring with an amalgam restoration.28, 29 There are many reasons why a provider may select to treat a tooth with a crown and not perform a pulpotomy: 1) decay on the mesial surface of a primary first molar, 2) three or more surfaces of decay, 3) decay on a hypoplastic molar, 4) treatment of a high-caries-risk patient, and 5) treatment of patients under sedation or in an operating room setting.11 Literature supports the conclusion that stainless steel crowns have consistently outperformed Class II restorations in the primary dentition.30 More evidence is needed to compare Zirconia crowns to stainless steel crowns, but short-term studies have shown equivocal results.31
4.
Teeth treated with pulpotomies that exhibit rarefying osteitis are a clinical success.
One of the possible outcomes to any treatment in dentistry is failure. Failures of Formocresol pulpotomies are estimated to range from three to 38 percent.11 Failures can be asymptomatic and may only be apparent radiographically. The proper diagnosis for these situations with rarefying osteitis is previously initiated therapy with asymptomatic apical periodontitis.4 An endodontist would not consider calling an asymptomatic tooth with a radiolucency after root-canal therapy a success. Nor should pediatric dentists consider an asymptomatic tooth with a radiolucency after pulpal therapy a success. Those teeth that exhibit apical or furcal radiolucencies should be treated by pulpectomy or extraction with subsequent space maintenance if necessary. Internal resorption should be monitored radiographically, and if perforation occurs, extraction should be the treatment of choice.
Tooth #L has been previously treated with a pulpotomy. The patient is asymptomatic and a furcal radiolucency is evident. The diagnosis for #L is previously initiated therapy with asymptomatic apical periodontitis, and extraction and space maintenance is planned due to root resorption.
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Ten Myths about the Pulp
*May be true
5.
Teeth treated with a pulpotomy should be restored with composite resin if parents want a white tooth.*
The success of pulpal therapy is dependent on three factors: 1) healthy tissue being present, 2) absence of a microbial flora, and 3) an intact coronal seal. Kakehashi, et al demonstrated in rats that teeth after pulp exposures without restorations could exhibit dentin bridging and healing if no bacteria were present.32 Moreover, a study comparing surfacesealed restorations (amalgam, zinc oxide eugenol, composite) concluded that the major determinates of healing were absence of microbial flora and an intact coronal seal.27 The American Academy of Pediatric Dentistry guidelines on pulpal therapy indicate that teeth treated with pulpal therapy should receive coronal coverage unless the tooth is expected to exfoliate in two years or less.33 Thus, parents who desire a long-term esthetic solution for coronal coverage should have their children treated with Zirconia crowns. If the tooth is expected to exfoliate in less than two years, a composite restoration may be placed.33
6.
Pulpectomies are more successful than pulpotomies on anterior primary teeth.
Three studies have been identified comparing pulpotomies to pulpectomies in anterior primary teeth. The most recent study was conducted at Baylor University, Texas A&M Health Science Center, and published in 2012. The randomized controlled clinical trial compared two groups, each composed of 37 teeth. Patients in one group received a pulpectomy, and patients in the other group received a Formocresol pulpotomy. After 23 months, radiographic success was 89 percent for the pulpotomy group, and 73 percent for the pulpectomy group. No statistical difference was found between the two groups. The other two studies that were identified by the author had a low sample size (12 per group), and used a low concentration of Formocresol (1.5 percent) with some teeth restored with composite restorations which may not have provided an adequate coronal seal.34
7.
A dark anterior primary tooth requires pulpal therapy after trauma.*
The most common age for dental trauma in the primary dentition is 1 to 3 years of age when children are learning to walk.35 Treatment at this time can involve behavioral issues that challenge practitioners as children may be pre-cooperative or uncooperative for dental treatment. Common sequelae following trauma involve discolored primary teeth. Discoloration can occur as a dark-colored tooth, or a yellowing of the tooth. Yellowish color is a result of calcific metamorphosis and the pulp laying down more dentin as a response to trauma. Discoloration can also be a greyish hue as the result of blood products staining dentin. No treatment is indicated in either of these cases unless pathology is present. The darkening of teeth after trauma was evaluated at Hebrew University and Hadassah School of Dental Medicine in Jerusalem in a study based on a change in policy. Prior to the policy change, primary teeth with discoloration were treated with root-canal therapy. After the change, teeth without clinical or radiographic pathology received only clinical and radiographic re-evaluation. No statistical difference was found between the two groups in relation to the eruption timing, path, or calcification of the permanent tooth. The study concluded that, “Root-canal treatment of primary incisors that had changed their color into a dark-gray hue following trauma with no other clinical or radiographic symptom is not necessary, as it does not result in better outcomes in the primary teeth and their permanent successors.� Teeth with darkening should be periodically reevaluated clinically and radiographically for pathologic changes.36 Tooth #S was successfully treated with an MTA pulpotomy and EZPEDO Zirconia crown.
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8.
Pulpectomies are less successful in primary teeth due to the complex anatomy of the roots.*
Primary teeth display variations in anatomy similar to those of permanent teeth. These variations can appear as lateral or accessory canals, variations in size and shape of the canals, and anatomical variation of the apex. The root-canal system is no more complex than in permanent teeth; however, the response to bacteria make for more anatomical challenges.37 When the pulp forms more dentin in response to carious insult, more calcifications occur, and cleaning and shaping become more difficult. It should also be noted that once root resorption occurs in primary teeth, the number of accessory canals increases, and elimination of the bacteria flora becomes more difficult.38 Pulpectomies have been reported to be highly successful with proper cleaning and shaping in the absence of resorption.39 Pathologic changes due to caries or trauma may make treatment of the root-canal system in primary teeth more complex.
9.
Sodium hypochlorite is dangerous to use in pulpectomies in primary teeth.
Sodium hypochlorite has been used effectively in endodontics to disinfect root canals. Its properties make it useful to dissolve organic matter and kill microorganisms. Low concentrations (less than 1 percent) will effectively dissolve necrotic tissue and deactivate microorganisms without dissolving vital tissue.5 Concentrations as high a 5.25 percent have been advocated for use in primary teeth.38 Many clinicians are fearful of a sodium hypochlorite incident or of causing damage to a permanent tooth due to apical extrusion. Sodium hypochlorite has been used safely in regenerative endodontic procedures with permanent teeth where canals and the apical foramen are much wider than in primary teeth.40 Use of a sidevented needle, staying 2−3 mm short of working length of teeth with wide apical foramens, and caution to never allow the needle to bind, will allow for the irrigant to be used safely with primary teeth.5
10.
Primary teeth with localized swelling cannot be treated successfully with a pulpectomy.
Teeth with apical pathology often present difficult decisions for clinicians. The offending tooth and the child’s stage in growth and development play key roles in determining treatment during the decision-making process. Primary canines and primary second molars may play a more strategic role in the mouth than other teeth. Loss of a primary canine would require extraction of the contralateral canine to prevent a midline shift. Similarly, loss of a primary second molar presents difficulties for clinicians if it occurs prior to the eruption of the permanent first molar, thus leading to difficulties with placement of a distal shoe.41,42 Use of space maintainers may also create clinical difficulties. A retrospective study evaluating 301 space maintainers between 1991 and 1995 showed a failure rate of 63 percent.43 A pulpectomy can alleviate the need to use a space maintainer if the tooth is maintained and infection is eliminated.
Prior trauma with root resorption evident on #E and #F, with large carious lesions. EZPEDO crowns were placed on #D, #E, #F and, #G, and they were treated with Biodentine pulpotomies due to vital tissue remaining. NOTE: Apical radiolucencies evident on #D and #E, and a widened periodontal ligament on #F. Primary teeth with resorption should be considered strong candidates for extraction.
The primary pulp dental infection can be treated similarly to infection in the permanent tooth. Pulpal debridement followed by obturation with a resorbable material can successfully treat the localized dental infection. The pulpectomy success rate can be correlated with the amount of preoperative resorption. Those primary teeth with no resorption had a success rate of 91.7 percent; those with minimal resorption (< 1mm) had 82.8 percent, and those with excessive resorption (greater than 1 mm) had 23.1 percent. No statistical difference was detected between incisors and molars treated with pulpectomies during the study period.39
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Deep carious lesion on #K (irreversible pulpitis after caries removal) was treated with an MTA pulpectomy due to the lack of a succedaneous tooth. The tooth is successfully maintained at six months and will be re-evaluated with radiographic follow up. Note no furcal pathology.
Conclusion My father, who is an endodontist and academic instructor, once stated, â&#x20AC;&#x153;Half of what we teach you in dental school will be wrong.â&#x20AC;? While the statement may hyperbolize, it has instilled within me the belief that we should constantly evaluate our treatment outcomes and adapt as a profession. This belief holds true with regards to vital and non-vital pulp therapy in the primary dentition. As practitioners who treat children, we should all seek to be lifelong learners and stay up-to-date with the current best evidence and practices within our profession.
Ten Myths about the Pulp
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1. Sweet C. Procedure for Treatment of Exposed and Pulpless Deciduous Teeth. J Am Dent Assoc. 1930;17(1):1150-1153. 2. Stanley H. Pulp capping: Conserving the dental pulp - Can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol.1989; 68(5):628-639. 3. Ford T, Torabinejad M, Abedi H, Bak land L. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc. 1996;127(10):1491-1494. 4. American Association of Endodontics. AAE Consensus Conference Recommendation Diagnostic Terminology. J Endod. 2009; 35:163-164. 5. Hargreaves K, Cohen S, eds. Cohen's Pathways of the Pulp. 10 ed. St Louis: Mosby; 2011. 6. Ricucci D, Loghin S, Siqueira J. Correlation between Clinical and Histologic Pulp Diagnoses. J Endod. December 2014; 40(12):1932-1939. 7. Qudeimat M, Alyahya A, Hasan A, BarrieshiNusair K. Mineral trioxide aggregate pulpotomy for permanent molars with clinical signs indicative of irreversible pulpitis: a preliminary study. Int Endod J. 2016. 8. Massler M, Pawlak J. The affected and infected pulp. Oral Surg. 1977;43(6): 929-947. 9. Frankl S. Pulp therapy in pedodontics. Oral Surg. 1972;34(2):293-309. 10. Chandrashekhar S, Shashidhar J. Formocresol, still a controversial material for pulpotomy: A critical literature review. J Rest Dent. 2014;2(3):114-124. 11. American Academy of Pediatric Dentistry. The Handbook of Pediatric Dentistry. 4th ed. Chicago: American Academy of Pediatric Dentistry; 2011. 12. Lewis B. The obsolescence of formocresol. J Calif Dent Assoc. February 2010;38(2): 102-107. 13. Milnes A. Persuasive Evidence that Formocresol Use in Pediatric Dentistry Is Safe. J Can Dent Assoc. April 2006;72(3):247-248. 14. Eidelman E, Holan G, Fuks A. Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: a preliminary report. Pediatr Dent. 2001;23(1):15-18. 15. Bogen G, Kuttler S. Mineral Trioxide Aggregate Obturation: A Review and Case Series. J Endod. 2009;35(6):777-790. 16. Yildirim C, Basak F, Akgun O, Polat GG, Altun C. Clinical and Radiographic Evaluation
of the Effectiveness of Formocresol, Mineral Trioxide Aggregate, Portland Cement, and Enamel Matrix Derivative in Primary Teeth Pulpotomies: A Two Year Follow-Up. J Clin Pediatr Dent. 2016; 40(1):14-20. 17. Airen P, Shigli A, Airen B. Comparative evaluation of formocresol and mineral trioxide aggregate in pulpotomized primary molars--2 year follow up. J Clin Pediatr Dent. 2012;37(2):143-147. 18. Septodont. Package Insert 19. Nowicka A, Lipski M, Parafiniuk M, et al. Response of Human Dental Pulp Capped with Biodentine and Mineral Trioxide Aggregate. J Endod. 2013;39(7743-47). 20. Rajasekharan S, Martens L, Vandenbulcke J, Jacquet W, Bottenberg P, Cauwels R. Efficacy of three different pulpotomy agents in primary molars - A randomised control trial. Int Endod J. 2016. 21. El Meligy O, Allazzam S, Alamoudi N. Comparison between biodentine and formocresol for pulpotomy of primary teeth: A randomized clinical trial. Quintessence Int. 2016;47(7): 571-580. 22. Bisco. Instructions for Use 23. Cannon M. New Biologic Material for Pulpotomy Treatment- research and Clinical Protocol. Paper presented at: American Academy of Pediatric Dentistry Annual Session, 2016; San Antonio. 24. Camilleri J. Hydration characteristics of Biodentine and Theracal used as pulp capping materials. Dent Mat. 2014;30: 709-715. 25. Poggio C, Ceci M, Dagna A, Beltrami R, Colombo M, Cheisa M. In vitro cytotoxicity evaluation of different pulp capping. Arh Hig Rada Toksikol. 2015;66:181-188. 26. Cannon M, Gerodias N, Viera A, Percinoto C, Juardo R. Primate pulpal healing after exposure and TheraCal application. J Clin Pediatr Dent. 2014;38(4):333-337. 27. Cox C, Keall C, Keall H, Ostro E, Bergen holtz G. Biocompatibility of surface-sealed dental materials agains exposed pulps. J Prosth Dent. 1987;57(1):1-8. 28. EZPEDO. Step-by-step Instructions. Technique - EZPEDO. 2016. Available at: https:// www.ezpedo.com/technique.html. Accessed July 19, 2016. 29. Chandra S, Chandra S, Chandra G. Textbook of Operative Dentistry. New Delhi: Jaypee Brothers Medical Publishers Ltd; 2007.
30. Randall R. Preformed metal crowns for primary and permanent molar teeth: review of the literature. Pediatr Dent. 2002;24(5):489500. 31. Holsinger D, Wells M, Scarbecz M, Donald son M. Clinical Evaluation and Parental Satisfaction with Pediatric Zirconia Anterior Crowns. Pediatr Dent. 2016;38(3): 192-197. 32. Kakehashi S, Stanley R, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surgery, Oral Medicine, Oral Pathology. 1963;20(3):340-349. 33. American Academy of Pediatric Dentistry. Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. Pediatr Dent. 2014;36. 34. Howley B, Seale S, McWhorter A, Kerins C, Boozer K, Lindsey D. Pulpotomy Versus Pulpectomy for Carious Vital Primary Incisors: Randomized Controlled Trial. Pediatr Dent. 2012;34(5):112-119. 35. Malmgren B, Andreasen J, Flores M, et al. International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 3. Injuries in the primary dentition. Dental Traumatology. 2012;28:174-182. 36. Holan G. Long-term effect of different treatment modalities for traumatized primary incisors presenting dark coronal discoloration with no other signs of injury. Dental Traumatology. 2006;22:14-17. 37. Weiss A. A Review of Endodontic Treatment in Primary Teeth. The Journal of Pedodontics. 1980;4(3):225-265. 38. Albert L, Goerig C, Camp J. Root canal treatment in primary teeth: a review. Pediatr Dent. 1983;5(1):33-37. 39. Coll J. Predicting pulpectomy success and its relationship to exfoliaton and succedaneous dentition. Pediatr Dent. 1996;18(1):57-63. 40. American Association of Endodontists. AAE Clinical Considerations for a Regenerative Procedure. Chicago, 2016. 41. Noar J. Interceptive Orthodontics: A Practical Guide to Occlusal Management. West Sussex: John Wiley & Sons; 2014. 42. Ngan P, Alkiire R, Fields H. Management Of Space Problems In The Primary And Mixed Dentitions. J Am Dent Assoc. 1999;130:13301339. 43. Qudeimat M, Fayle S. The longevity of space maintainers: a retrospective study. Pediatr Dent. 1998;20:267-272.
references
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YOU'RE COVERED A Q&A with Industry Experts on Expanding Insurance Coverage for Prefabricated Zirconia Crowns
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hough consumers would stand in line for an innovative new technology that solves a problem or promises to improve their quality of life, insurance companies, on the other hand, move at a snail’s pace. Getting insurance companies and state insurance programs to adopt a new dental technology can be much like plowing concrete– frustrating, tedious and out right baffling. The process is usually convoluted as several experts can attest. But, here’s the good news: it is not impossible. Insurance coverage for Zirconia crowns like EZPEDO has come a long way, but it still has a way to go. We spoke with experts across the dental industry about the challenges, process and landscape of the complex insurance ecosystem surrounding this groundbreaking technology. Here is their advice for dentists and parents.
"Insurance coverage for Zirconia
crowns like EZPEDO has come a long way, but it still has a way to go. " Why is understanding insurance important for dentists and patients? Cathy Jameson: Insurance has changed drastically over the last decade,
and knowing how to manage insurance is an essential business capability of a dental practice. The American Dental Association (ADA) tells us that on average more than 50 percent of revenues for practices come in the form of insurance reimbursement checks, and for some practices that number is closer to 70 percent.
Brenda Hansen: It’s clearly important for dental practices to understand
insurance, but it is equally important for parents and patients to understand insurance. Typically, you see changes to insurance plans annually. It’s important to familiarize yourself with any changes to your plan—it could mean better coverage for better technology, something every family should take advantage of.
When it comes to insurance, what are the biggest challenges you see for practices? Roger Levin: One challenge is that reimbursement from many insurance
companies is declining. We are seeing a trend going from classic indemnity insurance to the PPO level which is often about 15 percent lower in reimbursement to the doctor. Another challenge is the submission process. Practices have to submit using the right codes. They are pretty good at this, but, unfortunately, they don’t always get it right, so it takes more time, effort and more overhead to support the overall process.
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Cathy Jameson, PhD Founder, Jameson Management, Inc.
What is the process to garner coverage for a new dental procedure and material? Charles Blair: The first step is to get an insurance code by meeting a
Paul Reggiardo, DDS Pediatric Dentistry for Infants, Children and Adolescents.
David Stanley, DDS Wild About Smiles! Pediatric Dentistry
scientific bar. The American Dental Association and the code committee will review information about the new dental procedure and verify that it’s not experimental and that it has scientific success to back it up. Over a period of two to three years, the code will become more commonplace as demand increases. Every time a code can be used and put through the system, the odds are the better it will be accepted by insurance companies.
Paul Reggiardo: The code really is the first step in establishing legitimacy.
Codes are important so that the dentist can record in the patient record the exact service provided. Without a code, you can’t record the procedure and the third party reimbursement is hindered. It has to be established that there is a reasonable delivery of the service. By the time the code is issued, that procedure has been done in significant numbers and by a significant number of providers.
How are new codes established? And once established does that mean insurance will cover it?
Roger Levin: Establishing a new code is extremely difficult. We have
seen new procedures receive codes, but typically it takes some level of widespread use by the profession and time. You don’t just get a code overnight.
Paul Reggiardo: Requests for coding can be made by any dentist, any
Charles Blair, DDS Founder & CEO, Dr. Charles Blair and Associates, Inc. & Founder, Practice Booster
Charles Blair: A newer code, such as D2929 for Zirconia crowns, must
Nolan Gerlach, DDS Bellevue Pediatric Dentistry
Brenda Hansen, BS Executive Director, EZPEDO, Inc. & John P. Hansen DDS, Inc.
member of the public, a specialty organization, or the American Dental Association’s own Council on Dental Benefit Programs. It’s a very open process. Once a procedure code is adopted, then third-party benefit carriers make a determination if it will be a covered benefit under a dental policy and at what reimbursement level.
be covered in the plan document. Just because there is a code doesn’t mean the insurance company will pay—it can take a year or two for it to get embedded in the plan document where it is a covered benefit. In the meantime, dentists can submit the code and if insurance companies reject it, the dentist can go back and ask for an alternative benefit, say, or a stainless steel crown.
Cathy Jameson: The truth of the matter is, there are still insurance
companies where it’s difficult to get Zirconia crowns covered. When a majority of doctors in a particular area start filing a code for a procedure, insurance companies will come along and start paying for it. The pressure causes the insurance companies to cover. We encourage our clients to always file the D2929 code even if they know it is not covered. This is still a fairly new procedure in dentistry so we want doctors to use this service and present it to the parents, allowing them to see the physical and emotional benefits available to their children. Even though the fee may be higher, the insurance company may reduce the fee to the equivalent of a stainless steel crown. The more doctors in an area filing a certain procedure, the more likely it will be a covered benefit.
Brenda Hansen: When the code for Zirconia crowns (D2929) was added,
it was a big deal for EZPEDO because it gave our product validity in the industry and with more and more insurance companies and state medical programs reimbursing it, it has become more affordable to parents, making it even easier to make the right decision for their child. But just getting the code does not mean that Zirconia crowns are automatically covered. The level of reimbursement varies by state and plan.
Roger Levin, DDS Founder & CEO, Levin Group, Inc.
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Now that there is a code, are Zirconia crowns reimbursed at the same level as other procedure options such as composite crowns? Roger Levin: For privately held insurance plans, a lot of this comes down to
the employer. The same insurance company might cover Zirconia crowns for one set of patients and not another depending which plan the employer has selected.
Nolan Gerlach: The Washington State Health Care Authority updated its
Medicaid reimbursement of Zirconia crowns to equal that of composite crowns, but prior to this I noticed Medicaid was reimbursing the composite crowns at a higher rate than the Zirconia crowns. In my mind, the Zirconia crowns are at least an equal, if not better, alternative to restoring anterior teeth. Covering it at a much lower rate disincentivizes providers from using those type of crowns. On the other hand, equal coverage for the two types has further opened up what I see as a superior product or superior solution.
David Stanley: In Tennessee, TennCare, Tennessee’s Medicaid program,
recently changed its policy to begin reimbursing patients for Zirconia crowns. Though it is covered, we are walking a fine line right now because the reimbursement for Zirconia crowns is about $7 less than it is for stainless steel crowns and pre-veneered stainless steel crowns. The Zirconia crown is a better crown and it will last longer. Multiple times we have to replace pre-veneered crowns free of charge so, I am willing to take a hit on the Zirconia crowns because we avoid the overhead charge of having to replace them again.
Since every state and insurance plan is different, what can be done to facilitate an increase in reimbursement for Zirconia crowns in places where it is not currently reimbursed or only reimbursed at a very low level? Paul Reggiardo: If the purchaser of the insurance plan asks for the benefit,
then the insurance carrier can help determine the amount of premium that would cover this additional benefit. The demand has to come from the patients or, in pediatric cases, from parents. If the parents make it clear to their employers that they want Zirconia crowns as a covered benefit, then the employer will have a reason to explore adding them to the dental plan coverage.
David Stanley: Having more dentists providing Zirconia crowns will grow the demand for the technology, and ultimately the insurance industry will catch up with reimbursing them. More dentists providing the procedure will help educate parents on their options.
Cathy Jameson: One key for dentists to get a benefit reimbursed accurately
is a descriptive narrative. When filling out the narrative, step one is the status of the tooth. Note the size and condition of prior restoration, if any. Step two is to note the amount of remaining and/or lost tooth structure. Step three is to note any pathology or symptoms. Step four is to note any clinical observations not visible on the X-ray. Photos are beneficial. Dentists should include the words that are more likely to get coverage approval such as “decay” and “fracture” if they are applicable to the patient. The clearer the narrative the better chance at coverage.
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What advice do you have for dentists and parents regarding insurance for Zirconia crowns? Nolan Gerlach: I would encourage dentists and parents to simply ask
the question to their state medical group or employers. In my mind, I felt like I simply asked the right question to the right people, “Why are Zirconia crowns not being covered at the same rate?” I didn’t have any expectations as to what my simple emailed question would lead to, but with the incredibly supportive environment in Washington with The Access to Baby and Child Dentistry program (ABCD), a simple question facilitated a conversation and subsequent equal coverage of Zirconia crowns for patients age 6 and younger, as long as the dentist has completed an educational program.
Charles Blair: Dentists must always report the correct code. If it’s not paid,
appeal it and ask for an alternative benefit. The coverage should get better over time.
Paul Reggiardo: It’s essential that all providers are familiar with the
procedural coding system. The ADA publishes procedure codes annually, and there are a number of additions, deletions and modifications each year.
Cathy Jameson: If you are a dentist not familiar with Zirconia crowns, take
the time to research them. The Zirconia crown materials are healthier for a child and also aesthetically superior. For us to not introduce Zirconia crowns to our clients would be a mistake. We must bring to the table what is best for the patient and best for the practice.
David Stanley: We are getting patients that are calling our office and asking
specifically for EZPEDO crowns. They want a strong, white crown. Providing EZPEDO crowns to our patients has differentiated us from other practices and I would recommend other dentists take a look at the technology and attend courses (EZPEDO University for example) to familiarize themselves with Zirconia crowns and their ever-changing insurance coverage.
Roger Levin: It’s really about creating a groundswell by dentists and parents. When that groundswell takes place and parents are talking to employers and dentists are talking to their societies, that’s really what it’s all about. You are really after pressure by employers for insurance companies to look at a certain procedure as one part of standard care to ensure families have a specific option such as the Zirconia crown. It is not one person or one committee, but it is a combined effort that leads to the best reimbursement of new procedures.
Billing Health Canada 22601 - Primary Anterior 22611 - Primary Posterior Definition: Restorations, Prefabricated, Porcelain / Ceramic / Polymer Glass, Primary Teeth.
Brenda Hansen: At EZPEDO we are proud of our product, and proud that
insurers have begun recognizing its billing code. We are here to aid dentists and parents with reimbursement challenges and provide the educational materials they need to approach legislators and employers so we can all work together to facilitate the right conversation around the coverage of Zirconia crowns and the need for the industry to work together for coverage solutions that work. Insurance reimbursement for Zirconia crowns is just another step in the right direction to help us fulfill our vision and provide support to our customers through every phase of their EZPEDO experience.
For a product with the potential to shift an industry, changing the way insurance understands the technology simply comes with the territory. At EZPEDO, we believe the next generation of patients need next-generation technology. We know that proactive dental practices, industry influencers, dental educators and parents have the tools to bring the insurance industry along with us. Keep in mind the famous words of the great orator and British war leader, Sir Winston Churchill—“Never give up!” Working together, we can improve insurance reimbursements across the board and continue making this ground breaking technology more widely accessible and affordable than ever.
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Sedation and Medical Emergencies in the Pediatric Patient by David L. Rothman, DDS
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Two categories of pediatric emergency can occur during sedation. Anesthesiaassociated problems usually are airway related and lead to hypoxia and cascade to bradycardia and potentially death. Examples of these include drug/dose problems, unintended sedation-level changes, allergic reactions to the agents used, laryngospasm and loss of protective reflexes. Non-anesthesia emergencies can occur at anytime and are not related to the sedative or anesthetic agents. These may occur concurrently or separately and can include airway obstruction, allergic reactions, seizures and hypoglycemia. It is important for the practitioner to be able to identify and intervene early in the event to be able to manage the emergency and stabilize the patient before further progression.
Though there are many reported numbers for the incidence of emergencies during sedation and 1, 2, 3 anesthesia, they may be unreliable. There is no central agency in dentistry for reporting incidences of morbidity or simple complications which donâ&#x20AC;&#x2122;t affect the outcome of the sedation. Other than insurance company closed-case analyses, mortality numbers are difficult to obtain, and only estimates exist regarding the number of outpatient sedations given in a specific time period. In addition, some practitioners do not recognize problems or may choose to ignore them because they believe they are too minor to record such as temporary loss of protective reflexes as the patient drifts between sedation levels. Practices are inconsistent in their delivery and monitoring, making data recovery difficult.
In general, the pediatric heart and lungs are generally free of disease unless it is congenital. The second most common disease affecting children is asthma and is the most common cause of admission for the pediatric patient. It affects approximately 11â&#x20AC;&#x201C;15 percent of children and is now considered a lifelong disease. It is important to understand the severity of the asthma pre - and post-treatment and the medications used because of the impact they may have on the emergency treatment. Acquired infections of the airway in children require a sixweek healing period before sedation or general anesthesia should be done. Understanding allergic versus infectious etiology is key to treatment and prevention of medical emergencies. This article is by no means a complete discourse on pediatric emergency management and will only focus on respiratory, cardiovascular, and sedative and local anesthetic drug overdose related emergencies. Other pediatric emergencies will be covered in a future article. The reader is well advised to do additional research on pediatric diseases and emergency management of patients and take appropriate continuing education courses. Topics such as foreign body obstruction and complications of the routes of administration are covered in courses such as Pediatric Advanced Life Support by the American Heart Association and the American Academy of Pediatrics.
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for a self-inflating, bag-valve mask though the unit may be used to supply oxygen to the (BVM).
Response to Emergencies 2
The concept of â&#x20AC;&#x153;rescue,â&#x20AC;? as proposed by Cote states that the purpose of all emergency treatment is to manage and stabilize the patient until help arrives. Using local emergency services alone and waiting for their response is not adequate rescue. Know and understand if the emergency responders are EMTs or paramedics. The office must have the resources and training necessary to perform rescue from unintended sedation level changes, i.e. overdose, as well as other categories of emergencies. The chances for a successful outcome decrease as the distance from an emergency facility increases and as time passes. 2,5
Learning to rescue alone is not adequate emergency preparation. Prevention of the emergency through guidelines, understanding drug dosages and pharmacology (with potential interactions), and knowing your patient and his or her medical history will mediate the risks involved. Documenting sedation incidents in the office and reviewing those with staff and other practitioners allow us to learn from experience and modify our delivery, monitoring and especially our response, be it as simple as using a neck and shoulder roll or a more involved response such as a drug dose change. It is recommended that during sedations, children are maintained at the minimal or moderate level to maintain their protective reflexes and their airways patent. 4
By following guidelines, we are able to minimize but not totally eliminate risk. NPO guidelines may leave our patients at risk for hypovolemia, especially if they perspire profusely while in a medical immobilization device. The triad of hypovolemia, hypoxia and hypercarbia lowers seizure threshold, increases myocardial irritability and may hinder or prevent resuscitation efforts. In addition, certain sedation medications such as chloral hydrate may increase myocardial irritability and may negate the use of epinephrine during emergency care.
Emergency Kit The emergency kit for pediatric patients must be adequate to maintain a patent airway and stabilize the child at the level of sedation achieved as well as treat any concurrent emergencies until either help arrives or the patient emerges and recovers. This implies that if the patient drops to a level deeper than anticipated, the doctor must be able to monitor and maintain the patient at the unintended level and have the training, equipment and staff to do so. The emergency kit must also contain equipment and supplies to respond to other basic pediatric office emergencies and first aid. An appropriate list is available in the AAP/AAPD Guidelines for Monitoring and Management of Pediatric Patients During and After
Masks used in resuscitation should be transparent with a form-fitting, inflatable collar, which should also be checked on a regular basis. A variety of different sizes should be available and should fit comfortably between the nasal bridge and the chin. A 5cc syringe without needle should be kept with the mask to deflate or inflate the collar. Advanced airway devices for managing airways during emergencies include nasal and oral airways, endotracheal tubes (ETT) and appropriate placement equipment. A valuable adjunct for airway management is the laryngeal mask airway (LMA) which may substitute for intubation in compromised airways. It is recommended that experience be gained in this technique. The inflatable collar may block regurgitated stomach contents from entering the airway. Various sizes for pediatric patients must be available. Correct size oral airways are measured externally from the tragus to the commissure of the lips. Nasal airways are measured externally from the tragus to the corner of the nares. Automated Electronic Defibrillators (AED) are a conundrum in pediatric emergency care, but states are increasingly mandating their presence in dental offices. Short of aiding the staff in resuscitating the doctor, they have little purpose in pediatric practices as a first-line resuscitation device. Most cardiac problems are not due to disease or congenital issues, but instead are due to hypoxia leading to a transient tachycardia with the child succumbing to a fatal bradycardia. Performing defibrillation on a hypoxic heart will not revive it nor correct an arrhythmia.
Using local emergency services alone and waiting for their response is not adequate rescue.
4
Sedation for Diagnostic and Therapeutic Procedures (chart 1). The kit must contain specific equipment and sizes for pediatric resuscitation, including face masks, advanced airway devices and equipment for IV and IO access. The kit must be placed in an identified and easily reached area and the components must be clearly marked and labeled. Response must be organized and practiced with individual roles assigned to each member of the response team (chart 2). Oxygen is always the first drug of choice. Room air has 21 percent oxygen content. Oxygen, as a supplement in emergency situations, should be delivered at 100 percent with the assistance of an appropriately sized pediatric self-inflating, bag-valve mask system. A mobile E-sized tank is capable of delivering 10 liters/minute of oxygen for 60 minutes and may be used in areas not plumbed with oxygen. Alternative oxygen delivery methods may be available but must meet the requirements of access and transportability. Without modification, the standard N2O/O2 delivery unit is not capable of delivering positive pressure oxygen because of an overload pop-off valve in the system. The standard reservoir bag does not substitute
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SOBERING STATISTIC In a study of predictors of out-of-hospital survival rates, researchers found sobering results. SURVIVAL RATES POST CARDIAC ARREST
3â&#x20AC;&#x201C;17% Long-term survival
NOTE: Early detection and correction of an airway emergency can dramatically reduce the chances of a devastating event.
Routes for Administration of Emergency Drugs It is recognized that the optimum route of administration of all 4,5 emergency medications is intravascularly or intraosseously, although alternate means are available. Submucosal delivery in the area distal and superior to the maxillary molar in the region of the pterygoid plexus or intramuscularly into the nearest exposed muscle mass (gluteal or deltoid) may be used when there is optimum circulation. Because the dental practitioner is most comfortable in the oral cavity, the submucosal site mentioned is recommended for drugs that may be given intramuscularly due to the high vascularity of the area. This also avoids the possibility of swelling and airway obstruction if administered in the floor of the mouth or the tongue. Diazepam, because of its ethylene glycol base, is not appropriate for intramuscular or submucosal administration except in extreme cases.
Paradigm of Emergency Care The paradigm of emergency care should involve a system or method of treatment that guides our thoughts and actions. Prior to the 2012 revision of the American Heart Association’s Pediatric Advanced Life Support (PALS) course, the mnemonic of PABCD where P is position, A is airway, B is breathing, C is circulation, and D is drugs was used. As with the concept of rescue, the absence of prevention in the thought process leads us to a situation which may be preventable. Therefore, a paradigm of PPABCD, where the first P is prevention, PABC are the same, and the D is definitive treatment (realizing not all emergencies require drug intervention) can be considered. The mnemonic has been recently revised again to stress the increased focus on circulation. The key to success is not to progress to the next letter if the prior letter is not stabilized, i.e. do not attempt breathing if the airway is not stabilized.
Emergencies of the Respiratory System The most common emergency during pediatric sedations is hypoxia. It may be caused by airway obstruction, drug overdose, local anesthesia overdose or unintended sedation level, all of which may lead to reduced respiratory rate and volume. When respiratory and/or cardiac rates reach two-thirds of pretreatment rates, good quality CPR should begin including bag-valve mask (BVM) intervention. 6 Survival rates after hypoxia and cardiac arrest are 3–17 percent; therefore, early recognition and management are crucial. The early signs of hypoxia are restlessness and agitation, transient increase in heart rate then decrease, and irregular breathing patterns. The various sounds of respiratory problems may be summarized as follows:
Gurgling: Snoring:
fluid or foreign body in the upper airway
tongue/soft palate/ tonsil obstruction
Crowing:
large tongue, vocal cord paralysis or swelling, croup, epiglottitis, foreign body, allergic reaction with edema, laryngospasm
Wheezing:
bronchospasm or partial obstruction of the lower airway on expiration
CHART #1 EMERGENCY MEDICATIONS AND EQUIPMENT 1.OXYGEN 2.AMMONIA SPIRITS 3.GLUCOSE (50%) 4.ATROPINE 5.DIAZEPAM 6.EPINEPHRINE 7.LIDOCAINE (CARDIAC) 8.DIPHENHYDRAMINE HYDROCHLORIDE 9.HYDROCORTISONE 10.PHARMACOLOGIC ANTAGONISTS (AS APPROPRIATE) NALOXONE HYDROCHLORIDE FLUMAZENIL
AIRWAY MANAGEMENT EQUIPMENT 1.NASAL AND ORAL AIRWAYS AND CLEAR MASKS OF ASSORTED PEDIATRIC AND ADULT SIZES 2.PORTABLE OXYGEN DELIVERY SYSTEM CAPABLE OF DELIVERING BAG AND MASK VENTILATION GREATER THAN 90% AT 10L/MIN FLOW FOR AL LEAST 60 MINUTES (E.G. “E” CYLINDER) 3.SELF-INFLATING BREATHING BAGS AND RESERVOIR WITH MASKS THAT WILL ACCOMMODATE CHILDREN AND ADULTS OF ALL SIZES 4.DEEP SEDATION AND GENERAL ANESTHESIA: ASSORTED PEDIATRIC ENDOTRACHEAL TUBES, LARYNGOSCOPES WITH STRAIGHT AND CURVED BLADES, MAGILL FORCEPS
INTRAVENOUS EQUIPMENT FOR DEEP SEDATION & GENERAL ANESTHESIA 1.GLOVES 2.ALCOHOL WIPES 3.TOURNIQUETS 4.STERILE GAUZE PADS 5.TAPE 6.INTRAVENOUS SOLUTIONS AND EQUIPMENT FOR ADMINISTRATION APPROPRIATE TO THE PATIENT POPULATION BEING TREATED • INTRAVENOUS CATHETERS (22, 24 GAUGE) • INTRAVENOUS ADMINISTRATION SET (TUBING) (MICRO-DRIP 60 DROPS/ML) • INTRAVENOUS FLUIDS • ASSORTED NEEDLES FOR DRUG ASPIRATION AND ADMINISTRATION • APPROPRIATELY SIZED SYRINGES
CHART #2 TEAM MEMBER #1 1.INITIATES EMERGENCY CARE • TREAT PATIENT/BASIC LIFE SUPPORT • ACTIVATES OFFICE EMERGENCY PROTOCOL 2. REMAINS WITH PATIENT
TEAM MEMBER #2 1.BRINGS SUPPLIES/EMERGENCY KIT MEDICATIONS/O2 TANK 2.ASSISTS TEAM MEMBER #1
TEAM MEMBER #3 1.CROWD CONTROL 2.NOTIFIES EMERGENCY BACKUP SERVICE ON INSTRUCTIONS FROM TEAM MEMBER #1 3.MEETS EMS AND ESCORTS THEM INTO THE OFFICE 4.MAINTAINS RECORDS 5.ASSISTS AS NEEDED
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The treatment of hypoxia, regardless of cause, is as follows:
HYPOXIA P (PREVENTION)
P (POSITION) A (AIRWAY)
B (BREATHING)
C (CIRCULATION)
D (DEFINITIVE)
• NECK ROLL • LOOSE MEDICAL IMMOBILIZATION DEVICE • KNOW SEDATION LEVEL AND DRUG INTERACTIONS • RUBBER DAM CAREFULLY PLACED ON SINGLE SIDE–NOT CROSS ARCH • SUCTION READILY AVAILABLE • SPINE WITH HEAD TILT • MONITOR AND ASSESS AIRWAY & BREATHING • • • • • • •
ASSESS PATENCY POSITION TONGUE FORWARD/NO BLIND SWEEPS PLACE APPROPRIATELY SIZED NASAL AIRWAY OPA: TRAGUS TO CORNER OF THE MOUTH 100% O2 BY NASAL OR FULL FACE MASK LMA OR INTUBATE IF AIRWAY DOESNʼT OPEN MONITOR AND REASSESS
• ASSESS RESPIRATIONS SELF VS ASSISTED / ADEQUATE VOL AND SPEED • ASSIST AS NECESSARY WITH POSITIVE PRESSURE 100% O2 BY BAG-VALVE MASK (BVM) • MONITOR AND REASSESS • ASSESS PERFUSION BY PERIPHERAL/CAROTID PULSES • BEGIN CPR • MONITOR AND REASSESS • DETERMINE CAUSE AND TREAT WITH APPROPRIATE DRUG • ACTIVATE 911 AND TRANSPORT TO EMERGENCY FACILITY
Asthma is the most common cause for admission to hospitals in the pediatric population. Bronchospasm, the end result of asthma, may also be caused by allergies, reactive airway disease following infection or pneumonia, and mechanical or chemical irritation. The most common signs are congestion, wheezing, dyspnea, confusion or agitation and tachypnea and tachycardia. Because the pediatric patient has limited oxygen reserves, intervention must be immediate. The heart will tire quickly and hypoxia, hypovolemia and hypercarbia will ensue quickly with lactic acidosis leading to an irreversible condition. The treatment of bronchospasm is as follows:
BRONCHOSPASM P (PREVENTION)
P (POSITION) A (AIRWAY) B (BREATHING) C (CIRCULATION) D (DEFINITIVE)
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• • • •
HISTORY CHROMALIN/ STEROID/ PUFFER HANDY DECREASE ANXIETY/ SUPPLEMENT WITH O2 AVOID NARCOTICS (HISTAMINE RELEASERS)
• PARTIALLY RECLINING • 2–4 PUFFS OF ALBUTEROL INHALER • Q 2 MINUTES FOR 2 DOSES • ASSIST AS NECESSARY BAG/ VALVE/ MASK IF NEEDED • PREPARE TO INTUBATE • MONITOR AND CPR AS NEEDED • IF BRONCHOSPASM RESOLVES, CONTINUE TREATMENT • IF FAILS TO RESOLVE, NOTIFY EMS
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Laryngospasm may be caused by aspiration of a foreign body, depth of sedation with partial loss of protective reflexes or post-viral syndrome with reactive airway disease. With time, the situation progresses and is harder to reverse without drug intervention. The treatment of laryngospasm is as follows:
LARYNGOSPASM P (PREVENTION) P (POSITION) A (AIRWAY) B (BREATHING)
C (CIRCULATION) D (DEFINITIVE)
• HISTORY OF INFETION • USE OF RUBBER DAM AND HIGH-CAPACITY SUCTION • SUPINE WITH HEAD TILT AND SHOULDER ROLL • CHECK FOR FOREIGN BODY/ VOMITUS • PLACE APPROPRIATE LENGTH ORAL AIRWAY • 100% O2 THROUGH BVM • CONSTANT MILD TO MODERATE PRESSURE / NOT BURSTS • DRUGS PRN SUCCINYLCHOLINE 2–4 MG IM WITH ATROPINE 0.4 MG BE PREPARED TO VENTILATE FOR UP TO 30 MIN • MONITOR FOR PERIPHERAL PULSES • CPR PRN • EMS ACTIVATION AND TRANSPORT
Abnormal Cardiac Rhythm and Pulses Arrhythmias and dysrhythmias may have many causes but the most common include an undiagnosed congenital defect, hypoxia, effects of circulating catecholamines on a sensitized myocardium, drug effects and vagal stimulation. The end result of the arrhythmia is poor perfusion, lowered blood pressure, and the shunting of blood from the peripheral circulation to maintain perfusion of the blood-rich group. The Pediatric Advanced Life Support Course (PALS) provides excellent training in the management of this problem. Because arrhythmias have the potential to become fatal, rapid identification and treatment are imperative.
ARRHYTHMIAS P (PREVENTION) P (POSITION) A (AIRWAY) B (BREATHING) C (CIRCULATION) D (DEFINITIVE)
• KNOW THE PATIENT • KNOW THE DRUG, ITS INTERACTIONS AND ITS EFFECTS • SUPINE WITH NECK AND SHOULDER ROLL • MAINTAIN PATENCY • NASAL OR ORAL AIRWAY AS NEEDED • 100% O2 • MONITOR AND ASSIST AS NEEDED WITH BAG-VALVE MASK • BEGIN CPR IF NEEDED • MONITOR AND ASSIST AS NEEDED • BEGIN CPR IF NEEDED • NOTIFY EMS AND PRPARE FOR TRANSPORT
THE BEST WAY TO TREAT AN EMERGENCY IS TO NOT HAVE ONE Acquired infections of the airway in children require a six-week healing period before sedation or general anesthesia should be done.
IMPORTANT: Oxygen is always the first drug of choice. WHY: Because the pediatric patient has limited oxygen reserves, intervention must be immediate. EZP ED O M ag azi ne / S ept e m be r 2016
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Sedation Drug Overdose
Conclusion
Despite the practitioner’s best efforts in predicting patient response to a dose of sedative medication, there is always the chance of hyper or hypo reactions to the drug such that the patient slips into a deeper level of sedation than intended.
The successful treatment outcome of an in-office emergency of a pediatric patient during sedation is dependent upon rapid identification of a problem and immediate intervention. The emergency situation always takes precedence over the dental procedure. Using recommended monitors and monitoring techniques, early identification of critical events is possible. The practitioner is advised to always be suspicious of changes in the child’s responses. With a well-trained doctor and office staff, experienced in emergency response, the likelihood of mortality or severe disability decreases for the child. Continuous training for all staff members is recommended.
The practitioner must be prepared to respond appropriately and maintain and protect the airway if loss of protective reflexes occurs. The response to sedation drug overdose is as follows:
SEDATION DRUG OVERDOSE P (PREVENTION)
P (POSITION) A (AIRWAY) B (BREATHING) C (CIRCULATION) D (DEFINITIVE)
• KNOW DRUG DOSE, INTERACTIONS AND EFFECT • KNOW DRUG METABOLISM AND HALF LIFE • IDENTIFY LEVELS OF SEDATION AND RESPONSIVENESS • SUPINE WITH NECK AND SHOULDER ROLL • 100% O2 • ORAL AIRWAY OR INTUBATE IF NEEDED TO GUARANTEE PATENCY • ASSIST WITH BVM AS NEEDED • MONITOR AND REASSESS • MONITOR AND ASSIST WITH CPR IF NEEDED STOP DENTAL PROCEDURE START IV (REQUIRED FOR DEEP SEDATION / GA) MONITOR APPROPRIATE VITAL SIGNS REVERSAL AGENTS IF APPROPRIATE NALOXONE 0.01 MG/KG IM Q5M TO MAX 1MG FLUMAZENIL 0.2 MG IV Q1M TO MAX 1 MG • MONITOR AND ASSESS LEVEL OF SEDATION
• • • •
Local Anesthesia Overdose The administration of local anesthesia concurrently with sedative medications constitutes polypharmacy and requires additional caution because of the risk of potentiation and fatal arrhythmias secondary to lidocaine or epinephrine overdose. Because its presence decreases the rate of anesthetic absorption, there is no reason for not using local anesthetic with vasoconstrictor during sedation of ASA 1 or 2 patients. In the case of overdose, increasing CNS depression leads to the paradox of increasing CNS stimulation, agitation and talkativeness. The patient exhibits seizures until the blood level falls. Management of this emergency involves stabilizing the patient and monitoring until blood levels fall.
References 1. Moore PA. Adverse drug reactions in dental practice: Interactions associated with local anesthetics, sedatives, and anxiolytics. J Am Dent Assoc 1999;130(4):541-544. Domino, D. Are pediatric sedation deaths on the rise? 2010 May 18. 304662.drbicuspid.com. 2. Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000;105;805. 3. Guidelines for the use of sedation and general anesthesia by dentists (2012). American Dental Association. www.ada.org/ sections/about/pdfs/anesthesia_guidelines.pdf. 4. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures (2006). AAPD Reference Manual 2015;37(6):211–227. 5. American Heart Association. Pediatric Advanced Life Support (2010), course and manual. www.heart.org/PALS. 6. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation 2010;3(1):63–81.
LOCAL ANESTHESIA OVERDOSE P (PREVENTION)
P (POSITION) A (AIRWAY) B (BREATHING)
C (CIRCULATION) D (DEFINITIVE)
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• FOLLOW CURRENT LOCAL ANESTHESIA GUIDELINES AND DOSES NOT EXCEEDING 4MG/KG FOR COMMERCIALLY AVAILABLE DRUGS • STOP PROCEDURE • SUPINE IN THE UNRESPONSIVE, SEDATED PATIENT • NECK AND SHOULDER ROLL • USUALLY ADEQUATELY MAINTAINED • FOLLOW PRECAUTIONS FOR HYPOXIA • USUALLY MAINTAINED • 100% O2 TO PREVENT HYPOXIA, HYPERCARBIA/ AND ACIDOSIS • MAY BE DEPRESSED OR ABSENT • 100% O2 WITH BAG-VALVE MASK • USUALLY ADEQUATELY MAINTAINED • HYPOTENSION AND TACHYCARDIA REQURE BLS INTERVENTION • EMS ACTIVATION AND TRANSPORT
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A Special Thanks to the ADSA This article was originally published in the winter 2016 (Vol. 48 No. 3) edition of Pulse, the official publication of the American Dental Society of Anesthesiology. We are grateful for the opportunity to share this valuable information with our readers.
BE A HERO
KNOW WHAT TO DO!
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10
ESSENTIALS FOR A DYNAMIC, SUCCESSFUL PEDIATRIC PRACTICE By Cathy Jameson, PhD There is a special place in heaven for pediatric dentists and their teams. Children are not small adults. They are human beings going through normal stages of growth and life. The pediatric practice becomes and remains healthy when excellent clinical and management principles, specific to your specialty, are closely tied to the “human” principles of children or young people. Therein lies the key to success: combining people skills with management skills. At Jameson Management, we have a specific division that focuses on pediatric practices. Let’s look at 10 essentials for a dynamic, successful pediatric practice based on the experience of our pediatric consultants.
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Photography courtesy of Joelle Speed, DDS The Smile Galleryâ&#x20AC;&#x201D;Roseville, California
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In each and every encounter, settle for nothing but the best.
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1. Develop a practice that epitomizes excellent care of both the business and children. One goes hand in hand with the other. In a pediatric practice, you have certain requirements and issues. Your management systems must be established, administered, and monitored appropriately. The success of your practice will be in direct proportion to the success of your systems. Each system is vital. And—each system is tied to every other system. The efficiency and effectiveness of your systems allow you to focus on the business at hand—taking care of the children and their parents. In each and every encounter, settle for nothing but the best. Focus on both the physical and emotional needs of each child. One is tied to the other.
2. Create and deliver a new patient “experience” that is fun for the kids and informative and motivational for the parents.
qualified and dependable person to fill this role is essential. This person will provide third-party back-up support for the doctor’s treatment recommendations, make financial arrangements, and schedule appointments—both in the office and in the hospital, when appropriate. Coordinating schedules and making sure that patients/parents are well-informed is critical for assuring patient compliance and cooperation. This coordinator can be your liaison with the offices of your referring colleagues. The referring doctors need and want to be “in the loop” regarding patients whom they have referred to you. Follow-up and follow-through are vital elements of your office success.
5. Stay in contact with your referring doctors and their teams by scheduling special events and/ or offering informative courses. Make sure that your referral sources understand the following
The new patient experience is both the child’s and the parent’s introduction to your practice—and (hopefully) to a long-term relationship with you. From the parent’s initial meeting with you (perhaps through a referral or through your marketing) and throughout each successive encounter, the relationship moves in one direction or another. Every person on the team can make or break the relationship.
about your practice: 1) you can see
Kids are kids. They want and need to have fun. Keep their interest and meet them where they are coming from, and you will go a long way together.
original doctor, if that is their
When learning is informational and motivational for both parents and children, they gain insights, and your mutual relationship is nurtured. This type of reciprocal relationship fosters successful treatment, encourages cooperation, and builds long-term commitment.
Develop and refine your system of nurturing referrals—the lifeblood of your practice. While your external marketing protocols will certainly help your new-patient flow and your existing patient retention, your internal marketing, including nurturing referrals from other healthcare professionals, remains a stronghold for your practice development.
3. Plan, prepare, and present your
Consider hosting social events for these referring practices. Include the entire team. You want to have a solid, trusting relationship with the referring doctor. However, patients (parents) will often prefer to converse with a team member who they particularly like or trust. So include team members when you invite referring doctors to your office. Let them see who you are, what you do, and why coming to you is a good idea. Host CE programs that benefit the entire team. Serve a nice lunch at the CE event. Give door prizes, etc. Make it fun, informative, and motivational. Invest money in order to make this a memorable, high-quality event.
recommendations excellently using visual aids—particularly photography. Approximately 83 percent of learning takes place visually—for all people no matter what their age. Therefore, use visual aids to educate both children and parents. Remember that kids today (and most of their parents) have grown up with something digital in their hands. So again, meet them where they are coming from. Use photography, visual education programs, video and digital formats. They could probably run the programs for you. Use visual aids, and you will have a much more cooperative child.
4. Develop the role of a patient or surgical coordinator. The responsibilities of a patient or surgical coordinator are adaptable according to the needs of your individual practice. However, in today’s sophisticated world of dentistry, finding a
all children, not just children with special needs or behavioral challenges, and 2) you will send referred patients back to their request.
Make sure your entire team is there—hosting and interacting. Pass out material about your practice. Have the doctor or a team member welcome the guest group and briefly introduce what you emphasize in your practice. Make sure that you clearly identify the type of children you see and outline how you welcome patients to your practice. Also, acknowledge certain situations in which a patient may be referred to you for a particular treatment while emphasizing your willingness to return the patient to the general practice, if so desired. Make a point of thanking the attendees. The purpose of this event is to show appreciation to the referring practice.
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6. Scheduling is the heartbeat of your practice. Be prepared. Know the school holidays. Identify your homeschooled children so that they may be called on short notice. Determine how many children from the same family can be seen at one visit. Learn proven ways to reduce broken appointments and no-shows. Your parents will be very grateful that you know when their children will be in or out of school. Your efforts to schedule appointments during those times provides excellent customer service and is also a good marketing strategy. Of course, your kids who are home schooled will be available at times when children in public or private schools are unavailable. Keep track of those kids. Jameson Management consultant, Dru Halverson, RDH, recommends that you try the “every other” appointment scenario. For example you can say, “Mrs. Jones, I’m sure you can appreciate that all of our parents would like the after-school appointments. And so, in order to accommodate everyone to the best of our ability, we schedule one appointment after school and the next one during school hours. Then we switch back. In this manner, everyone has a chance to schedule those after-school, popular times.” If you allow more than one child to come at a scheduled appointment time, make sure the parents understand that you are making an exception, and that you must be able to count on them showing up on time. If they cancel at the last minute, of course, you will not be able to reserve that much time in the future. Send a welcome packet and ask the parents to fill out the information sheets and health history forms. Ask them to send these documents back to you prior to the appointment. This will reduce your broken appointments and no-shows at those first visits. Data has shown that when someone completes the forms and sends them back—either physically or digitally—they will be more likely to show up.
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Getting to know your patients on a personal level can be very rewarding, both personally and professionally.
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The better you listen to the child (or parent), the better they will listen to you when it comes time for you to speak, teach, or recommend.
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7. Communicate with your kids:
9. School visits and community
know that your children hear
outreach are vital. Know your
everything, see everything, and
school nurses and teachers. They
are frightened of everything. Use
care about their students and will
your visual aids, digital teaching
value your support of them and
tools, and comforting words. Be
their students.
interested in them personally. Make their day—know their sports teams, pets, and special interests. Communication is the bottom line to your success. Relationships depend on accurate and empathetic communication. All our senses are involved in effective communication. Tour your own office and see what it says. Is it comforting? Child friendly? Fun? Use visual aids throughout every encounter. Focus on the senses— constructively. Use music, fragrance, colors, activities, tasty oral products, visual educational materials, and hands-on teaching tools —things your patients and their parents can hear, smell, see, taste, and touch. Speaking of hearing and music, it’s been said that the sound of a person’s name is music to their ears. Personalize every encounter with the child and/or the parent. Know their names. Call them by name. Know something about them. This is another reason why it is so valuable to send the welcome packet prior to the appointment. Brenda McNulty, Jameson Management consultant and pedo specialist, says that when anyone—but specifically a child— realizes that you know something about them and care about them, they respond by opening up, connecting, and listening. And, by the way, the better you listen to the child (or parent), the better they will listen to you when it comes time for you to speak, teach, or recommend.
8. Communicate with the parents: know that they feel badly if their child has a cavity or any other issue. Empathize while you educate. McNulty points out that oftentimes when a parent is shown a disturbing condition in their child’s mouth, they feel guilty and distressed. This drives home the point that education is valuable, not only to the child but also to the parents. Show parents the photos of their child’s mouth. Don’t sugarcoat the situation. Focus on how to restore the child’s health and how to prevent further deterioration. Focus on what can be. Give them the instruction and motivation to handle home care in a more proactive and effective manner. If things have improved when they return for their next visit, be sure to note that and give the parent positive reinforcement for work well done. Even though things may not be perfect, provide that constructive reinforcement. Michael LeBoeuf says, “That which is rewarded is repeated.” Appreciation and acknowledgement are the most powerful of all rewards and motivators.
You are a part of a compassionate healthcare team. School nurses, teachers, principals, and lay persons are all interested in the health and well-being of the children in their school—or they wouldn’t be there. When you take an interest in the children at their school, they will wrap their arms around you. Provide educational events, celebrate Children’s Dental Health Month, or provide toothbrushes and toothpaste along with training sessions. Be there. Be a significant, participating member of the school’s educational team. Show you care.
10. Turn to the AAPD for marketing support and practicedevelopment tools. The American Academy of Pediatric Dentistry provides courses on all aspects of clinical, management and marketing for your practice. In addition, they provide materials to support your practice and educate your parents and kids. When you are planning CE events for your referring doctors or scheduling educational events for your schools, you can access AAPD materials that are applicable to your event. The academy introduces new materials, technology, and products at their annual sessions and at state and local venues. Be a part of your supportive organization. Access the marketing and practicedevelopment tools that they provide.
IN SUMMARY Your pediatric practice provides unique, essential care for a healthy, growing child. You are definitely “on purpose” with the service and care you deliver. Excellent management systems combined with effective people skills support your ability to provide outstanding clinical treatment. This combination leads to a dynamic, successful pediatric practice. Study the 10 essentials described in this article. Ask yourself, “What am I doing well?” Acknowledge those things. Reinforce them. Keep doing them. Then ask yourself the more productive question, “How can I do these things even better?” Therein lies the key element for growth. Follow this path of continual improvement —a path designed to ensure your success.
For information regarding Cathy’s lectures or the services of Jameson Management, see their website: www.jamesonmanagement.com or contact their email: info@jamesonmanagement.com.
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DID YOU KNOW?
EXPERIENCE 70% of buying experiences are based on how the customer feels they are being treated.
ACQUISITION It is 6-7 times more expensive to acquire a new customer than it is to keep a current one.
BUSINESS 91% of unhappy customers will not willingly do business with you again.
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Next Generation Technology
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I
Influence. How I Found My Unique Humanitarian Role in Story Telling.
by Daniel Vakaryuk This life in not about what we can get but what we can give. This motto is one I’ve pondered throughout my life as I’ve traveled with friends documenting people's stories around the world. But previously, I spent years battling a question that haunted me for as long as I could remember. “What are you doing with your life?” Or to put it another way, “What difference will you make in this world?” These are questions I’ve had in the back on my mind since childhood—questions you get asked your entire adolescent life from family, friends, teachers, and just random people that you meet. They have become a starting point for conversations with old and new friends alike. But we’ve taken something with such deep meaning and turned these profound questions into simple basic conversation starters. Allow me to take you back a little into my past, and hopefully I can show you why such questions have such a weight on my heart. I was born in one of the poorest countries in Europe called Moldova. Being heavily devastated by the world wars and then the fall of the Soviet Union, life wasn’t so easy for the people in this country. My grandpa—having been involved in humanitarian efforts his entire life—was asked to partner with several humanitarian relief organizations from other countries in Europe to help the people suffering in Moldova get back on their feet.
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June 2016 Burkina Faso An elder of a tribe from the northern region of Burkina Faso looks out of his house at the festivities happening that day. His tribe is composed of 5,000 members. The tribe uses Hââbré, a Kô language word that means “writing,” but also stands for the practice of scarification that’s common in West Africa. Followers of the custom make superficial incisions on their skin, using sharp stones, glass, or knives, creating permanent body decoration that communicates a myriad of cultural expressions.
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November 2012 Uganda While caring for her younger sibling, in an orphanage caring for about 1,000 children, a young girl steps up on her tippy toes to watch the other children learn in a classroom. She herself cannot attend school since she hasnâ&#x20AC;&#x2122;t been sponsored yet. She is one of the many orphans waiting for that moment when someone agrees to sponsor her so she can be on the inside receiving an education, too.
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The earliest memories I have are of people, who I’ve never met before, always coming and going, speaking foreign languages, setting out for other villages with different groups every month and simply helping people. Being so young, I never understood why they were coming to our houses and living with us and helping our people. At the age of seven, my parents decided to move to the United States to provide a better future for our family, leaving my grandpa and several other family members behind to continue working with those organizations, which they still do today. Growing up, I continued to ponder the question, “What are you doing with your life?” It was a difficult question to answer. I switched from one major to another, trying to figure out what it is that I can do that will leave some sort of impact in the world. During my high school years, and then later while in college, I would mess around with cameras for fun. Taking pictures and making videos came natural to me, but I was still trying to figure out what I was going to do with my life. I started volunteering with different church groups and nonprofit organizations, going on trips with them to other countries to help people in need. Each time I would go on a trip, I would try helping with the variety of projects they were sponsoring. But what I kept finding myself enjoying most was taking pictures of people and telling their stories—the work of documenting what other others were doing. At the end of those trips, however, the pictures I took and the stories I documented just seemed to gather “digital dust” on my hard drives, shared only among a few friends but never seeing the light of day anywhere else. Eventually, a friend of mine that had seen some of my work asked me to come on a trip with him. I was hesitant to go since I didn’t know what value I might be able to contribute on this trip. Then he shared his perspective with me that gave me an entirely new view on life and what I would be doing with mine. “What do you have in your hands?” he asked me. At first, I was confused by the question. What does he mean, “What do you have in your hands?” He then said “What you have in your hands represents three things. First, your identity—what your profession is. Second, your income. And third, your influence.”
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My mind instantly began to race from one thought to another. I’m a videographer/photographer. I make money making videos and taking pictures, but even though I’d considered it before, it had never actually dawned on me how far my influence might extend by using these two skills to influence others in this world. I always thought that if I didn’t personally make an impact in a person's life, then I had never helped them. But my friend convinced me, “Even though some see your work merely as taking pictures or making a video, the truth is that by you sharing someone else's story, that story can in turn influence others to stand up and use their gifts, talents, or influence to make a change in this world.” I started volunteering on these humanitarian trips with a new perspective. Now I understand that by using the cameras I have in my hands, I will finally have the influence to affect change and make a difference in the world—the very ambitions I have aspired to achieve for so long. Yet I have made another enlightening discovery. By capturing these stories and images, the biggest influence has been left on my own outlook. I’ve learned that each person is unique in their own way; every person has a story to tell. What they need is someone who is willing to give them a chance to share it.
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June 2016 Burkina Faso A group of children fill whatever containers they can find with fresh, clean water from a well that was just opened for their tribe. Previously, they had to make a seven-mile journey (one-way) every few days and haul containers of water back to their homes. Now thanks to donations, Tèbo was able to build a well that gave 4,800 people access to fresh water.
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What influence will you
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have in this world?
November 2013 Nigeria A group of village children surround Danny, fascinated by how something in his hands is able to capture their image and then display it on the screen for them to see. The children walked with Danny, curiously watching as he documented life in their village.
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Dr. Levi S. Palmer attended the University of Oregon and ultimately acquired a degree in nutrition from UC Davis. After two years of surgical research at the UC Davis Medical Center, he acquired his dental degree at USC School of Dentistry. He took his pediatric dentistry residency at the University of Colorado Children’s Hospital. Dr. Palmer lives in Chico, California, with his wife and two children.
performance) which has given me success when determining the prognosis of severely decayed anterior teeth.
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e’ve all had parents say, “Do whatever you can to save my child’s teeth.” Then after having the kiddo lay back into your lap, you find their teeth are covered with shmutz (decay/dirt) and look like the child has been eating Cheetos through a chain link fence. Then you look the father or mother in the eye and tell them, “I’m sorry, your child’s teeth are farcockt (gone bad/messed up)!” This elicits a few reactions—denial, crying, or worst of all, a second opinion. I try not to give a direct prognosis of a child’s teeth until I have their X-ray in front of me, because I have had huge success saving primary anterior teeth even when decayed down to the gum line.
Take X-rays in your own office.
This may sound obvious, but you may put it off until you go to the OR. Don’t. Do a lap X-ray when at all possible with the help of the patient’s parent(s) serving as assistant(s). This will give you an opportunity to explain in detail the prognosis and treatment options with confidence while in “your house.” You do not want to do this in an OR or in a I can honestly say I wastes have tried every type of primary surgery center. Taking X-rays there time—you have to anterior crown system. I will also be forthright in saying rush your explanations, you don’t have examples of pedo I have no financial interest in EZPEDO; however, their are hands in down the best solution in just about partials, you don’t have crowns the X-ray your hand. every anterior situation. My endorsement is based on
BADLY BROKEN-DOWN TIPS ON RESTORING
ANTERIOR TEETH
Improve your technique while learning some Yiddish vocabulary By Levi Palmer, DDS
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e’ve all had parents say, “Do whatever you can to save my child’s teeth.” Then after having the kiddo lay back into your lap, you find their teeth are covered with shmutz (decay/dirt) and look like the child has been eating Cheetos through a chain link fence. Then you look the father or mother in the eye and tell them, “I’m sorry, your child’s teeth are farcockt (gone bad/messed up)!” This elicits a few reactions—denial, crying, or worst of all, a second opinion. I try not to give a direct prognosis of a child’s teeth until I have their X-ray in front of me, because I have had huge success saving primary anterior teeth even when decayed down to the gum line.
EZPEDO crown color, size, shape, durability, and Worst of all, even thoughtechnology parents appreciate you coming to . talk to them, they are stressed out, and you only have a Case selection is obviously the most important prognosisfraction of their attention because they are worried about dependent factor. Therefore, your personal technique will determine if the parent(s) will be happy with the their child. Experts tell us to never get consent for anything outcome, or if the patient will need to return and have extracted. Below I will you my while a patient is on N20their or teeth under duress. In share suchwithsituations, five-point shtik (trick/helpful tips) which has given me don’t ask a worried parent for consent child’s success when determiningto the have prognosistheir of severely decayed teeth. teeth extracted. They will notanterior be thinking correctly, and you may have given them false nowown a stomach Takehope X-raysand in your office. ache on top of it all. This may sound obvious, but you may put it off until you go to the OR. Don’t. Do a lap X-ray when at all possible with the help of the patient’s parent(s) serving as assistant(s). This will give you an opportunity to explain in detail the prognosis and treatment options with confidence while in “your house.” You do not want to do this in an OR or in a surgery center. Taking X-rays there wastes time—you have to rush your explanations, you don’t have examples of pedo partials, you don’t have the X-ray in your hand.
Stick to your shtik (talent/style of performance).
Don’t be a pisher (child/inexperienced person). Start with Worst of all, even though parents appreciate you coming to easy cases so you can master the Slowly work your talk to them, theypreps. are stressed out, and you only have a fraction of their attention because they are worried about way up to the harder cases. Don’t badly about their child. Expertsfeel tell us to never get consent for anything while a patient is on N 0 or under In such situations, expecting extractions when developing yourduress. treatment plan, don’t ask a worried parent for consent to have their child’s and then trying to save teeth theextracted. teeth They after the kiddocorrectly, is sleeping. will not be thinking and may have given them false hope and now a stomach This is the best time to you demonstrate some chutzpah ache on top of it all. (audacity/courage) and learn the proper technique. 2
Stick to your shtik (trick/comfort
When parents who werelevel). expecting extractions find out you be a pisher (child/inexperienced were able to save their Don’t child’s teeth, they willperson). loveStart youwith easy cases so you can master the preps. Slowly work your forever. (However, makewaysure you give your best up to the harder cases.them Don’t feel badly about expecting extractions when developing your treatment prognosis in advance). Be mench person), plan,aand then trying(responsible to save the teeth after the kiddo is is the best time to demonstrate some don’t charge parents forsleeping. yourThis “practice” crowns. You both chutzpah (audacity/courage) and learn the proper technique. will feel better if their child ends up eventually having When parents who were expecting extractions find out you extractions in the future. were able to save their child’s teeth, they will love you forever. (However, make sure you give them your best
I can honestly say I have tried every type of primary anterior crown system. I will also be forthright in saying I have no financial interest in EZPEDO; however, their crowns are hands down the best solution in just about every anterior situation. My endorsement is based on EZPEDO crown color, size, shape, durability, and technology. Your treatment plan is obviously the most positive prognosis-dependent factor. Therefore, your personal technique will determine if the parent(s) will be happy with the outcome, or if the patient will need to return and have their teeth extracted. In this article I will share with you my five-point shtik (talent/style of
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Notice the decay is arrested. Leave it alone! Make your preps as ideal as possible, and then advance to prep the roots to fit the crowns.
prognosis in advance). Be a mench don’t charge parents for your “pra will feel better if their child ends u extractions in the future.
h (responsible person), actice” crowns. You both up eventually having
“In some cases, I even leave decay behind and cover it with Lime-Lite.™ ”
Use the slow speed, not hand tools. I used to hate using the slow speed, but now it’s my favorite tool. Don’t use the spoon or any excavating tools. You’re not a miner, and you run the risk of exposing the pulp the majority of the time when treating hard cases. Sounds counter intuitive, but so does saving a kid’s teeth that, to the naked eye, look clearly like they will need to be extracted. Use the largest round burr you can and go slowly. In some cases, I even leave decay behind and cover it with Lime-Lite™ (lots of studies supporting its use right now). I hear Sodium Diamine Fluoride (SDF) might be a good alternative in these cases, so I ordered my first bottle this week. As soon as you involve the pulp, you weaken the tooth and compromise the longevity of the tooth. Avoid the pulp like I avoid gefilte (stuffed) fish. Feh! (Yuck!)
Don’t be afraid to prep the roots. In cases where the tooth is decayed to the gum line, I typically free up the gingival attachment circumferentially, and then do my prep. A simple beavertail or sharp carving instrument works well. Try to avoid doing this with the burr because the surrounding tissue doesn’t respond well. I use a green strip, blunt-nosed flame Neo Diamond. Occlusal reduction is done last, if at all, with a diamond wheel.
No hemostasis? No problem. Try to avoid using anesthetic to control the bleeding because doing so will sometimes leave bloody puncture sites and make the problem worse. Instead try NeoSynephrine—good old-fashioned nose spray. The anesthesiologists always have it. Hold a 4x4 below the teeth to the palatal side, and then drip some directly on the teeth. (Keep it away from eyes, or else you may end up with anisocoria and freak out the anesthesiologist.) After that initial treatment, use the now soaked gauze and apply direct pressure for 30 seconds while your assistants mix the cement. For best results, use Fuji II LC®. It’s thick and will push away the blood from the preps when seated. It also gives you reliable working time versus trying to time the setting of standard cement. You can cure it, and won’t have to worry if the gingiva is bleeding into your beautifully restored new teeth. Grey teeth are only cool if you’re Austin Powers. You may end up with grey crowns while first learning, so don’t plotz (burst/explode) when you do. You’ll know what to do differently the next time. Once seated, these crowns are not fun to cut off on a screaming 2-year-old because the mother insists the tooth color be fixed. So, take your time with the preps, and don’t shlep (move awkwardly) around while cementing.
Notice that I removed the decay to see how extensive it was (top pic). Next I removed all the decay with a slow speed prior to prepping (middle pic). This step allowed me to determine if it was EXT or CRN. After the initial prep, I had to advance the prep apically to ensure the crowns had the appropriate amount of tooth structure to support them (bottom pic). We are blessed to live in an age of advanced technology. I'm so happy the days of composite faces chipping and open-faced crowns are gone. Retention is now better, too. I have only had one crown fall off in the three to four years I've been using EZPEDO crowns, and I'm certain it was my fault. As I mentioned earlier, I have no financial interest in EZPEDO; I just have tried all the other options, and these work best for me. You are bound to have some that fail at first until you develop your ideal schtik (talent/style of performance). I have found that if I'm 100 percent honest with the prognosis, parents are always grateful I tried my best. Feel free to contact me at drlevi@att.net if you have questions. Good Mazel! (May this drip of inspiration from your soul not dissipate but rather have a positive lasting effect on all the children you help)!
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A LOOK BEHIND THE SCENE True innovators create their own content and that’s exactly what we do at EZPEDO. So remember, the beautiful pictures of smiling children in our ads are not stock photos, they’re all unique because they’re our patients.
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© Copyright 2016 EZPEDO MAGAZINE, a subsidiary of EZPEDO, Inc. All Rights Reserved.
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