implantologyinpossiblewhat’sRedefiningsystemsurgicalroboticonlyandfirstDentistry’sRobotic-assisted dental implant technologyplacement Dr. Bruce Smoler Dental infections: help avoid antimicrobial resistance — part 1 Wiyanna K. Bruck, PharmD, and Jessica Price Company spotlight CareCredit — Financing Simplified Aarohi Dental Applying robotics to implants PROMOTING EXCELLENCE IN IMPLANTOLOGY AAID Special Section n 4 CE Credits Available in This Issue* Fall 2022 Vol 15 No 3 implantpracticeus.com
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Mali Schantz-Feld, MA, CDE (Managing Editor)
Investing in technology and ourselves
A s the seasons begin to change for much of the country, many of us will also be looking forward to changes in our practices. The end-of-the-year meet ing with dental accountants often includes talk of larger pur chases to offset taxes and to take advantage of a successful financial year. Inside this edition of Implant Practice US, you will find information on exciting technology at the forefront of implant dentistry. Whether you are looking at enhanced scanning and digital planning solutions, in-office fabrication via 3D printing, 5-axis milling units, or even robotic-assisted implant surgical units, it is all at your fingertips. I encourage every implant dentist to become familiar with the bleeding edge of technology in our field, even if the price tags and time and training investment seem too much to consider. It was not long ago that dental cone beam units were a luxury with invoices rivaling the new robotic surgical units, and now they are ubiquitous in dental implant offices and are considered the standard of care for diagnosis and treatment planning of implant cases. My friend and mentor, Dr. Justin Moody, was the first dentist to purchase a CBCT in the state of Nebraska for a cool $216,000 in 2006. Many considered the investment to be excessive and a bad financial decision, including Justin’s rancher father in his hilar ious recounting of the purchase, but now it would be difficult to find an implantfocused dentist without one. Many high-quality CBCTs are now available for less than $75,000 and are a staple in general dentistry, orthodontics, endodontics, and surgery. So do not wave off the newest entrants of high-price technology in dental implants; robotics are now flirting with standard-of-care discussions — it may be in 15 years’ time, but no one should be caught flat-footed. The fall also brings with it one of my favorite annual events, the AAID Annual Conference. This year it is hosted in Dallas, and there is no better avenue for explor ing all of these technologies in implant dentistry than the conference’s vendor exhibit hall. Investments in ourselves are more important than large investments in technology. Whether an investment is an implant continuum, advanced surgical or restorative courses, or networking with like-minded professionals, the AAID Annual Conference is a conduit to all of these opportunities. I was honored last year to receive my Diplomate in the ABOI at the Annual Conference and am delighted to attend this year to witness the recognition of my close friends and colleagues, Drs. Josh Nagao and Andrew Farkas, as they receive their own Diplomate designa tion. They and 38 other extraordinary dentists have made a goal a reality this year to receive the highest credential currently bestowed upon implant dentists in the United States, requiring several years and several hundred hours of implant-focused CE, a grueling 200-question written exam, and a live oral exam defending their own cases and proving their deep understanding of all things implant dentistry. Con gratulations to them and the class of 2022 ABOI Diplomates, AAID Fellows, and Associate Fellows. I look forward to advancing organized implant dentistry together in the years to come!
Steven Vorholt, DDS, FAAID, DABOI, is a general dentist who focuses on dental implant surgery and restoration. He is currently the Clinic Director of the New Horizon Surgical Center in Tempe, Arizona. He is also the Implant Director for Implant Pathway and is on the faculty for NYU Langone’s AEGD program at the New Horizon Dental Center. Dr. Vorholt is a Fellow in the AAID and a Diplomate in the ABOI. Dr. Steven Vorholt
Jeffrey Ganeles, DMD, FACD Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Ara Nazarian, DDS Jay B. Reznick, DMD, MD Steven Vorholt, DDS, FAAID, DABOI Brian T. Young, DDS, MS CE Quality Assurance Board Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA
1implantpracticeus.com Volume 15 Number 3 INTRODUCTION
Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher)
© MedMark, LLC 2022. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.
Lou Shuman, DMD, CAGS
ISSN number 2372-6245
Fall 2022 n Volume 15 Number 3
Editorial Advisors
2Implant Practice US Volume 15 Number 3 TABLE OF CONTENTS COMPANY SPOTLIGHT CareCredit — Financing Simplified PUBLISHER’S PERSPECTIVE Calculated risks add up to greatness Lisa Moler, Founder/CEO, MedMark Media............................... 6 AAID SPECIAL SECTION Cool Jaw .................................. 14 LOCATOR® implant system 15 CONTINUING EDUCATION Dental infections: help avoid resistanceantimicrobial—part1 Wiyanna K. Bruck, PharmD, and Jessica Price start their discussion on the judicious use of antibiotics in the dental practice ......................................... 16 128COVER STORY Aarohi Dental — applying robotics to implants Cover image of Dr. Sathish Palayam courtesy of Neocis.
4Implant Practice US Volume 15 Number 3 TABLE OF CONTENTS PRODUCT PROFILES The OsteoGen® Plug The one-step bone-grafting solution for socket preservation without a membrane 28 Panthera Dental CAD/ CAM SUB Implant™: a new approach (part 2) Marc Desjardins asks, “K1 div. C-h diagnosis — now what are your options?” ......................................... 30 LEGAL MATTERS Implications of the False Claims Act Kerry Cahill, Esq., discusses how practitioners need to protect themselves even in altruistic circumstances ................................32 PRACTICE DEVELOPMENT Should you be billing medical insurance instead of dental? Rose Nierman and Courtney Snow discuss the steps you can take to help patients access care, especially for larger cases 36 LEGAL MATTERS Navigating malpracticedentallawsuits — part 1 Kristin Tauras, JD, guides dental specialists through the legal elements .......................................... 38 Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter CONNECT with us on social media www.implantpracticeus.com 22CONTINUING EDUCATION Robotic-assisted dental implant placement technology: overview, implementation, and case report Dr. Bruce Smoler discusses the clinical benefits of robotic-assisted implant surgery *Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://implantpracticeus.com/category/continuing-education/
Sales Assistant & Client Services Melissa melissa@medmarkmedia.comMinnick
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One of the most interesting parts of being a publisher is that I get to meet people and read articles by people who take calculated risks. In the dental business, that usu ally entails devising new techniques or products. Sometimes it seems that everything that could be invented has already been invented. Who would have thought that implants could have a success rate of up to 98% or that sleep-disordered breathing could be treated at a dental practice? Remember when braces were just metal wires, brackets, and bands? Now we can chose from lingual braces, 3D-printed brackets, clear aligners, and many other ways to create perfect smiles in less time than ever before. Endodontics also has come a long way too — lasers, files of different shapes, sizes, and materials, and cleaning and disinfection instrumentation that leads to less pain and positive outcomes. All thanks to dentists, scientists, and nonclinical people who saw a problem that needed not just a solution, but their solution.
“Be not afraid of greatness. Some are born great, some achieve greatness, and others have great ness thrust upon them.” – William Shakespeare Each of us has our own idea of greatness. While some want to stand in the spotlight, others want to aim the spot light. It’s all a matter of perspective and how you choose to see the light. On the news and social media, we see people who have achieved success. Copycats abound — whether it’s wearing the same styles or seeking the same lifestyle. But what really is success? After so many years in the pub lishing business, I have seen many people, both doctors and nonclinical, achieve success. But the ones who achieve greatness have something in common. They don’t do what everyone else is doing. They find their passion, think outside of the box, and take calculated risks to reach their goals.
Managing Editor Mali Schantz-Feld, MA, CDE
To your best success, Lisa MedMarkFounder/PublisherMolerMedia
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6Implant Practice US Volume 15 Number 3 PUBLISHER’S PERSPECTIVE
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Calculated risks add up to greatness
April socialmedia@medmarkmedia.comGutierrez
Whatever profession you chose, and whatever path you take, make sure that you follow your passion. Work hard and build a trusted team to help reach your goals. While your dreams are becoming reality, there are sure to be some nightmares, even during the day. But the things you lose sleep over can bring you satisfaction beyond your wildest dreams. We all have greatness in us. We just have to have the courage to discover it and share it.
Hana support@medmarkmedia.comKahn
In the fall issue, our innovative authors have reported on interesting and edu cational content. Our cover story takes a look at how Yomi® robotic technology brought Aarohi Dental intraoperative flexibility, reduced surgery times, and confi dence to accept more challenging cases. Our CE by Dr. Bruce Smoler delves into the evolution of robotic haptic dental implant technology — the advances, implementa tion, and review of a case study. Wiyanna K. Bruck, PharmD, and Jessica Price start a two-part series on dental infections and how to avoid antimicrobial resistance. Our AAID special section features details on the exclusive, hands-free patented designed postoperative hot/cold therapy wraps from Cool Jaw® as well as the trustable and affordable LOCATOR® implant from Zest Dental.
Ultimate comfort and reliability for the best results Boyd Industries’ specialized equipment for implant dentistry ensures patient comfort and your peace of mind. Our latest surgery chair innovation, the Bluetooth-enabled wireless foot control, enables the surgery team to safely operate the chair within a range of 10 feet without the worry of cables or obstructions. Products like our S2614 Surgery Chair, mobile tables and carts, S300 surgery lights and more are key to managing a busy dental implant practice.Start the conversation today and learn what it means to have your equipment “Builttolast.Builtforyou.BuiltbyBoyd.” NEW!wirelessBluetooth-enabledfootcontrol
The Yomi Robotic System within an operatory at Aarohi Dental
The learning curve associated with Yomi has been very manageable, and the support we’ve received from the Neocis team has been topnotch. Incorporating a new clinical technology into your practice can be a disruptive, overwhelm ing experience, but that wasn’t the case as we got up and running with our Yomi system. Once we purchased our robot, our team received two full days of in-depth, hands-on training, and a com prehensive 90-day plan to build competency. The onboarding process was seamless — any dental practice can do it. It felt as though the Neocis team was with us every step of the way, helping us build the skills and knowledge needed to become a successful robotic implant practice. The whole experience felt consultative and tailored to our unique needs.
Describe your onboarding process with Yomi®
My name is Dr. Sathish Palayam, and my wife, Dr. Minal Narayan, and I practice dentistry together in New Bedford, Massachusetts. At Aarohi Dental, we deliver a wide range of services with a focus on robot-assisted implant placement as well as LANAP and LAPIP procedures. I’ve been prac ticing as a general dentist for more than 2 decades and have always been passionate about using cut ting-edge technologies to deliver the best possible patient care. We have such an amazing team at Aarohi Dental, and we take great pride in provid ing a tech-forward approach to dentistry within a compassionate, patient-focused environment.
Sathish G. Palayam, DDS, and his team at Aarohi Dental in New Bedford, Massachusetts
8Implant Practice US Volume 15 Number 3 COVER STORY
Aarohi Dental — applying robotics to implants
Tell us about yourself and your practice
First, I should mention the demo experience, which was incredibly valuable and convenient. I reached out to Neocis (manufacturer of the Yomi platform) to schedule a demo at which point I learned about the Yomi Mobile Showroom. After working with us to find a time that fit our schedule, a Neocis sales representative brought a Yomi robot right to our office in one of the Neocis demo buses. This gave my team and me a chance to learn more about robot-guided implant placement and get our hands on the system. I was so glad my staff had the opportunity to see the robot in action and experi ence firsthand how user-friendly the platform is.
Dentistry is one of my biggest passions in life, and I treat every patient who walks into our office like family. Just as I would want my family to receive the best possible treatment, I strive to deliver the highest quality of care for each one of my patients. I take the comfort and well-being of my patients very seriously. By embrac ing and regularly using our robotic system and other high-tech clinical technologies, we are able to alleviate some patient fears,
In addition to intraoperative flexibility, robotic guidance allows for excellent visualization and irrigation of the osteot omy site throughout a procedure. Unlike surgical guides, which can significantly obscure parts of the mouth, a robot-assisted approach allows me to freely irrigate the surgical site and main tain a clear field of view. The haptic, visual, and audio feedback Yomi provides throughout a procedure helps prevent me from deviating from the angulation and position I’ve pre-planned. This real-time assistance gives me tremendous peace of mind in the operatory.
By embracing and regularly using our robotic system and other high-tech clinical technologies, we’re able to alleviate some patient fears, execute minimally invasive treatment when possible, and deliver on our promise of providing truly life-changing dental care.
execute minimally invasive treatment when possible, and deliver on our promise of providing truly life-changing dental care. I feel good knowing my patients are receiving treatment facilitated by the best technology available. When you think about the robotic workflow compared to that of a static-guided approach, what advantages have you encountered?
YomiPlan software provides the clinician with visual guidance during implant insertion and drilling procedures
9implantpracticeus.com Volume 15 Number 3 COVER STORY
A tooth-borne splint holds the fiducial array for registering the robot to the patient’s anatomy via the CT scan
How has your practice changed since adopting the Yomi robotic system? What were you using before, and what prompted you to switch?
My practice has changed significantly since adopting robot ics. The team is excited about how efficient Yomi has made our planning process, and we have a strong sense of confidence going into every surgery. It’s also great to see just how interested in the system patients are. Many patients are generally aware that robotic devices are now commonplace across a wide range of medical procedures. Some have read about or seen news segments on this new surgical methodology within implant den tistry specifically. Patients are initially intrigued by the idea of a robot-assisted procedure, and after hearing us talk about it in more depth, they get even more excited to have their implant(s) placed with the help of Yomi. Before Yomi, I was using static guides in many of my implant cases. I found this method too cumbersome and time-consum ing. I wanted to be able to move from consultation to placement more seamlessly and wanted to eliminate treatment delays due to ill-fitting guides. I saw many of my col leagues around the country incorporating robotics into their practices, so I decided to dive in. With Yomi, I no longer have to wait on a third-party lab to manufacture and ship me guides or fuss with 3D printing, which allows me to perform same-day surgery in many cases. We also don’t need to plan as far ahead. The Yomi platform has truly been a game changer for my practice. What do you like most about being a robotic clinician? How does it make you feel?
In general, robot-assisted implant placement provides much more flexibility than surgical guides. With robotic guidance, I’m not limited to certain implant systems or drill lengths. When a case calls for a change in what has been planned for, static guides simply can’t accommodate those changes while main taining their intended level of accuracy. Having the intraopera tive freedom to modify my treatment plan, change drill lengths, or switch to an implant with a different specs on the fly are some of the biggest benefits of robot-assisted surgery compared to sur gical guides. The days of having to reschedule procedures due to an ill-fitting guide or missing parts are over.
How has the business side of your practice before-and-after Yomi changed?
Our treatment times have significantly improved since we went live with Yomi. In fact, we’ve been able to reduce our average surgery time by almost half. Typically, I can go from CT scan to placement in about 25 minutes. This helps our team establish and stick to a more predictable schedule and deliver a timely in-office experience for patients. As mentioned previ ously, we also no longer need to reschedule appointments due to a guide that doesn’t correctly fit a patient or guide kits with missing parts.
We’ve seen a steady increase in the number of patients inquiring about the robot and scheduling consultations. Before installing Yomi, each year I was placing roughly 200 implants and performing about four to five full-arch cases. Now I’m using the robot for all my implant cases, which has given me the con fidence to plan and execute more surgically and prosthetically challenging cases. With Yomi, we’re performing three to four full-arch cases a month, and we’re on pace to hit 400 implants this year alone. In short, Yomi has made a huge difference in our ability to scale our implant services and help more patients. We’re looking to continue growing our business further. I don’t think we’re even close to our ceiling yet.
Dentistry has always been a distant cousin to medicine and has lagged behind when it comes to technological advances. Yomi has given dental professionals an opportunity to set their practices apart by seamlessly pivoting to robot-assisted implant placement. When it comes to clinical outcomes, oper ational efficiency, and practice expansion, the results speak for themselves. IP Dr. Palayam (above) during an implant procedure using the software as a visual guide while the robot guides the drill into position. Dr. Palayam (right) and his team tend to a patient as they prepare the patient for robot-assisted implant treatment
How have robotics affected your treatment times?
What kind of reaction have you received in your community since adopting robotics?
What would you say to your peers who are still placing implants freehand or with static guides?
Yomi not only is a game changer in the operatory, but also is a very powerful marketing tool. Once we started to hit our stride as a robotic implant practice, the Neocis team worked with us to launch a successful PR campaign that ultimately resulted in an exclusive segment with a local news station and a front-page story in our community newspaper. We saw an immediate lift in interest after that coverage. Since then the Aar ohi Dental team has been recognized by Neocis as a Yomi Gold Center of Excellence, and I have been named a Yomi Diamond Doctor of Excellence, which has helped stir up interest among prospective patients. More and more patients are calling and stopping by to learn about robotic implant treatment and how it impacts clinical outcomes. People are clearly gravitating to this new technology, and we’re happy to explain why we use it for every implant case.
10Implant Practice US Volume 15 Number 3 COVER STORY
Yomi® assists clinicians during pre- and intra-operative phases of implant placement, making it easy to create precise treatment plans, operate confidently and efficiently, and tap into the many advantages of robot-guided implantology. With three distinct modes to choose from, the expanding YomiPlan™ software suite gives you the freedom to adopt a robotic workflow that aligns with your team’s preferred clinical approach.
FIND WORKFLOWROBOTICYOUR Deliver a better patient experience | Boost practice efficiency | Expand your treatment offerings Dentistry’s first and only robotic surgical system YomiPlan Dynamic Drill-tip planning with CT verification NEW YomiPlan Go The speed of freehand surgery meets robotic precision YomiPlan Complete Detailed digital planning for unsurpassed accuracy
A robotic workflow for every practice
Yomi is the first and only FDA-cleared robot assisted dental surgery system. Yomi is a computerized navigational system intended to provide assistance in both the planning (pre-operative) and the surgical (intra-operative) phases of the dental implantation surgery. The system provides software to preoperatively plan dental implementation procedures and provides navigational guidance of the surgical instruments. Yomi is intended for use in partially edentulous adult patients who qualify for dental implants ©2022 Neocis, Inc. NEOCIS and YOMI are registered trademarks of Neocis, Inc. All rights reserved. LB-1027-00 RevA. (066/0822)
1. Place a CareCredit practice display that features your custom link QR code in your reception area and through out your practice to let all patients know you accept CareCredit. This can be especially helpful for the 12.7+ million current CareCredit cardholders who may already have a way to pay for care.
12Implant Practice US Volume 15 Number 3 COMPANY SPOTLIGHT
It’s simple. Accepting CareCredit to help more patients get care is easier than ever because there are so many ways to learn about and apply for the CareCredit credit card. If your practice management software has CareCredit integrated, you can access the payment calculator, help patients see if they prequalify, and apply within the software (at their request),* saving your team time and helping improve efficiency. Or you can use your cus tom link to have patients learn about and apply privately from their home computer or on their smart device while in the prac tice. It’s financing simplified, and here’s how it works:
*Exceptmycustomlink.forproviders
for ideas on how to celebrate your #AwesomeOM. And all #AwesomeOMs are invited to the same site for a special experience just for them! Did you know that 1 out of every 10 residents in the United States has or has had a CareCredit credit card?**
in California who are prohibited under state law from submitting applications on behalf of patients for certain healthcare loans or lines of credit, including the CareCredit credit card. **CareCredit 2021 Analytics and 2021 U.S. Census Bureau IP Visit https://omam.carecreditvirtual.com
September is Office Manager Appreciation Month.
If you have yet to accept the CareCredit credit card, join a network of more than 260,000 provider and health-focused retail locations by calling 800-300-3046 Option 5.
CareCredit — Financing Simplified
Youappointment.nolongerneed to share the details about CareCredit, assist with the application, or communicate credit decisions, which may save your team some valuable time. And your patients no longer need to share sensitive information for the application. It’s that easy and convenient — for patients and for your team.
If you accept CareCredit and would like to get your custom link and more valuable resources that make financial conver sations easier, call 800-859-9975, or visit www.carecredit.com/
2. Have patients scan your custom link QR code with their smart device to learn about CareCredit, see if they pre qualify (without impacting their credit bureau score), and apply for the CareCredit credit card privately. You can also use provided custom link digital assets to enable patients to see if they prequalify and apply before their
You proactively recommend the CareCredit credit card to patients. Have patients scan your custom link QR code where they can privately see if they prequalify, apply and pay with CareCredit. #1: #2: It’s financing simplified. To learn more scan this QR code. If you’ve yet to add the CareCredit credit card as a financing solution call 800-300-3046 (option 5). MMIMQ322DA It takes two steps to help patients get care
14Implant Practice US Volume 15 Number 3 SPECIAL SECTION SECTIONSPECIALAAID
Cool Jaw ® Cool Jaw® has paved the way to postoperative hot/cold therapy through the creation of our exclusive, handsfree, patented designed wraps. The hands-free Cool Jaw system reduces postoperative swelling and discomfort and allows patients to recover in a convenient manner. Combine with our extensive variety of hot/cold gel packs to create a post-op recovery solution that best suits your patients. Our Soft-sided Round Gel packs are a convenient, post-op cold therapy option for after numerous procedures, including implants and cosmetic injections such as Botox. These packs come in a variety of color options to match your office or sim ply add an element of fun to any procedure. Choose from bright solid colors as well as eye-catching glitters. These reusable gel packs are 4 inches in diameter and remain flexible when fro zen, allowing for uniform cold therapy. Take the Cool Jaw products to the next level and add customization! Customization is a subtle, yet effective way to promote your practice and enhance your professional image. Cool Jaw helps you to continue promoting your practice long after the surgery date. Visit us at Booth No. 706, and ask for a FREE SAMPLE! Visit Cool Jaw at AAID Booth No. 706
relationships
your patients
Learn more today and schedule an in-office LOCATOR Life presentation LIVE WITH CONFIDENCE FROM PARTIAL TO FULL EDENTULISM, YOU CAN LOCATOR ATTACHMENTREMOVABLESYSTEM LOCATOR R-TXATTACHMENTREMOVABLESYSTEM LOCATOR OVERDENTUREIMPLANTSYSTEM LOCATOR FIXED COMINGSOON LOCATOR ATTACHMENTROOT
Always one to innovate, Zest Dental Solutions is prepar ing to release a paradigm-shifting and less invasive fixed fullarch solution that empowers clinicians to expand their patient base and grow their practice. Be on the lookout in the coming months for more on this new twist on LOCATOR. And best of all, it will be compatible with our trusted and universally chosen LOCATOR abutments and workflows! Offer upgraded, affordable quality of life with LOCATOR FIXED. Stop by booth No. 801 at AAID, September 21-24, in Dal las, Texas, for more information on LOCATOR overdenture solutions and the continuum care they provide, or go to www. ZestDent.com. Visit Zest Dental Solutions at AAID Booth No. 801 the complete spectrum from Zest. See how a LOCATOR Life promotes ongoing with by giving them live life with more and confidence. Offer your patients for every stage of their journey with LOCATOR systems solutions today.
outstanding aesthetics and clinically proven performance
Clinicians can confidently place LOCATOR implants with Zest Dental’s premium, intuitive surgical kit, which now includes Diamond-Like Carbon (DLC) coated drills for enhanced visibil ity, increased wear resistance, and reduced friction.
freedom to
800.262.2310 • WWW.ZESTDENT.COM Discover
Premium and predictable results at a less than premium price Building on the tried-and-true LOCATOR® platform, the trusted and affordable LOCATOR implant system from Zest Dental Solutions offers all diameters for both stan dard and narrow ridges. By reducing the cost of implant and LOCATOR pairings by 50% or more, LOCATOR implants exponentially increase the universe of treatable cases, allowing clinicians to provide overdentures to a wider range of patients. LOCATOR implants are available in 2.4 mm, 2.9 mm, 3.5 mm, 3.9 mm, 4.4 mm, and 4.9 mm sizes and are designed to work with original LOCATOR abutments as well as the next generation LOCATOR R-Tx abutments, which deliver an increased range of divergence and enhanced durability.
a
In addition, LOCATOR implants work seamlessly with ENCOMPASS™, an all-inclusive, digitally powered overden ture treatment solution, through a partnership with Absolute Dental Services. Driven by precision and efficiency, ENCOM PASS can reduce patients visits by 50%, while providing them with customized, boutique-quality overdentures.
LOCATOR ® implant system
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15implentpracticeus.com Volume 15 Number 3 SPECIAL SECTION SECTIONSPECIALAAID
• Identify antibiotic treatment for specific dental infections.
Dental infections: help avoid antimicrobial resistance — part 1
Jessica Price is a Doctor of Pharmacy candidate at South College School of Pharmacy in Knoxville, Tennessee. She has a Bachelor of Arts degree in Advertising and Public Relations, with minors in Business and English Writing from the University of Central Florida. Price completed her post-baccalaureate track in Biology at Florida International University and at the University of Tennessee, Knoxville.
This self-instructional course for dentists aims to provide an overview of judicious use of antibiotics in the dental practice.
• Recognize considerations related to the administration of medications for pedi atric patients.
2 CREDITSCE
Educational aims and objectives
Implant Practice US subscribers can answer the CE questions by taking the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:
Expected outcomes
Bacterial pathogens implicated in dental infections
16Implant Practice US Volume 15 Number 3 CONTINUING EDUCATION
An odontogenic infection is a frequently encountered infec tion of the alveolus, jaws, or face that begins from a tooth or from its supporting structures. The most common cause of den tal infections are dental caries, deep filling or failed root canal treatments, pericoronitis, and periodontal disease. The infection remains where it originates at the tooth or can spread into adja cent tissue or structures. The course of infection depends on sev eral elements, including the virulence of the oral pathogens, the host resistance factors, and the surrounding anatomy.10
Wiyanna K. Bruck, PharmD, BCPS, BCIDP, BCPPS, is an assistant professor of Pharmacy Practice at South College School of Pharmacy as well as an Antimicrobial Stewardship and Emergency Medicine Clinical Pharmacist practicing at a community hospital. She teaches infectious diseases as well a pediatric pharmacotherapy to both pharmacy and physician assistant students. Dr. Bruck received her bachelor of science in biology, followed by a Doctorate of pharmacy degree, then completed a postgraduate pharmacy residency program at William Beaumont Hospital in Troy, Michigan. Her research interests include antimicrobial stewardship, infectious diseases, as well as food allergy awareness. Dr. Bruck is Board-certified in pharmacotherapy, infectious diseases, and pediatrics.
Wiyanna K. Bruck, PharmD, and Jessica Price start their discussion on the judicious use of antibiotics in the dental practice
Introduction
Antibiotics are one of the greatest medical advances since their first introduction in the late 1920s. Alexander Fleming’s breakthrough discovery of penicillin paved the way for a domain of medicine that has enabled once deadly infections to be read ily treatable.1Excessive antibiotic use comes with steep consequences of real-time adverse effects; downstream antibiotics resistance (also referred to as collateral damage); and superinfections, such as Clostridioides difficile. Overuse and inappropriate use of antibiot ics has led to an increased prevalence of resistance, which trans lates to limited effectiveness of antibiotics, increased healthcare cost, and rising mortality rates. Antibiotic resistance is recognized as a global health threat. According to the Centers for Disease Control and Prevention (CDC), approximately 2 million Amer icans are infected with resistant pathogens that result in 23,000 deaths annually.2 The CDC conservatively approximates that 30% of all outpatient antibiotic prescriptions written from 2010 to 2011 were unnecessary.3 If the previous statistic was applied to the 2020 CDC data for number of antibiotic prescriptions written by dental practitioners in the United States, 7.29 million antibiotic prescrip tions would be deemed as inappropriate within that 1 year.4 Judicious antimicrobial prescribing is essential in all fields of healthcare, including dentistry.5-7 The 5Ds of antimicrobial stewardship is a popular concept that should be applied to the appropriate prescribing of antibiotics. The 5Ds, include the right Drug, Dose, Delivery route, Duration of therapy, and De-escala tion.8 Along with the concept of the 5Ds of optimal antimicrobial therapy, the CDC has constructed a Checklist for Antibiotic Pre scribing in Dentistry (see Table 1), which serves as an excellent introduction to concepts that will be discussed in further detail.9
Bacteria that are frequently found in dental infections nor mally comprise the typical oral flora, which include a mixture of gram-positive streptococci (e.g., Streptococcus anginosus,
• Analyze how to determine the drug-of-choice for certain Analyztreatments.eprescribing indications related to duration of treatment.
• Identify bacterial pathogens implicated in dental infections.
Determining the drug-of-choice for the treatment of odonto genic infections requires an understanding of which pathogens are implicated and whether antibiotics are truly necessary. Even when antibiotics are needed to treat dental infections, they might not be the first line therapy, but rather an adjunct after surgical drainage of an abscess, tissue debridement, or below the gum manipulation.
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• Correctly diagnose an oral bacterial infection.
• Implement national antibiotic prophylaxis recommendations for medical concerns for which guidelines exist (e.g., cardiac defects).
• Assess patients’ medical history and conditions, pregnancy status, drug allergies, and potential for drug-drug interactions and adverse events, any of which may impact antibiotic selection.
Pretreatment
• Make and document the diagnosis, treatment steps, and rationale for antibiotics (if prescribed) in the patient chart.
Additionally, the treatment of abscesses depend on the loca tion. If the dental abscess is localized, incision and drainage (I&D) alone is usually sufficient for proper recovery. In these cases, the patient will have a better outcome with a procedural Table 1: Checklist for antibiotic prescribing in dentistry
• Use the most targeted (narrow-spectrum) antibiotic for the shortest duration possible (2 to 3 days after clinical signs and symptoms subside) for otherwise healthy patients.
Most patients with gingivitis or periodontitis can be effec tively treated with mechanical debridement or scaling and root planing (SRP) without the need of antibiotic therapy. In patients that lack a response to SRP alone and have few sites of disease, a onetime local delivery of topical antibiotic can be utilized (e.g., chlorhexidine 2.5 mg chip, doxycycline 10% gel, minocycline 1 mg microsphere, or tetracycline 12.7 mg fiber). In patients with refractory cases that have extensive disease or those with severe or aggressive disease, strong evidence suggests adjunctive sys temic antibiotics. Obtaining a culture to guide therapy prior to initiation is strongly encouraged if feasible.17-19
Streptococcus mutans, Streptococcus intermedius group); anaer obic gram-negatives (e.g., Bacteroides spp, Prevotella spp., Fuso bacterium); anaerobic gram-positives (e.g., Actinomyces spp., Peptostreptococci); and some rarer aerobic gram-negatives such as Eikenella corrodens. In general, the routinely used antibiotic agents (natural penicillin, aminopenicillin, penicillin combined with a β-lactamase inhibitor, and first-generation cephalosporins, tetracyclines, and macrolides) have good empiric coverage of the commonly implicated pathogens with the exception of coverage against anaerobic gram-negative bacilli.11-14 If there is a reason to suspect Prevotella species or other anaerobic gram-negative bacilli such as Fusobacterium or Bacteroides spp. that are positive for β lactamase (e.g., surveillance data suggest high prevalence), metronidazole is often added to the empiric coverage.5
Antibiotics are infrequently necessary for pulpal pain, gingi vitis, and periodontitis. Irreversible pulpitis is characterized by acute and intense pain and is one of the most frequent reasons that patients seek emergency dental care. Antibiotics are not effective at treating pulpal pain, and treatment is not deemed appropriate if the patient has no signs of a spreading infection or systemic symptoms. Most important to note, inappropriate treat ment of pulpal pain does not prevent the development of severe complications. Evidence suggests that combination therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and acetamino phen during meals and at bedtime is an effective way to manage pulpal pain.16 Aside from the removal of the tooth, the usual approach in the management of pulpitis is relieving the pain by drilling the tooth and removing the inflamed pulp and cleaning the root canal. There is no proof of benefit with using analgesics and or antibiotics in irreversible pulpitis.
• Discuss antibiotic use and prescribing protocols with referring specialists.
Abscesses
• Prescribe only when clinical signs and symptoms of a bacterial infection suggest systemic immune response, such as fever or malaise along with local oral swelling.
Staff Education
Antibiotic treatment in dental infections
• Ensure evidence-based antibiotic references are readily available during patient visits. AVOID prescribing based on non-evidence-based historical practices, patient demand, convenience, or pressure from colleagues.
Patient Education
• Educate your patients to take antibiotics exactly as prescribed, take antibiotics only prescribed for them, and not to save antibiotics for future illness.
Pulpal pain, gingivitis, and periodontitis
Most dental abscesses are secondary to dental caries and, therefore, can largely be prevented when basic and consistent preventative oral health measures are followed. Dental infec tions are common, including suppurative infections (abscesses), but not all need to be treated with antibiotics. It is therefore important to elucidate the presence of regional or hematologic spread suggesting disseminated infection and distinguish local versus systemic signs and symptoms of infection.20
• Revise empiric antibiotic regimens on the basis of patient progress and, if needed, culture results.
• Weigh potential benefits and risk (i.e., toxicity, allergy, adverse effects, risk for Clostridium difficle infection) of antibiotics before prescribing.
• Prescribe antibiotics only for patients of record and only for bacterial infections you have been trained to treat. DO NOT prescribe antibiotics for oral viral infections, fungal infections, or ulcerations related to trauma or aphthae.
Prescribing
• Ensure staff members are trained in order to improve probability of patient adherence to antibiotic prescriptions .
• Consider therapeutic management interventions, which may be sufficient to control a localized oral bacterial infection.
However, some experts recommend additional coverage of β-lactamase producing Prevotella and Fusobacterium with amoxicillin/clavulanate or a historic agent combined with met ronidazole. Cephalexin — a first-generation cephalosporin with similar gram-positive aerobic coverage as the historic first line agents but that lacks robust anaerobic activity — is the antibi otic of choice in those with a history of penicillin allergy without history of anaphylaxis, angioedema, or hives. In patients with a severe allergy to penicillin agents or other β-lactams, azith romycin or clindamycin can be prescribed. When deciding on an agent to use for dental infection, consider azithromycin has higher rates of gram-positive aerobic resistance and clindamycin substantially increases the risk of developing a Clostridioides dif ficile infection but has much more robust coverage of mouth flora with the exception of Eikenella. Therefore, the risks and benefits of treatment in patients with a severe β-lactam allergy should be weighed prior to prescribing an alternative agent.20-23 A summary of antibiotics used for dental infections in adult patients as well as red flags for progressing infection are available in Table 2.
pathogens ∆ Add-on agent if Prevotella is suspected # Considered
amoxicillin,
± Addition
or
In patients who have severe systemic illness, in-patient treatment with intravenous antibiotics initially is generally justified.
If antibiotics are deemed necessary for either non-suppura tive or suppurative odontogenic infections the agent selection is based on the coverage of oral typical oral pathogens. His torically, the drugs of choice were amoxicillin or penicillin V potassium. Although both agents were regarded as first line, amoxicillin was generally preferred due to having more robust gram-negative anaerobic coverage, less frequent dosing, ability to be taken on an empty stomach, and a lower incidence of gastrointestinal side effects.
* Only consider in patients intolerant or
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¥ More expensive
If treatment is initiated for non-suppurative indications (e.g., gingivitis and periodontitis), antibiotic therapy is usually until oral lesions have healed and pain has subsided, typically 5 to 7 days. Antibiotic duration of therapy for suppurative infections is usually 3 to 7 days depending on clinical improvement. The implementation of follow-up for patients initiated on antibiotic therapy is of utmost importance. Dentists should reevaluate patients for improvement or lack thereof with an in-person visit, telehealth appointment, or follow-up phone call. In gen eral, most patients can stop taking antibiotics after 24 hours of complete symptom resolution, irrespective of re-evaluation after 3 days. If patient symptoms do not improve with initial therapy, clinicians should consider broadening therapy by either add ing metronidazole to first- line therapy or discontinuing initial therapy and beginning amoxicillin/clavulanate (both options are typically for a 7-day duration).23 With adequate source control, short antibiotic courses have been found to be effective. A prospective clinical study was Table 2: Antibiotics for dental infections in adult patients15,20
clindamycin 300 – 450 mg PO Q6h# doxycyclineOR 100 mg PO BID azithromycinOR 500 mg PO Day 1 then 250 mg PO x 4 days ampicillin/sulbactam 3 g IV Q6h ceftriaxoneOR 2 g IV every 24 hours + metronidazole 500 mg IV q8hPorphyromonas,actinomycetemcomitans,(AggregatibacterPeriodontitisTreponema, Prevotella) (streptococci,Abscess Peptostreptococcus spp, Bacteroides, and other oral anaerobes [+ Pseudomonas and other gram-negative bacilli IF patient is immunocompromised])
intravenous;
amoxicillin/ clavulanate 250 –500 mg PO BID/ TID or 875 mg PO BID¥ clindamycin 300 – 450 mg PO Q6h# moxifloxacinOR 400 mg PO daily* levofloxacinOR 750 mg PO daily + metronidazole 250 – 500 mg PO BID/TID∆ ampicillin/sulbactam 3 g IV Q6h aqueousOR penicillin IV = BID = twice daily; TID = three times daily; q6h = every 6 hours; WBC = white blood cell than more gastrointestinal upset (mainly diarrhea), more broad coverage includes anaerobes gram negative 1st line in severe cases, those with penicillin/β-lactam allergy, if anaerobes predominant, does NOT Eikenella allergic to penicillins/β-lactams/clindamycin of agent with Pseudomonas and other gram-negative bacilli coverage if patient is immunocompromised
Duration of treatment
and
aeruginosa
I&D to obtain source control in comparison to the ineffective use of antibiotics alone. If the abscess is in the periapical region, treatment, including I&D, endodontic therapy, and adjunctive antibiotics are recommended.20-22
Antibiotic Dose Forms Usual Dosing Common Side Effects (streptococciGingivitis [e.g., Streptococcus mutans), Actinomyces spp.]) amoxicillin 500 mg PO TID + metronidazole 250 – 500 mg PO BID/TID∆ TID250amoxicillin/clavulanateOR–500mgPOBID/or875mgPOBID¥
cover
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G 2 – 4 million units + metronidazole 500 mg IV q8h Piperacillin/tazobactamOR 4.5 g IV every 6 hours± Red flags: might indicate spreading infection Tachycardia, tachypnea, raised tongue/drooling, difficulty speaking, swallowing, breathing, lymphadenopathy, pyrexia, trismus, dehydration, hypotension, ↑ WBC, periorbital cellulitis PO = oral,
ablecapsule,Suspension,inject- 10–25 mg/kg/day in divided doses every 8 hours (max 450 mg/dose) Methicillin resistant Staphylococcus aureus (MRSA) 30–40 mg/kg/day in divided doses every 6–8 hours
Constipation, diarrhea, stomach pain, stomach cramps, nausea, vomiting, metallic taste, headache, joint pain
injectabletablet,Suspension,capsule, Children ≥ 6 months up to 16 years old: 10 – 12 mg/kg on day 1 (max of 500 mg), followed by 5 – 6 mg/kg once daily x 4 days (max of 250 mg/day) [total duration of 5 days]
Black Boxed Warning: Carcinogenic in rats and mice, unnecessary use should be avoided; ingestion of alcohol as a beverage or an ingredient in medications or propylene glycol-containing products should be avoided
Children and adolescents (anaerobic skin and bone infections): 15–50 mg/ kg/day in divided doses 3 times daily (max of 2,250 mg/day)
Penicillin V potassium (penicillin/β-lactam antibiotic)
tablet,chewableSuspension,tablet,capsule Infants > 3 months of age < 40 kg: 25–45 mg/kg/day in divided doses every 12 hours (max 875 mg/dose)
ablecapsule,releasetablet,Suspension,extendedtablet,inject-
Headache, stomach pain or diarrhea, nausea, vomiting Option for patients with Type 1 allergy to penicillin or cephalosporin antibiotics; can cause cardiac arrhythmias in patients with preexisting cardiac conduction defects β-lactam antibiotic)
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In addition, pediatric patients still have the same risks of side effects from antibiotics as adult patients, including the potential of increased resistance, allergic reactions, development of Clostridioides difficile infections, drug interactions, and common as well as rare side effects. Pediatric patients as young as 4 years old were found to harbor multidrug resistant bacteria in their mouths because of the overuse of antibiotics.28 Moreover, some antibiotics routinely used in adults have either not been studied in children or have demonstrated concern in animal models or in pediatric case reports. Tetracyclines and fluoroquinolones are two classes of antibiotics that are generally avoided in children.29
Antibiotic treatment — pediatric considerations
Antibiotic Dose FormsUsual Dosing Common Side EffectsComments
cephalosporin/(1stCephalexingeneration
Nausea, diarrhea,vomiting,diaperrash
performed over a 3-year period with the objective to evaluate shortened courses of antibiotics in the management of dentoal veolar abscesses. After abscess drainage, patients were treated with amoxicillin, erythromycin, or clindamycin. A robust 98.6% of the 759 patients had full resolution of symptoms at day three of treatment, and antibiotics were discontinued at that time. The study concluded that the duration of antibiotics in most patients with acute dentoalveolar infections can safely be 2 to 3 days, provided I&D has been performed.26
Nausea, vomiting, head ache, diarrhea May take with or without food
tabletchewableSuspension,tablet, Infants > 3 months of age: 25–45 mg/ kg/day in divided doses every 12 hours (max 875 mg/dose; dosed off the clavulanate component)
With or without meals, w/meals increases absorption and decreases GI upset. ES needs to be taken with food. Use the lowest dose of clavulanate to decrease GI side effects (macrolideAzithromycinantibiotic)
Liquid solution, tablet Children and adolescents: 25–50 mg/ lg/day in divided doses every 6 hours (max of 2 grams/day)
Administer with or without food (with food decreases stomach upset, but can also decrease absorption); take with fluid and remain in upright position to decrease throat irritation)
Nausea, discoloration,abdominalvomiting,pain,tonguediarrhea Should be taken on empty stomach for adequate absorption
ClavulanateAmoxicillin/ (penicillin/ β-lactam- β-lactam inhibitor antibiotic)combination
tablet,Suspension,capsule Infants, children, and adolescents (mild–moderate infection): 25–50 mg/kg/day divided every 6 to 12 hours [max of 2 grams/day]) Severe infection: 75–100 mg/kg/day divided every 6–8 hours (max of 4 grams/day)
The administration of medications for pediatric patients is even more complex compared to adults because of the need to dose based on the child’s weight and take into consideration concerns that are not applicable to adults. Adverse reactions caused by antibiotics are the most commonly reported reason for emergency department (ED) visits by those who are under the age of 18, which is represented by 140,000 ED visits each year specifically due to antibiotic adverse drug events.27
antimicrobial)(nitroimidazoleMetronidazole
Volume 15 Number 3 CONTINUING EDUCATION
Stomach pain, diarrhea, nausea, vomiting, bad taste in mouth Black boxed warning: Clostridioides difficile-associated diarrhea; Option for patients with Type 1 allergy to penicillin and/or cephalosporin agents; no longer recommended for infective endocarditis prophylaxis antibiotic)(tetracyclineDoxycycline ablecapsule,releasetablet,Suspension,delayedtablet,inject- Children > 8 years old: 2.2 mg/kg/dose every 12 hours (max 100 mg/dose) Tooth diarrhea,nausea,discoloration,vomiting,lackofappetite
Table 3: Antibiotics for dental infection in pediatric patients33-41
Amoxicillin (penicillin/ β-lactam antibiotic)
Nausea, vomiting, abdom inal pain, diarrhea Should not be used in those with a history of anaphylaxis, angioedema, or urticaria with penicillin agents (lincomycinClindamycinantibiotic)
33. American Academy of Pediatric Dentistry. Use of antibiotic therapy for pediatric dental patients. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Den tistry; 2021. American Academy of Pediatric Dentistry. Useful medications for oral conditions. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2019. 34. Amoxicillin. Pediatric and Neonatal Lexi-Drugs. Lexicomp. https://online.lexi/com Lexicomp; 2022. Accessed June 23, 2022. 35. Amoxicillin/Clavulanate. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https:// online.lexi/com. Accessed June 23, 2022. 36. Azithromycin. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. . https://online.lexi/com. Lexicomp; 2022. Accessed June 23, 2022. 37. Cephalexin. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022. 38. Clindamycin. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022. 39. Doxycycline. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022. 40. Metronidazole. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022. 41. Penicillin V potassium. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online. lexi/com. Accessed June 23, 2022. IP
28. Ready D, Bedi R, Spratt DA, Wilson M. Prevalence, proportions, and identities of antibiotic-re sistance bacteria in oral microflora of healthy children. Micro Drug Resist. 2003;9(4):367-372.
24. Jaworsky D, Reynolds S, Chow AW. Extracranial head and neck infections. Crit Care Clin. 2013;29(3):443-463.
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Summary It is important to properly walk the fine line of treating infections that need to be managed with a short course of nar row spectrum antibiotics versus overprescribing antibiotics for either noninfectious indications or localized dental infections that don’t warrant antibiotics. With judicious use of antibiotics, dental practitioners can help curb the global threat of antibiotic resistance as well as avoid unnecessary side effects and increased cost for patients. Table 1 provides a summary of tools that can enable such practice.
4. Centers for Disease Control and Prevention. Outpatient Antibiotic Prescriptions – United States, 2020.
Fluoroquinolone (moxifloxacin) use within dentistry should be reserved for pediatric patients who are unable to take firstand-second line agents due to allergy or resistance. When a dental clinician is considering antibiotic use in chil dren, it is important as with adults to make sure that antibiotics are truly warranted.30-33 If caregivers are pressing for a prescrip tion despite lack of evidence for necessity, it is wise to educate on the downstream negative effects. If antibiotics are considered appropriate, dosing and route of delivery should be taken into consideration as well as common and uncommon red flags for use in pediatrics (summarized in Table 3).33-41 Not only should the negative effects of antibiotics be discussed, but the preven tion of dental caries with appropriate oral health maintenance should be reinforced.32
12. López-González E, Vitales-Noyola M, González-Amaro AM, et al. Aerobic and anaerobic microorganisms and antibiotic sensitivity of odontogenic maxillofacial infections. Odontol ogy. 2019 107(3):409-417
6. Durkin MJ, Hsueh K, Haddy Y, et al. An evaluation of dental antibiotic prescribing practices in the United States. J Am Dent Assoc. 2017:148(12):878-886
Tetracycline antibiotics (including doxycycline) may cause per manent tooth discoloration, enamel hypoplasia in developing teeth, and hyperpigmentation of the soft tissues. Because of the tooth and soft tissue related side effects of tetracyclines, their use is not recommended for pregnant women or children under the age of 8 years old. However, short-term (less than 21-day) use of doxycycline is advocated by the American Academy of Pedi atrics as appropriate when benefits outweigh risks for certain infections due to the lack of evidence of the tooth discoloration side effect.30 Fluoroquinolone antibiotics appear at first glance to be an attractive choice since they are broad-spectrum agents, highly active in vitro against gram-positive and gram-negative pathogens, and are dosed only 1 to 2 times a day. However, these agents have numerous warnings associated with their use in patients of all ages as well as concerns related to increased possibility of musculoskeletal adverse effects in children.30
19. Mylonas I. Antibiotic chemotherapy during pregnancy and lactation period: aspects for con sideration. Arch Gynecol Obstet. 2011:283(1):7-18.
32. Fontana M, Karimbux NY, Cabezas C, Kim DM, Dragan IF. Dental Caries and Gingival and Periodontal Infections. In:. Pediatric Infectious Diseases: Essentials for Practice. Shah SS, Kem per AR, Ratner AJ (eds). McGraw Hill; 2019.
13. Peterson LR, Thomson RB. Use of the clinical microbiology laboratory for the diagnosis and management of infectious diseases related to the oral cavity. Infect Dis Clin North Am. 1999;13(4):775-795 14. Brook I, Frazier EH, Gher ME. Microbiology of periapical abscesses and associated maxillary sinusitis. J Periodontol. 1996;67(6):608-610.
3. Fleming-Dutra KE, Hersh Al, Shapiro DJ, et al. Prevalence of inappropriate prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873.
EDUCATION
16. Moore PA, ZieglerKM, Lipman RD, et al. Benefits and harms associated with analgesic medi cations used in the management of acute dental pain: an overview of systemic reviews. J Am Dent Assoc. 2018; 149(4):256-265.
17. Santos RS, Macedo RF, Souza EA, et al. The use of systemic antibiotics in the treatment of refractory periodontitis: A systematic review. J Am Dent Assoc. 2016;147(7):577-585.
23. Shukairy MK, Burmeister C, Ko AB, Craig JR. Recognizing odontogenic sinusitis. A national survey of otolaryngology chief residents. Am J Otolaryngol. 2020;41(6):102635.
1.REFERENCESMacfarlane G. Alexander Fleming: The Man and the Myth. Harvard University Press; 1984.
22. Ahmad N, Abubaker AO, Laskin DM, Steffen D. The financial burden of hospitalization associ ated with odontogenic infections. J Oral Maxillofac Surg. 2013;71(4):656-658.
15. Tanner A, Stillman N. Oral and dental infections with anaerobic bacteria: clinical features, predominant pathogens, and treatment. Clin Infect Dis. 1993;16(suppl 4):S304-S309.
26. Martin MV, Longman LP, Hill JB, Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy. Br Dent J. 1997;183(4):135-137.
Disclaimer Clinician expertise in addition to evidence should be used when making treatment decisions for patients.
CONTINUING
18. Gonzalez JR, Harnack L, Schmitt-Corsitto G, et al. A novel approach to the use of subgingival controlled-release chlorhexidine delivery in chronic periodontitis: a randomized clinical trial. J Periodontol. 2011;82(8):1131-1139.
8. Joseph J, Rovold KA. The role of carbapenems in the treatment of severe nosocomial infec tions. Expert Opin Pharmacother. 2008;9(4):561-574.
2. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States; 2013.
29. Jackson MA, Schutze GE, Committee On Infectious Diseases. The Use of Systemic and Topical Fluoroquinolones. Pediatrics. 2016;138 (5):e20162706.
7. Ralph D, Azarpazhooh, Laghapur N, Suda KJ, Okunseri C. Role of dentists in prescribing opioid analgesics and antibiotics: an overview. Dent Clin North Am. 2018: 62(2):279-294.
21. Jaramillo A, Arce RM, Herrera D, et al. Clinical and microbiological characterization of peri odontal abscesses. J Clin Periodontol. 2005;32(12):1213-1218.
9. Centers for Disease Control and Prevention. Antibiotic Stewardship. https://www.cdc.gov/ oralhealth/infectioncontrol/faqs/antibiotic-stewardship.html. Accessed June 23, 2022.
30. Committee on Infectious Diseases, American Academy of Pediatrics. Antimicrobial agents and related therapy, Section 4. In: Kimberlin DW, Barnett ED, Lynfield R, et al. eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
20. Robertson DP, Keys W, Rautemaa-Richardson R, et al. Management of severe acute dental infections. BMJ. 2015;350:h1300
27. Centers for Disease Control and Prevention. Antibiotic/Antimicrobial Resistance Threats in the Unites States, 2013.
31. Goel D, Geol GK, Chaudhary S, Jain D. Antibiotic prescriptions in pediatric dentistry: A review. J Family Med Prim Care. 2020; 9(2):473-480.
10. Ogle OE. Odontogenic Infections. Dent Clin N Am. 2017(61):235-252.
5. Fluent MT, Jacobsen PL, Hicks LA. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc. 206:147(8):683-686.
11. Dental and Periodontal Infections. In: Ryan KJ. eds. Sherris & Ryan’s Medical Microbiology, 8th edition. McGraw Hill; 2022. https://accessmedicine.mhmedical.com/content.aspx?book id=3107§ionid=260928993. Accessed June 23, 2022.
25. Zawislak E, Nowak R. Odontogenic head and neck region infections requiring hospitalization: An 18-month retrospective analysis. BioMed Res Int. 2021;708763.
CREDITSCE
Continuing Education Quiz
1. Alexander Fleming’s breakthrough discovery of ________ paved the way for a domain of medicine that has enabled once deadly infections to be readily treatable. a. penicillin b. cholera c. tetanus d. streptomycin 2. According to the Centers for Disease Control and Prevention (CDC), approximately _________ Americans are infected with resistant patho gens that result in 23,000 deaths annually. a. 500,000 b. 1 million c. 2 million d. 3 million 3. The CDC conservatively approximates that ________ of all outpatient antibiotic prescriptions written from 2010 to 2011 were unnecessary. a. 10% b. 30% c. 40% d. 50% 4. Even when antibiotics are needed to treat dental infections, they might not be the first line therapy, but rather an adjunct after ________. a. surgical drainage of an abscess b. tissue debridement c. below the gum manipulation d. all of the above 5. ________ is/are characterized by acute and intense pain and is one of the most frequent reasons that patients seek emergency dental care. a. Dental caries b. Irreversible pulpitis c. Pericoronitis d. Gram-positive streptococci
7. ______ — a first-generation cephalosporin with similar gram-positive aerobic coverage as the historic first line agents but that lacks robust anaerobic activity — is the antibiotic of choice in those with a history of penicillin allergy without history of anaphylaxis, angioedema, or a.hives.Cephalexinb.Cefaclorc.Cefuroximed.Ceftibuten
8. In patients with a severe allergy to penicillin agents or other β-lactams, _________ can be prescribed. a. azithromycin or clindamycin b. doxycycline and levoflaxin c. cefzil or tetracycline d. metronidazole or moxifloxacin
AGD Code: 148 Date Published: August 25, 2022 Expiration Date: August 25, 2025 2
21implantpracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
6. (When choosing an antibiotic for non-suppurative or suppurative odontogenic infections) Although both agents were regarded as first line, _________ was generally preferred due to having more robust gram-negative anaerobic coverage, less frequent dosing, ability to be taken on an empty stomach, and a lower incidence of gastrointestinal side effects. a. penicillin V b. cephalexin c. amoxicillin d. azithromycin
9. If treatment is initiated for non-suppurative indications (e.g., gingivitis and periodontitis), antibiotic therapy is usually until oral lesions have healed and pain has subsided, typically _______. a. 1 day b. 2 to 4 days c. 5 to 7 days d. 8 to 10 days 10. Tetracyclines and fluoroquinolones are two classes of antibiotics that are ________. a. preferred for treatment of children b. generally avoided in children c. always recommended for use by pregnant women d. none of the above
To provide feedback on CE, please email us at education@medmarkmedia.com
Dental infections: help avoid antimicrobial resistance — part 1 BRUCK/PRICE
Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496, or visit https://implantpracticeus.com/ subscribe/ to subscribe today. n To receive credit: Go online to https://implantpracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.
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22Implant Practice US Volume 15 Number 3 CONTINUING EDUCATION
Introduction
Dental implant therapy has always been considered a pros thetically driven modality with the final tooth position supported by implant services. In 2022, the majority of FDA-cleared den tal implants have relatively good survival and clinical success rates.1 Interestingly enough, the marketplace has placed a focus on precise implant placement in 3D, unlike 20 years ago when the focus was on osseointegration itself. The proper positioning of implants seems to be of paramount importance to the longterm success more so than the implant-to-bone interface. Proper implant placement seems critical to achieving the most pleasant estheticMoreover,outcome.2thesurvivability of implants vis-à-vis peri-implan titis relative to the correct positioning of the fixture has also been studied. One study estimated that nearly half of the peri-implan titis cases could be caused by implant malpositioning.3
• Identify types of surgical guides.
• Realize the differences in robotic devices available today.
2 CREDITSCE
Robotic haptic-guided implant surgery provides unique clin ical benefits for patient care presently unavailable with any other type of technology.
This self-instructional course for dentists aims to discuss the evolution of robotic haptic dental implant technology: the advances, implementation, and review of a case study.
Conclusion
Robotic-assisted dental implant placement technology: overview, implementation, and case report
This article aims to highlight the evolution of robotic haptic dental implant technology — the advances, implementation, and review of a case study. Results
Educational aims and objectives
For decades, implant surgeons performed freehanded place ment based upon what some have termed “brain guides.” The optimal implant position, long-term survivability, and esthetics were directly related to the surgeon’s capabilities, experience, and knowledge. This required a large amount of preplanning and workup with photos, bite evaluation, clinical observation, and in some cases a wax-up of the proposed implant placement. Subsequently, the explosion of available software packages to
Expected outcomes Implant Practice US subscribers can answer the CE questions by taking the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:
Background/PurposeAbstract
• Realize the capabilities of haptically guided stereotactic guidance.
• Observe an implant case using a roboti cally assisted dental implant system.
Robotic-guided implant placement can effectively help save significant patient treatment time while offering high precision with predictable outcomes.
Bruce Smoler, DDS, FICOI, FAGD, is a general dentist with an implant-based practice located in Westland Michigan. He received his DDS from Northwestern University in Chicago. He has been involved in over 10,000 implant procedures and has attained over 6,000 hours of CE. Innovations and advances in full arch dental implant reconstruction drive Dr. Smoler. His mission is to help patients lead healthier lives.
Certainly through the years, advances in technology have helped both the visualization of the prosthetic outcome and surgical implantation. One key factor is the increased use of computer-aided planning for implant surgery. The ability to sim ply preplan a case on software in three dimensions combining the surgical and prosthetic components before any treatment has been started has been quite revolutionary.4 Improved scan ning technologies and surgical procedures have evolved to offer today’s clinicians ways to increase efficiencies and ensure accurate implant placement while helping to drive restorative options. This has resulted in ways to increase case acceptance and deliver same-day procedures.
The surgical guide bonanza
• Realize some challenges of static surgical guides.
Disclosure: The author is a key opinion leader for a number of dental manufacturers and suppliers, including Neocis, the maker of the Yomi®.
Dr. Bruce Smoler discusses the clinical benefits of robotic-assisted implant surgery
23implantpracticeus.com
Volume 15 Number 3
CONTINUING EDUCATION
FreehandSurgicalGuides RoboticsSurgical Same-day surgery 4 l 4 Minimally invasive options l 44 Digitally integrated workflow X 44 Physical guidance to plan X 44 Visual and audio guidance XX 4 Use standard drill kit 4 X 4 Intraoperative changes possible 4 X 4 Visibility with irrigation access 4 X 4 Figure 1: Yomi® robot-assisted dental surgery Figure 2: Comparison of surgical workflow advantages among different implantation techniques
help connect the patient’s clinical parameters with the expected surgical outcome allowed for an increase in surgical predictability with the advent of surgical guide options. Surgical guides can be classified as the following: static guides (tooth-borne, soft tissue-borne, stackable; i.e., NDX®, Chrome™), dynamic guides (X-Nav Technologies, Navident), and most recently, robotic-assisted implant placement (Yomi® by Neocis) (Figure 1). To be sure, not all guides are created equally. One study found a significant variation between the accuracy of a tooth-supported guide and tissue-supported guide.5 Increasing the ease-of-use of various computer software diagnostic systems has increased the ease-of-use and availability of surgical guides. As recently as a few years ago, obtaining a static surgical guide often required days if not weeks, due to the lead time necessary for impressions, scans, guide design, and fabrication. With 3D printing and more intuitive software, static surgi cal guide fabrication has reduced the workflow consistently to days not weeks. Aside from the ease of fabrication of surgical guides, the mainstream acceptance of this workflow has only added to the widespread use of surgical guides in implant sur gery. However, one often overlooked subject is “Who is guiding the guide?” Some practitioners have felt a higher level of confi dence, a phenomenon known as “risk homeostasis,” not due to their increased skill set, but simply relying upon a guide to allow them the predictability they seek. Extensive evidence has shown the fallibility of static guides requiring the use of freehanded surgical procedures if and when a guide goes wrong.6 Ill-fitting and poorly designed guides can occur with static guides. Addi tionally, static guides are made for just one preplan and cannot be altered if the clinical conditions change, rendering the guide useless. Physical guides can decrease visualization and limit the cooling of the drilling sequence through the guide. Overheating has been shown as a risk of static guides, which block access to the surgical site.7 The inability to reliably place or seat the guide due to variations in clinical conditions and a myriad of unex pected surgical complications are all reasons a surgeon should not substitute knowledge and experience in lieu of the use of a guide. It’s been said that guided surgery can make the expe rienced surgeon better, but it cannot make a beginner surgeon accomplished. A clear understanding of the limitations, goals, and objectives of using static guides is required to accurately assess the risks, benefits, alternatives, and complications. Once done, the distinct advantages of an alternative protocol of roboticassisted implant placement will become evident (Figure 2).
Robotic-aided procedures in healthcare and the dawning of haptically guided technology Robotic-assisted procedures started in the late 1990s in the medical field. Today it has become the standard of care in a multitude of minimally invasive surgical procedures in medicine globally.8 One key to understanding the differences between the first and only FDA-cleared, robotic-assisted dental implant device and other robotic devices in medicine is knowing about the tech nology. In dental applications, the Yomi® allows the surgeon to guide the drill based upon the intended surgical preplan. It is not remote-controlled (called telerobotics), but directly under the control of the surgeon. This direct involvement allows the surgeon to be in control to confirm that the execution of the implantation is indeed following the desired placement. The robotic guidance is designed to prevent any iatrogenic-induced errors or variations of the intended plan. Dynamic guidance without haptic robot ics still requires the surgeon to follow the plan. With dynamic guidance, the surgeon is not restricted physically from inducing errors such as off-angle drilling, chatter of drills in the osteotomy, as well as overpreparing the implant site in depth or angulation. The surgeon must focus on a screen and cannot directly observe the drill site while utilizing the benefits of dynamic placement. Robotic-assisted placement allows for visual, audio, and hap tic guidance during the osteotomy preparation and the implant placement. These are the main differences between dynamic guidance and robotic-assisted implant placement.
Figure 3: The Eisenhower Matrix — a time management strategy to help determine which tasks should be prioritized, delegated, scheduled for later, or eliminated altogether
“Success is good at any age, but the sooner you find it, the longer you will enjoy it.” “A goal is a dream with a deadline.” Case review
Figure 5: Panoramic CBCT of the surgical site with the tooth-borne splint on the contralateral side
Figure 4: Clinical presentation of tooth No. 30
One of the most challenging roles of a business owner who happens to be a dentist is incorporating new technologies in the dental office. All too often the dentist embarks on a journey with out holistically including the rest of the organization. The result is that often new technology becomes less likely to be used on a consistent basis. Moreover, if the technology happens to have a higher learning curve, cost or staff involvement, and training, the return on the investment is even less likely to occur. Taking a page from other industries to implement new technologies can be quite useful when incorporating robotic-assisted implant procedures. Without a game plan to have the whole office staff involved and excited, the owner operator is left to feel like Sisyphus pushing a boulder uphill day after day. One technique is to tie the benefits of the new technology to the core values of the office. Once the team can see the value of the new technology and how it benefits patients, there should be fewer hurdles to overcome. Given the ability to get the team onboard with an open mind, the next step is to have clear-cut ways to build systems to help utilize and optimize the new tech nology. In business the use of the Eisenhower Matrix is an effec tive way to eliminate, delegate, plan, and do (Figure 3). Typically, this is achieved once the training allows for systems to become grooved in, and the “flow” of the procedures can become very smooth. Finally, once having the systems in place and the team onboard, the office will be able to realize maximize efficiency and performance.Ourteamutilizes the concept of “name it, want it, get it” when formulating plans to bring new technologies into the prac tice. The clear focus of being able to name what it is we want to achieve, the reasons we want to achieve it, and a way to get it are all central to the successful use of new technology. Two apropos quotes from author Napoleon Hill follow:
Implementation of new technologies
24Implant Practice US Volume 15 Number 3
CONTINUING EDUCATION
A 51-year-old female patient presented at the end of busi ness day with hopeless tooth No. 30 (Figure 4). The patient had a previous history of endodontic therapy with a 10-year-old full crown placement. Recently, she had lost the crown resto ration, and the area around the tooth was irritated. She wanted a replacement. Initial images of the tooth, CBCT scan, as well as intraoral examination, revealed hopeless tooth No. 30 with presentation of immediate implant replacement with minor bone grafting and PRGF bone graft modifications. A review of the patient’s health history, as well as informed consent and financials, was performed. The patient had a history of implant replacement 10 years ago and desired immediate placement due to her hectic work schedule.
Panoramic CBCT view shows the robotic tooth-borne splint in place on the patient’s lower left side (Figure 5). This link allows for both the registration of the preplan to the intraoperative 3D space as well as the direct connection of the patient to the robot via the tracker arm. This connection allows the real-time movements of the patient to be precisely tracked by the robot, so minor movements of the patient do not reduce the accuracy of the implant placement from the preplanned idealized place ment. In other words, no patient immobilization is required, and
Robotic-assisted implant surgery allows the surgeon to guide the handpiece directly to match the preplanned surgical implant position. The specific technology that sets robotic-assisted guided surgery apart from dynamic guidance is the use of haptically guided stereotactic guidance. There is no other technology avail able on the market today that allows the control and precision to follow a preplanned surgical plan as intuitively. The ability not only to have visual and audio cues, but also most importantly to provide tactile feedback is unique. One of the only drawbacks of Yomi is that it is contraindicated for use with patients who have insufficient bone or teeth to retain a splint rigidly throughout a surgical procedure.
The patient was adamant to have work done at the same visit due to her past experience, although her upper-left implant replaced a single-rooted tooth. Obviously, an immediate place ment of a two-rooted molar poses more challenges for initial stability than a single-rooted bicuspid. We discussed the use of our Yomi. The patient was agreeable to have her surgery done all at one time. The requirement to place an implant in an imme diate extraction site requires a higher level of precision for a number of reasons: Osteotomy drill chatter can lead to an over expansion of the site preparation leading to poor initial implant stability. Poor access and visibility as well as implant location, which can migrate to the mesial root or the distal root, are all common occurrences. The need to have a guided approach is central to a predictive, successful outcome. However, the desire to offer not only a same-day guide, but also a guided approach immediately for an emergency patient meant the only way to achieve this was with a robotic-assisted device. The before-and-after periapical views show a clear rep resentation of what is possible with immediate molar replace ment with the robotic-assisted implant device (Figure 7). The preplanned surgery was followed precisely with the implant being placed in a predetermined position mesial to distally as well as apically. The initial insertion torque was measured at 40Ncm. The patient had no desire to have an immediate provi sional placed. The patient returned at the 2-week mark for suture removal with uneventful healing. At the 3-month mark, she will be evaluated with an Osstell® reading for implant stability and an intraoral scan for her final prosthetic.
• Attach patient to the robot with the tracker arm end effector attached to the splint once the fiducial array is removed from the splint.
Robotic workflow
The start-to-finish of the presented case was less than 45 minutes from the time of the new patient arrival to case conclusion. The steps are as follows for the orchestrated movements of the team to be able to provide such a high level of care promptly, effi ciently, and expeditiously:
• Attach tooth-borne splint to opposite side of same jaw to allow for linking the patient to the robot.
• With advanced features, a dynamic plan can allow for desired placement and planning of the implant based upon clinical conditions.
Figure 7: Before-and-after periapical views of immediate molar replacement with robotic-assisted surgery
Figure 6: Quantified evaluation of the implant placement site for implant siz ing and planning
Clinical notes
• Take CBCT with fiducial array in place attached to the splint.
• Load CBCT to the planning work station to virtually plan the placement of the implant to the extraction site.
• A few steps to “landmark” and guide the handpiece and arm to the surgical site.
• Complete removal of tooth as atraumatically as possible.
25implantpracticeus.com Volume 15 Number 3 CONTINUING EDUCATION the 3D plan moves with the patient during the procedure. The evaluation of the implant placement site was 10.5 mm in width and had a residual intraseptal width of 3.6 mm at the coronal portion. Additionally, the remaining bone above the inferior alveolar nerve was abundant with 17.7 mm of bone (Figure 6). A BioHorizons® 4.6 x 12 mm tapered internal implant was selected in the Yomi Plan software.
There are several steps in the sequence of the delivery of robotic-assisted procedures. Proper training and guidance are providing new technologies promptly, efficiently, and effectively.
• Changes to the plan can be made by simply selecting “Place Implant at Tip” mode to confirm the clinical
Conclusion If surgical guides can improve the accuracy of implant den tistry, and robotic-assisted haptically guided implants offer a dis tinct advantage over any other guided system, a closer evaluation of this advanced technology is suggested to provide the highest level of precision in guided dental implant placement.
26Implant Practice US Volume 15 Number 3
5. Varga E, Antal M, Major L, et al. Guidance means accuracy: A randomized clin ical trial on freehand versus guided dental implantation. Clin Oral Implants Res. 2020;31(5):47-30.
3 REASONS TO SUBSCRIBE • 16 CE credits available per year • 1 subscription, 2 formats – print and digital • 4 high-quality, clinically focused issues per year 3 SIMPLE WAYS TO SUBSCRIBE • Visit www.implantpracticeus.com • Email subscriptions@medmarkmedia.com • Call 1-866-579-9496 Implant Practice US 1 year $149 / 1 year digital only $79 EnvistaPeterVitruk,PhD,MInstP,CPhys implantpracticeus.com CreatingtheultimateimplantpracticeAninterviewwithSimonOh—DDS,FICOI Spring2022Vol15No1 DigitalWorkflow&GuidedSurgery n 4CECreditsAvailableinThisIssue CompanyspotlightSofttissuelaserdentalsurgerybasicsPracticalconsiderationsforutilizingPrescription
4. Deeb GR, Tran DQ, Deeb JG. Computer-Aided Planning and Placement in Implant Surgery. Atlas Oral Maxillofac Surg Clin North Am. 2020;28(2):53-58.
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3. Canullo L, Tallarico M, Radovanovic S, et al. Distinguishing predictive profiles for patient-based risk assessment and diagnostics of plaque induced, surgically and pros thetically triggered peri-implantitis. Clin Oral Implants Res. 2016;27(10):1243-1250.
8. George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of Robotic Surgery: From Skepticism to Standard of Care. JSLS. 2018;22(4):e2018.00039. IP Connect. Be Seen. Grow. Succeed. www.medmarkmedia.com
6. Tatakis DN, Chien HH, Parashis AO. Guided implant surgery risks and their prevention. Periodontol 2000. 2019;81(1):194-208.
• Once ready for the drilling sequence, the robot is placed in the “Guided” mode, and the drill/handpiece is moved with haptic feedback to mirror the virtual plan precisely.
2. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applica tions in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2014;29 (suppl):25-42.
1.REFERENCESDeAngelis F, Papi P, Mencio F, Rosella D, Di Carlo S, Pompa G. Implant survival and success rates in patients with risk factors: results from a long-term retrospective study with a 10 to 18 years follow-up. Eur Rev Med Pharmacol Sci. 2017;21(3):433-437.
7. dos Santos PL, Queiroz TP, Margonar R, et al. Evaluation of bone heating, drill defor mation, and drill roughness after implant osteotomy: guided surgery and classic drill ing procedure. Int J Oral Maxillofac Implants. 2014;29(1):51-58.
CONTINUING EDUCATION position and the preplanned virtual position. A critical differentiator when comparing the robotic-assisted guid ance to any static-guided technology is the ability to change the virtual plan during the case.
• When the drill sequence is complete, the placement mode is selected to place the implant in the exact loca tion with no deviation, chatter, or skiving (bouncing) of the virtually planned placement. With a well-trained team, the process becomes smooth and seamless. The surgeon’s time is limited to just the actual place ment of the implant with the setup and preplan work delegated to the robotic coordinators. The bottom line is a huge advantage over any other static guide as well as any other dynamic sys tem due to the haptic feedback allowing for the placement of the implant precisely where planned. All in all, this service had greatly increased our ability to deliver precise implant placement in a predictable, efficient manner.
a. photos b. bite evaluation c. clinical observation d. all of the above 4. One study found ________ between the accuracy of a tooth-supported guide and tissue-supported guide. a. no variation b. a significant variation c. only slight variation d. a partial variation
9. In business the use of the ________ is an effective way to eliminate, delegate, plan, and do. a. Risk Bearing Concept b. Eisenhower Matrix c. High Achievement Capacity Concept d. Truman Concept
10. With robotic implant placement, ________. a. the surgeon sets up, preplans, and places the implant b. robotic coordinators place the implant and the surgeon does the setup and preplan c. the surgeon’s time is limited to just the actual placement of the implant with the setup and preplan work delegated to the robotic coordinators d. the robot preplans, sets up, and places the implant independently Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496, or visit https://implantpracticeus.com/ subscribe/ to subscribe today.
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8. The specific technology that sets robotic-assisted guided surgery apart from dynamic guidance is the use of ________. a. haptically guided stereotactic guidance b. remote control c. 3D printing d. iatrogenic variation
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Robotic-assisted dental implant placement technology: overview, implementation, and case report
5. With surgical guides, some practitioners have felt a higher level of confidence, a phenomenon known as not due to their increased skill set, but simply relying upon a guide to allow them the predictability they seek. a. “risk homeostasis,” b. “risk aversion,” c. “anti-instability,” d. “visualization limitation,” 6. With dynamic guidance, the surgeon _______ from inducing errors such as off-angle drilling, chatter of drills in the osteotomy, as well as overpreparing the implant site in depth or angulation. a. is restricted physically b. is not restricted physically c. is totally protected d. none of the above 7. __________ allows for visual, audio, and haptic guidance during the osteotomy preparation and the implant placement. a. A surgical guide b. A software diagnostic system c. Robotic-assisted placement d. A tooth-borne guide
a. one-third b. one-fourth c. one-half d. three-fourths 2. (When referring to implant surgeons providing free-handed implant placement) The optimal implant position, long-term survivability, and esthetics were directly related to the surgeon’s __________. a. capabilities b. experience c. knowledge d. all of the above 3. This (freehanded implant placement) required a large amount of pre planning and workup with ______ and, in some cases, a wax-up of the proposed implant placement.
AGD Code: 690 Date Published: August 25, 2022 Expiration Date: August 25, 2025
27implantpracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
1. One study estimated that nearly ___________ of the peri-implantitis cases could be caused by implant malpositioning.
CREDITSCE
Continuing Education Quiz
SMOLER
• The large size is the most popular at 10 mm x 20 mm, which can be cut, if necessary, to fit root morphology.
All OsteoGen® Plugs can be trimmed using sharp scissors or a scalpel, or multiple plugs can be used to fill the site. A box of 5 Plugs is $279 or box of 10 Plugs for $499.
The OsteoGen ® Plug
Impladent Ltd. also offers the OsteoGen® Strip — a mineral ized collagen strip that is used most often to fill the gaps around implants or for sinus lifts. These bone-grafting strips are an easyto-deliver solution that can be used anywhere particulate graft is used without the worry of particulate migration or wash out. For more information, visit www.impladentltd.com, or call 800-526-9343. This information was provided by Impladent Ltd.
28Implant Practice US Volume 15 Number 3 PRODUCT PROFILE
Theangiogenesis.collagenfound in the OsteoGen® Plug provides a scaffold for keratinized tissue to develop over the grafted site. To prepare the socket, entirely remove infected periodontal ligament, flush out, and repeat. Make holes or partially remove lamina dura to the alveolar process to initiate blood flow and trigger the regional acceleratory phenomenon. Taper the OsteoGen® Plug apically, deliver dry into socket, and let it soak up blood. Compact the OsteoGen® Plug to make a membrane, and condense to 1 millimeter below soft tissue crestally. Crisscross suture over top, not through the OsteoGen® Plug. The low-density nature of the OsteoGen® graft means that the OsteoGen® Plug will show radiolucent on the day of placement and radiopaque in 4 to 5 months as the graft turns over, depend ing on the specific patient. This transition from radiolucent to radiopaque is a key indicator of bone turnover. At this point, the OsteoGen® Plug has been replaced with host bone and is ready for implant. Impladent Ltd. offers the OsteoGen® Plug in three sizes:
The Impladent Ltd. OsteoGen® Bone Grafting Plug combines OsteoGen® bioactive resorbable cal cium apatite crystals with bovine Achilles tendon collagen for a one-step socket preservation solution with out the need of a separate membrane. The bioactive calcium phosphate crystals and crystal clusters combined with collagen create a hydrophilic structure that mimics the composition of physiologic bone. The result is a bone graft combined with a collagen plug for ease of clinical delivery — all for less than $50 per extraction. The OsteoGen® bone-grafting production process yields a resorbable bone graft with a unique cal cium-to-phosphate (Ca:P) ratio that is not a ß-TCP, not a non-resorbable dense ceramic HA, and not a biphasic mixture of the two. It is a unique low-density calcium phosphate graft that is resorbable. The bovine Achilles tendon collagen carries the bone graft for easy, efficient delivery to the site, eliminating the hassle and time spent mixing and packing particu late bone grafts, while also eliminating the potential for graft washout. The Type I collagen acts as a wound dressing, not only to stabilize the clot, but also to absorb and deliver blood flow to the slowly resorbing graft — a feature critical for the initiation of bone formation and early
The one-step bone-grafting solution for socket preservation without a membrane
IP
• The slim size (6 mm x 25 mm) is ideal for the anterior region.
• The extra large size should be used for the largest of molars.
LTRA COARSE DIAMOND (UCD) OCKET DEBRIDEMENT BURS Call 800-526-9343 or visit us online at www.impladentltd.com LIMITED TIME OFFER: FREE OSTEOGEN® PLUG ($50 VALUE) WITH EACH UCD BUR KIT PURCHASED D EBRIDE D ECORTICATE G RAFT Ultra Coarse Diamond (UCD) Debridement Burs are specifically engineered to quickly and effectively grab and remove granulation tissue following tooth extraction Make multiple “bleeders” using the included round carbide bur by perforating the lamina dura into the alveolar process to trigger the Regional Acceleratory Phenomenon1 Deliver the bioactive OsteoGen® Bone Grafting Plug into the bleeding socket, compress and suture over top - no membraneadditionalrequired OPTIMAL SOCKET PRESERVATION BEGINS W ITH O PTIMAL S ITE P REPARATION AND E NDS WITH AN O STEO G EN ® P LUG 1. Frost HM: The Regional Acceleratory Phenomenon: a Review. Henry Ford Hosp Med J 1983;31(1):3-9. Scan for Protocol Scan for references
All these benefits are achieved in only one surgery, which ultimately improves the patient experience and the simplicity of the Visitprocess.www.pantheraimplant.com to learn more about this unique 1.REFERENCEsolution.CécileBailly.Revue de la littérature : implantologie sous-périostée en secteur postérieur mandibulaire atrophique. Apport des technologies CAD/CAM. Sciences du Vivant [q-bio]. [Trans: Literature review: subperiosteal implantology in the atrophic posterior mandibular sector. Contribution of CAD/CAM technologies.] 2022; dumas-03617025 This information was provided by Panthera Dental.
Today there are different treatment plans to consider for md K1 div. C-h diagnosis — a mandible with a severely vertically atro phied posterior alveolar bone. Some are to be prescribed like short implants. However, forces applied on implants by the long lever arm of the crowns or bridges could cause bone loss around the implants (cantilever effect) and the failure of the treatment. Another option is to extract healthy anterior teeth and to place implants and an implant-supported prosthesis. Although let’s be honest; your patients do not want to extract their last precious healthy teeth. Partial dentures can also be an option, but it will accelerate the atrophy of the bone of the man dible and can cause long-term painful pressures. Other treatment options are adequate but are sensitive to the technique of the surgeon — e.g., vertical bone augmentation (graft). This technique has also proven itself and allows adequate vol ume of bone for the placement of implants and the prosthetic restoration. However, it requires a great surgical expertise, two surgeries, two surgi cal sites, and an additional healing period. What if vertical bone grafting is impossible? What other option could those patients possibly have?
Figures 1 (left) and 2 (right): 1. Bilateral CAD/CAM SUB Implant™ top view on the patient model. 2. CAD/CAM SUB Implant™ positioning. Courtesy of Dr. François Veuve, Neuchâtel, Switzerland, 2020 Figure 3 (left) and 4 (right): 3. Panoramic radiography. Courtesy of Dr. François Veuve, Neuchâtel, Switzerland, 2020. 4. After the surgery of a bilateral CAD/CAM SUB Implant™. Courtesy of Dr. François Veuve, Neuchâtel, Switzerland, 2020
Marc Desjardins asks, “K1 div. C-h diagnosis — now what are your options?”
Marc Desjardins, TPAD (Technologue en Prothèses et Appareils Dentaires), [prosthetic and dental appliance technologist], Senior Technical Advisor for Panthera Prosthetic Division, has been a member of the College of Dental Technicians in the province of Quebec, Canada, and a laboratory director since 1977. He has more than 40 years of experience in the field. Founder of Laboratoire Lafond, Desjardins et associés, a laboratory recognized and respected for the quality of its work, he defines himself as a visionary person with respect to new technologies in the dental industry. IP
Panthera Dental CAD/CAM SUB Implant™: a new approach (part 2)
Thanks to CT scan technology, the CAD/CAM SUB Implant™ can achieve, in only one surgery, all the goals of a complete and successful rehabilitation: contour, function, comfort, esthetics, phonetics, and health. The power of new technologies took an old concept and brought it back to life totally redefined. The subperiosteal implant is now perfectly adjusted to the bone, and the titanium grants the possibility of osseointegration, minimizing the risk of rejection.1 The shape of the supporting arches is carefully studied and designed from the CT scan impression in Panthera Dental’s proprietary software for an easy insertion that fits perfectly to the bone morphology, optimizing the osseointegration and offering the optimal pros thetic treatment plan to meet the patient’s demands and oral conditions. The CAD/CAM SUB Implant™ is milled from blocks of Ti-6Al-4V titanium, the same alloy commonly used for rootform implants.
30Implant Practice US Volume 15 Number 3 PRODUCT PROFILE
What if a new type of implant could meet all the criteria for predictable success?
“Qui tam” cases are on the rise
Additionally, providers should note that it is not just the government that may institute suit. In addition to allowing the United States to pursue FCA violators, the FCA allows private citizens (called relators) to file suits on behalf of the U.S. govern ment (called “qui tam” suits) against those who have defrauded the government. Private citizens who successfully bring qui tam actions may receive a portion of the government’s recovery, 31 U.S.C. §3730(d). If the government declines to pursue the claim, and the relator prevails, it is statutorily entitled to recover 25% to 30% of the damages, in addition to being reimbursed reasonable counsel fees. The significant reward in assertion of these claims is evidenced by the U.S. Department of Justice’s collection of more than $5.6 billion settlements and judgments for the fiscal year ending on September 30, 2021.* Kerry Cahill, Esq., is an attorney with Lindabury, McCormick, Estabrook & Cooper, P.C. (www.lindabury.com) based in Westfield, New Jersey. Her practice focuses on advising clients in the healthcare industry — including dentists, orthodontists, and endodontists. She can be reached at kcahill@lindabury.com.
• First, it is unlawful to knowingly submit a false or fraud ulent claim to the federal government for payment or approval, 31 U.S.C. § 3729(a).
Although there is no statutory definition as to what consti tutes a “false” claim, relevant case law provides that a claim is factually false “when the claimant misrepresents what goods or services that it provided to the Government,” (United States ex rel. Wilkins v. United Health, 659 F.3d 295, 305 [3d Cir. 2011]).
Implications of the False Claims Act
The False Claims Act Under the FCA, there are four primary provisions that prac titioners should understand.
As a matter of practicality, when a provider offers or accepts discounted rates or fails to universally balance bill and collect from his/her patients, the provider may have exposure under the FCA. For example, if a provider receives $250.00 per hour from Medicaid, is reimbursed on average $200.00 per hour after bal ance billing privately insured individuals, and charges his/her uninsured patients $150.00 per hour, there is an inherent ques tion as to the true value of the provider’s services. Is the true value of the services $150.00 or $250.00? With niche orthodontic, endodontic, or implant practices, these payment discrepancies may be very large. As a result, this discrepancy in valuation often leads to costly protracted litigation, which can include a lengthy trial. At present, if found liable for an FCA violation, a civil pen alty of between $5,500 and $11,000 is assessed per claim, plus 3 times the amount of damages which the government sustains because of the act, 31 U.S.C. § 3729(a)(1).
• Fourth, conspiring to participate in any of the foregoing activities is also prohibited, 31 U.S.C. § 3729(c).
• Second, it is unlawful to directly or indirectly make or use a false record or statement in support of a false or fraudulent claim, 31 U.S.C. § 3729(b).
Kerry Cahill, Esq., discusses how practitioners need to protect themselves even in altruistic circumstances
32Implant Practice US Volume 15 Number 3 LEGAL MATTERS
Altruism and the ability and competency to help others are replete in the dental profession. In most providers’ experience, patients have approached them who may not be able to afford their services. With inflation continuing to rise, many patients may not have the financial means to afford reconstructive or cosmetic dentistry, orthodontics, or endodon tics. However, if a practice accepts federal funds such as Med icaid, FEDVIP, or the Enhanced Provider Relief Fund Payments, and the practitioner is considering offering discounted rates, be forewarned — these discounts have the potential to run afoul of the federal False Claims Act (FCA), 31 U.S.C. § 3729 et seq., and its equivalent statutory state counterparts.
• Third, it is unlawful to possess, have custody, or control of property or money used by the government, while deliv ering less than its full value, 31 U.S.C. § 3729(d).
Indisputably, billing for services not provided, upcoding, and illegal kickbacks are unlawful and would warrant FCA claims. Conversely, providers may have the most altruistic intentions with respect to rendering clinical services and unknowingly sub ject themselves to a potential FCA claim. A provider who offers discounted rates or prepayment incentives to patients who he/she knows are uninsured or underinsured, or who are asset limited, income constrained, and employed (ALICE) may be problematic.
The leading Oral Surgery partnership group Our family of brands OS1partners.com I 305-206-7388 At OS1, we provide the resources needed to help you grow your practice. Our support will take the stress of practice management off your plate so you can focus on providing high-quality care to patients.
34Implant Practice US Volume 15 Number 3
In spite of risk of potential FCA claims, there are a number of preemptive measures a practitioner can take to mitigate its risk. Ensuring that a practice is adequately structured is imperative. When forming a practice, practitioners should take into con sideration the roles and responsibilities that they will directly and indirectly undertake — for example, whether they will be handling their own billing, contracting with a third-party billing service, or partnering with a Management Services Organiza tion (MSO).
Implant Practice US Webinars LEARN about the lastest techniques and technology from industry leaders with our free live and archived educational webinars. Our online seminars are a convenient way to access great information and upskill. Check out our most recent webinars: • 5 Ways to Decrease Overhead and Increase Productivity with host Dr. Jason Streeter • Evolution of Implant Connections with host Dr. August de Oliveira • Growing Full-Arch with Robotics with host Dr. Sathish G. Palayam WATCH NOW at https://implantpracticeus.com/webinars/ Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com
Finally, conducting periodic audits and reviews of patient reimbursement rates is wise. Similar to the preceding, these audits and reviews help the practice to implement practical policies and procedures, which can be timely modified — if necessary.
LEGAL MATTERS
Generally, practitioners can obtain Commercial General Liability (CGL), Employment Practices Liability (ELI/EPLI), mal practice, and umbrella policies to offset a large amount of risk associated with maintaining their practices. Also, practitioners may maintain a Directors and Officers (“D&O”) policy, in order to protect the personal assets or corporate directors and offi cers from liability resulting from their management decisions.
Insurance coverage is questionable
Practice mitigation of liability
Next, diligent record keeping and records retention is of the utmost importance. This obligation extends to all records relating to the treatment of a patient. For some FCA claims, the issue in question is whether the services for which payment was requested or received from the federal government were actually rendered. By following best practices, practitioners can provide an affirmative defense that they relied upon universally accepted industry practices, which can help to mitigate damages.
However, be forewarned that FCA claims may be excluded from coverage under any potentially applicable insurance policies that the practitioner and practice may have. As a result, a practi tioner without insurance coverage may have to pay any damages awarded against it.
Additionally, having a well-defined Operating Agreement and up-to-date policies and procedures is integral. Together, these should delineate the responsibilities of the practitioners, their staff, and the patients with respect to handling billing matters. For practitioners in a group practice, the Operating Agreement should address insurance and the apportionment of liability for potential FCA claims among the practitioners. Even if a practice relies upon a separate business entity such as an MSO, this may not insulate the practitioner’s liability. Under the FCA, if a provider has actual knowledge or is deliberately ignorant or recklessly disregards the truth or falsity of the information, it may face liability, 31 U.S.C. § 3729(b)(1). As a result, it is imperative to have contractual provisions with third-party billing agencies regarding the communication and status of billing practices, adequate levels of insurance, and indemnification provisions.
* Department of Justice. Office of Public Affairs. Justice News. Justice Department’s False Claims Act Settlements and Judgments Exceed $5.6 Billion in Fiscal Year 2021. www.justice.gov/opa/pr/justice-department-s-false-claims-act-settlements-and-judgments-https:// exceed-56-billion-fiscal-year. Accessed June 24, 2022. IP
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Manuscript review
Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice man agement, technology, clinical updates, literature reviews, and continuing education.Typically, clinical articles and case studies range between 1,500 and 2,400 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, tech nology, or research reports. Clinical articles and continuing education arti cles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, pro vide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” para graph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.
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How to submit an article to Implant Practice US
35implantpracticeus.com Volume 15 Number 3 AUTHOR GUIDELINES
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Rose Nierman and Courtney Snow discuss the steps you can take to help patients access care, especially for larger cases
• Why bill medical insurance?
36Implant Practice US Volume 15 Number 3 PRACTICE DEVELOPMENT
Courtney Snow is the vice president and CE faculty member at Nierman Practice Management. With 12 years’ experience in medical billing in dentistry, she constantly strives to help dental practices make medical billing easy using reliable education, support, and software solutions. Her areas of expertise include obstructive sleep apnea, TMJ disorders, oral surgery, and other services. Contact Nierman Practice Management at contactus@ dentalwriter.com, or call 800-879-6468. IP
The How The first step is to obtain a verification of medical benefits. This will give us a good snapshot of their coverage and out-ofnetwork benefits. If it looks good, then the next step is to have a conversation to set proper expectations on reimbursement. Then gather the pertinent chief complaints and document your exam findings and diagnosis in a medical necessity format (SOAP reports) and complete the medical claim. If that sounds like a lot of work, don’t worry; there is software that can do it for you.
What steps can you take to help patients access care in today’s economic environment, especially for larger cases? Dental practices are offering great financing options to make care accessible, and many are taking it a step further by filing medical insurance for patients that want to move forward. Medical insurance billing for oral surgery such as cone-beam CT, bone grafts, and implants can be the icing on the cake as patients gain extra financial help from their medi cal plan. Keep in mind, you can remain fee-for-service and file a patient’s medical benefits as courtesy billing. Here are three common questions we get from practices wanting to get started with medical billing:
• How do you start and make it easy for you and your team?
• When would you file for medical instead of dental?
The When Criteria for bone grafts and implants to qualify for medical coverage are accidental injury, cyst or tumor removal, and func tional impairment. For accidental trauma, the medical plan must cover services to return the patient to pre-accident condition. If teeth need to be removed to excise or drain a cyst, some medical plans will cover the replacement of those teeth. For functional impairments, you may encounter patients whose condition lim its their diet to semisolid, soft, or liquid food, and who cannot tolerate or accommodate a denture. Other billable procedures include exams, radiographs, frenectomies, mucositis, myofascial pain dysfunction (Botox®), third molar extractions, obstructive sleep apnea and TMJ appliance therapy.
The Why Case acceptance increases when patients know their insur ance benefits are being maximized, reducing the out-of-pocket cost for services or helping satisfy medical deductibles. In the current economy, flexible financial options (outside financing and medical billing combined) make it more possible for many patients to afford treatment. The more affordable the treatment, the more likely patients will say “yes.” Happy patients lead to increased word-of-mouth referrals, and many are thrilled to find a dental practice that files medical. Here at Nierman Practice Management, we frequently receive inquiries via email, phone, and live chat directly from patients seeking a dental practice that knows how to file medical! Patients are increasingly asking dental providers if they can tap into their medical benefits and are even shopping around for those providers. You may also run into situations where dental insurance requires filing of medical plans first.
Many practices outsource the billing to make it easy, taking less dental team-member time away from patient care. Now that you know the why, when, and how, it’s time to take action! You can incorporate medical billing in your practice with the right tools. Now is the time to transform your practice by offering another financial option to help patients move forward while setting your dental practice apart — above the rest.
Should you be billing medical insurance instead of dental?
Rose Nierman is the founder and CEO of Nierman Practice Management. Rose has been teaching dental offices medical billing for over 30 years through the iconic Successful Medical Insurance in Dentistry seminars. She is the creator of DentalWriter Plus+, a system for generating documentation for physician referrals and to demonstrate medical necessity in conjunction with the Nierman Medical Billing Service.
Use Code IP22 by 12/31/22 for a free medical billing seminar included with DentalWriter Plus+ Schedule a demo today at DentalWriterPlus .com or call 1-800-879-6468, opt. 1 MEDICAL BILLING SERVICE DONE-FOR-YOU MEDICAL REIMBURSEMENT FOR FULL ARCH, BONE GRAFTS, CBCT & SLEEP APNEA Make it Easy for Patients to Say YES Provide an Exceptional Patient Experience Gain a Competitive Edge & Attract More Cases Save Time and Stress with Proven System & Experts Set your practice apart, do more cases, & add more revenue with the proven, streamlined system of DentalWriter Plus & Nierman Medical Billing Service.
Just because the dental professional did not cause the injury, he/ she may still be liable for the acts of others. This includes their dental hygienist, nurse, or anesthesiologist.
38Implant Practice US Volume 15 Number 3 LEGAL MATTERS
Kristin Tauras, JD, guides dental specialists through the legal elements
Kristin Tauras, JD, is a partner in the law firm of McKenna Storer in Chicago, Illinois. She has a litigation practice in the areas of employment law, insurance coverage, and professional malpractice. McKenna Storer is a fullservice law firm providing legal services to individuals and small to midsize companies, including defending professional malpractice negligence lawsuits and Illinois Department of Professional Regulation investigation, as well as advising dental and medical professionals regarding business and employment matters.
• Damages to the patient
Dental specialists are increasingly being sued for professional malpractice. As one plaintiff’s coun sel explained, it is easier to get a dental specialist to settle than any other medical professionals these days. While most other medical professionals are aware that they are the target of lawsuits and have themselves been sued or see their colleagues getting sued, the same cannot be said for the dental profession. While not new, dental malpractice lawsuits are still a novelty to most in the pro fession. Dental specialists are unprepared for the havoc a lawsuit can cause in their practice, are embarrassed when they are sued, are less likely to tell colleagues that they have been sued or seek advice, and are more apt to settle quickly and quietly than fight what is oftentimes a defen sibleThecase.term dental specialist used throughout this arti cle encompasses all dental and medical providers who treat diseases and problems of the teeth, gums, and jaw — including dentists, cosmetic dentists, pediatric den tists, prosthodontists, periodontists, endodontists, oral and maxillofacial surgeons, and orthodontists. This also encompasses the liability of the dental specialist’s staff — includ ing dental hygienists, dental assistants, nurses, anesthesiologists, and other medical providers who assist with the dental treatment and potentially can be named in a dental malpractice lawsuit.
Navigating dental malpractice lawsuits — part 1
Duty of care
• Breach of duty of care by the dental specialist
First, the plaintiff must establish that the dental specialist owed the patient a duty of care. This first element requires that there is a relationship between the dental specialist and the patient. Usually this element is easily proven through the use of medical records showing that the dental specialist treated the Otherpatient.times though, the patient relationship falls within a gray area — for example, where the patient does not return for the treatment, the dental specialist declines or refuses to treat the patient for a dental issue, or the dental specialist refers the patient to someone else before the malpractice occurs. It is also important to note that dental specialists are also liable in most states for those who work under their supervision with them and, in some cases, those to whom they refer cases.
Proving professional malpractice
• Duty of care owed by the dental specialist to the patient
In every state, a patient may pursue a malpractice claim against a dental healthcare provider if the healthcare provider causes injury or death to the patient through a negligent act or omission. In dental treatment, professional malpractice is defined as any act or omission by a dental specialist, or some one under their direction, during the treatment of a patient that deviates from the accepted standard of care and causes harm to the Topatient.recover for alleged dental malpractice, the plaintiff must allege and prove that the dental specialist (or someone under his/her supervision) was negligent in the treatment of a patient, and that the negligence caused harm to the patient. The elements may be broken down further:
• Injury caused to the patient by the breach of duty of care by the dental specialist
• Causing damage to bone or soft tissue.
• Causing an infection.
• Misaligning the teeth by improperly fitting fillings, crowns, or implants, resulting in issues with bite and speech.
• Performing an improper extraction.
• Improperly treating or failing to treat the dental condition.
• Failing to adequately supervise employees under their direction or control.
• Improperly administering anesthesia that leads to com plications such as brain damage or death.
Breach of duty of care
• Ignoring the current standards when recommending or pursuing a course of treatment.
In rare cases, punitive damages may also be awarded. For this to occur, there must usually be malfeasance or malintent alleged.
• Failing to accurately diagnose an infection, lesion, can cer, periodontal disease, or other oral diseases.
• Drilling too deeply, resulting in permanent injury to the tooth.
• Recommending unnecessary dentures or failing to cor rectly fit dentures.
• Recommending and performing treatments that are not medically necessary.
• Failing to refer the patient to the proper dental specialist such as an oral surgeon or an endodontist.
• Using excessive force on patients.
Dental specialists are familiar with the term art of dentistry. Despite enormous advances in the practice of dentistry, the personal encounter between patient and physician remains the cornerstone of dental care. The dental professional becomes the diagnostic and therapeutic expert who applies the knowledge and skills of dentistry. It includes not only what is required for a diagnosis and healing, but also the ability to apply the general ized knowledge of dentistry to individual patients. Dental spe cialists should not allow the fear of a malpractice suit to hamper their judgment and their application of the art of dentistry, but they should be aware of the types of claims so they may make sure to protect themselves against a claim that they committed dental malpractice. Best practice Dental specialists should make sure they chart their thought processes, conversations with patients, and treatments thor oughly so that they may defend themselves against claims of malpractice.Thelack of charting is not listed as a basis of the typical allegation of negligence against a dental specialist, but lack of adequate charting may be a factor in a lawsuit against the dental specialist. A plaintiff’s counsel may argue that if it wasn’t charted, it didn’t happen; or if it wasn’t charted, it wasn’t considered. The failure to chart essential aspects of the patient’s care may lead to difficulties in defending the dental specialists’ reasons for their decisions and treatment. While all dental specialists know that a substantial part of their treatment of a patient is the “art of dentistry,” taking into account the patients they see, their knowledge, training, and expertise, it makes it easier to defend their actions when these considerations are included in the chart. IP Dental specialists are unprepared for the havoc a lawsuit can cause in their practice. ...
• Failing to consider a patient’s existing medical conditions, allergies, and physiology before treating the patient.
Second, the plaintiff must establish a breach of duty of care. To do so, the plaintiff must establish the standard of care. The stan dard of care is a “reasonable person standard,” which is a legal fiction, created by laws, referencing a standard of care that all dental professionals in a similar situation and similar locale should follow. A breach of the standard of care occurs when the provider fails to act as a reasonably prudent and trained dental professional would under the same or similar circum stances when treating a patient. Both the standard of care and the breach of the standard of care must almost always be established through expert witnesses. The exception is where the breach is of such an obvious nature that the breach speaks for itself.
40Implant Practice US Volume 15 Number 3 LEGAL MATTERS
• Causing nerve injuries that lead to complications such as neuropathy or paralysis.
Breach of standard of care Third, the breach of the standard of care must cause an injury. A plaintiff must prove that the healthcare provider caused the injury or made an existing condition worse by his/her action (or inaction). The patient must show a direct relationship between the alleged breach and the subsequent injury. This is known as “proximate cause.” The malpractice must proximately cause the injury suffered by the patient. Damages Fourth, there must be damages. Damages can be in the form of medical bills (the cost of medical treatment and corrective treatment), disfigurement, pain and suffering, loss of normal life, and economic losses (lost wages). When dental errors result in permanent disability or death, family members may also, in most states, recover for the “loss of society” and/or wrongful death of the patient.
Art of dentistry
• Using improper instrumentation, improperly maintained instrumentation, or using outdated tools.
Types of dental malpractice
Any deviation from the standard of care can constitute mal practice if it proximately causes a patient injury. There are an infinite number of ways dental practitioners can deviate from the standard of care. Examples of deviations from the standard of care that may result in a malpractice claim follow.
• Failing to obtain informed consent and failing to explain the risks of the procedure to the patient in a manner and language in which the patient can understand.
4:
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