Let me share with you the tale of a young patient who I first met at an American Academy of Facial Esthetics (AAFE) live patient training course who presented for Botox treatment of her masseters. There is a lot to learn from her story as it is very instructive as to a universal challenge that plaques every single dentist on a daily basis.
This patient came with the complaint “I grind my teeth and my implant is beginning to get loose”. The interesting thing about this patient was that she is only 22 years old and already has a dental implant. After a complete dental, head and neck examination I found that many of her teeth have some restorations but she has a very low caries index. She reports that many of her restorations are a result of teeth that have chipped or broken by themselves and not from “cavities”.
She goes on to explain a very common scenario as to why she has this dental implant. Her tooth suffered a fracture when she was about 19 and was restored with a tooth colored filling. A year later, the tooth and filling broke and was restored. A year later, it broke again and now she needed a root canal, post, core, and full crown. Three months later, the patient woke up one morning with the crown and post out of her mouth. She took this back to be treating dentist who for the first time mentioned that she must have sleep bruxism. As the tooth was non-restorable, a dental implant was now necessary. The dental implant was placed, she waited 6 months, and a crown was fabricated. Now, after spending thousands of dollars, it felt as if the crown was becoming loose, she sought out another opinion.
Just looking at this patient, it was obvious she had significant masseter hypertrophy. Using AAFE protocols that we teach, I had her take a STATDDS home bruxism/sleep monitor test and soon found that her bruxism episodes index (BEI) was well over 8.0 which makes her a very significant destructive bruxer. We treated her masseter muscles with 20 units of botulinum toxin (Xeomin, STATDDS). Two weeks later, she was tested again and had a BEI of only .6 which has resolved her bruxism as long as she maintains this botulinum toxin treatment.
With this new objective data about this patient's bruxism, I could now properly formulate a treatment plan for this patient that will include restorative materials that are very strong and can withstand very high occlusal forces for when the patient regains full contraction of her masseter muscles until she returns for botulinum toxin treatment. In this patient's case based on her BEI numbers, for any restorative treatment necessary I would use a fracture resistant universal nano-hybrid composite resin such as Gaenial Sculpt (GC America) or Reflectys (Itena USA). In her case, I had to drill through the crown to unscrew the abutment. I replaced the implant crown with a full mono zirconia crown (Bruxzir Translucent, Glidewell Lab) cemented with a temporary cement (Dentotemp, Itena). Should any other full crowns become necessary due to her other large restorations failing, I would use either Bruxzir with conventional cementation or Emax (Ivoclar) with full resin bonding cementation. These restorative choices are the result of the objective bruxism data so now I can insure a good long term prognosis.
For this first treating dentist, it would have been nice to know an objective bruxism number to guide them in treating this patient, but it wasn’t available then. With 1 out of 3 patients and now our capability to obtain specific evidence based, objective data on patients that will allow us to properly treatment plan patients, it is no wonder that Dr. Gordon Christensen says, “bruxism monitoring is one of the most important concepts we have today.”
This technology is very cost effective, also tests for sleep disorders, and is easy to administer. This testing can help you finally measure bruxism so you can formulate a treatment plan with an excellent long term prognosis and not guess if the patient has bruxism. The AAFE can teach you how to implement this in your office, get trained today!
Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org Go to www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain, Botox and dermal fillers training, Dental Implant Training, Frontline Bruxism Therapy / Dental Sleep Medicine, Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.
Disclosure: Dr. Malcmacher is President of the AAFE and is a consultant for STATDDS.
by Dr. Louis Malcmacher
That is the question that dentist have been the debating for the nearly 40 years that I have been in dentistry. I would venture to say that while there has always been an anti-PPO sentiment and, if given the choice, most dentists would love to rid themselves of insurance once and for all, this is not realistic for most dental practices. I can tell you from our own group practice, and on behalf of many American Academy of Facial Esthetics (AAFE) members that I represent, many of us have chosen be in a number of PPO networks.
So if you are like our offices, how can you make the best of the PPO networks that you are a part of? The first thing is to realize that you don’t have to participate in every single PPO in your area. Before you sign up, careful evaluation is critical to see if the proposed fees make sense for your practice. Loss leaders do not work for private dental practices unless you are literally seeing many hundreds of patients from one particular PPO. Even then, it would be rare that this would ever make sense.
Once you have made the decision which PPOs to be involved with, how do you make the most out of this PPO relationship? Most dentists are unaware that they are able to maximize insurance reimbursement even with already negotiated PPO fees. You have already been locked into a PPO fee schedule so every single patient you treat under that fee schedule is going to determine a set procedure production. What if you could increase some or all of the fees in that PPO? That would mean that every single patient you treat would result in a higher reimbursement – meaning more profit for your practice without seeing any increase in patients.
Here is how this can be done – hire someone to negotiate an increase in the PPO schedules. I will tell you the truth we have tried to do this ourselves over the years. We would occasionally call up a PPO and ask for a higher crown fee or molar endo fee. To our surprise, every so often they would actually agree to our request. I know many of you have had the exact same experience and really feel good about yourself thinking that you were a master negotiator. Little did we realize, the PPO manager on the other end of the phone was getting quite a chuckle from our little “negotiation.” Essentially, the PPO manager had just thrown us a bone that, over time, really did not develop into any significant production increase. We did not have the proper information to ask for what would result in significantly more production. Not only that, we never thought to even check whether not that new fee schedule was, in fact, in place by checking monthly EOBs. We just assumed that once we hung up the phone, that was the end
of the matter and we would automatically get the increase. To our dismay, we never really saw any significant income increase.
Thankfully, we did find a professional team at STATDDS that handles PPO optimization management. This is the same company that handles Medicare enrollment for thousands of dental professionals and did a great job for us as well. These are real insurance professionals who understand what information is needed before negotiations with a PPO even take place. They also know what steps need to be taken to implement the new negotiated fee schedules so that we actually start seeing the increased insurance reimbursement. Their team has over 35+ years of industry experience including knowing how to perform demographic studies of patients and dentists in the area, UCR schedules, and knowing which and how many fees have the best potential for maximizing insurance reimbursement.
The negotiation time for the PPOs that we deal with was approximately 4-6 months at which time the STATDDS professionals confirmed that the new fee schedule was in place and that we were actually getting paid on the new fee schedule through their monthly contract monitoring. The best part of the arrangement is that they are paid solely on a successful outcome so if we don’t make more money, they don’t get paid. This insures that they work hard to optimize all of our office PPO schedules on a continual basis. I will take that deal any day as I know many dentists who have spent thousands of dollars with other companies and have nearly no results to show for it.
We dentists think that we know everything and so many times we overreach into areas thinking we are getting the best deal for ourselves. PPO optimization management is crucial to obtaining higher profitability in your office while not having to see one more patient. Outsource this to professionals.
The Medicare application deadline is rapidly approaching. According to the ADA, applications should be submitted by January 1, 2016 or as close to it as possible to allow for enough processing time. You can contact STATDDS at info@ STATDDS.com or 800 693-9076.
Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org. Go to www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain training, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, Botox and dermal fillers training, download this resource list, and sign up for a free monthly e-newsletter. Mention you are a TPD reader and STATDDS will offer you a special discount of $300 off Medicare enrollment and $200 off the activation fee for PPO Optimization Management. This offer is limited to the first 50 TPD
After nearly three decades of lecturing and teaching dental professionals, I sometimes feel that I pretty much have seen it all when it comes to what can happen during a seminar. What every experienced speaker expects is for some minor things to go wrong, whether it is the computer or projector not working properly, the lights aren’t the way you want, or a dead microphone battery so you just have to shout to be heard until it gets fixed. Then there is then the next level of inconveniences of power outages during a lecture or the fire alarm going off for an hour which can pretty much disrupt the flow of a lecture. I have also had over the years an occasional participant faint during a course mostly because they were pretty much dehydrated or hadn’t eaten breakfast or lunch. Earlier this year, something happened that has never happened before – an attendee went into a full cardiac arrest right in the middle of my lecture. This article hopefully will be a good review as to what really happens during a medical emergency and a kick in the pants to all of us to update our emergency training and medical emergency kits in our office.
Here is what happened - I was at the front of the room just about to delve into a new hottest topic in dentistry when, all of a sudden, I saw about 20 people in a room of a few hundred just stand up and concentrate their attention to someone in the audience. I walked over to see what was going on and a few people were holding one of the attendees in a semi-reclined position who had looked like he had fainted, except that his eyes were open. We immediately moved some chairs away and placed this doctor on the floor. I and a few others yelled out to call 911 and a couple of dentists ran out into the hallway of this convention center looking for an automated external defibrillator (AED). Myself and two other dentists were monitoring this doctor’s pulse which was weak and going fast. He was totally unresponsive, not sweaty and we found out from the person sitting next to him that he had previously experienced no pain or complaint of anything wrong. All of the attendees in the room were extremely helpful, moving chairs away so that the EMTs would have a direct line access to the patient and the rest of the attendees all calmly started filing out of the room.
Another dentist, Dr. Frank Martello, and I immediately began chest compressions on this patient at a rate of approximately 100 compressions per minute to a depth of 2 inches. For those who need a reminder about CPR, there are conflicting guidelines as to whether or not to include rescue breathing but all agree to begin chest compressions as soon as possible. Previously, the acronym for beginning CPR began by checking the ABC’s (Airway, Breathing, Compressions). The most significant changes in the 2010 AHA Guidelines involve changing ABC to CAB (Compressions, Airway, Breathing). This change allows rescuers to begin chest compressions right away. For victims of sudden cardiac arrest, the critical elements of resuscitation are chest compressions and early defibrillation, which can begin earlier if there is no delay to open the airway and give breaths. If the patient is unconscious/unresponsive, send someone to call 9-1-1, take a quick look to see if the patient is breathing normally and then immediately begin compressions. For those who actually have never done chest compressions, they are done in a pretty hard and fast manner, a few fingers above the notch in the sternum. While you are doing chest compressions, you will hear and feel some popping noises and possibly ribs cracking.
I can tell you this and everyone present felt the same way, when you in the middle of this situation, it seems like it takes forever for emergency services to get there, when in reality it was probably only about seven to eight minutes. We found out later that there were no AEDs in the halls of the convention center because they have full time EMTs on staff. Being that it is such a big convention center, though, it still took about seven to eight minutes for them to get to our room. The EMTs got straight to work by hooking up an AED. The AED diagnosed the patient as being in ventricular fibrillation (V-fib). As you may remember, ventricular fibrillation is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly. While there is activity, it is undetectable by palpation (feeling) at major pulse points of the carotid and femoral arteries. This means that the heart muscles were just floundering around without pumping any blood. At this point, the AED did what it was supposed to do – it shocked the patient three times until some heart rhythm was established.
As we all watched in amazement, they then drilled, and I do mean drilled, a central line into the long arm bone of the patient with an intra-osseous syringe attached to a dremel drill. An ER doctor who is on our faculty of the American Academy of Facial Esthetics explained to me that in the emergency room, they do not look for veins anymore to start a central line into a patient. These patients do not have a pulse so it is very difficult to find a vein. The long bones in the arms and legs are perfectly suitable to be able to infuse saline and medications and they are easily accessible. The EMT’s started the patient on saline, intubated the patient, and myself and Dr. Frank Martello kept up the chest compressions until they set up an automatic chest compression machine. This machine was a true wonder and kept up contractions on the patient as the EMT’s then took this doctor out on a gurney to the local university hospital.
The great news is that within 18 minutes of leaving the convention center, he arrived straight into an operating room and two stents were placed into his heart. I spoke to this doctor a week after this course when he was home and had just done a little bit of gardening in his backyard. Yes, he was quite sore and actually did have a couple of cracked ribs, but he was alive and very thankful, as were we all.
By the way, what is the difference between a myocardial infarction (heart attack) and a sudden cardiac arrest? With a myocardial infarction, the patient will feel perhaps crushing in the chest, pain radiating down the arm and jaw, become very sweaty and pale. For that situation, you call 911 and you either deliver aspirin or a nitroglycerin tablet to the patient and pretty much wait until 911 gets there. A cardiac arrest is very sudden, acute event where the heart just stops as is what happened in the case described here. There was no time for the patient to get sweaty or complain about pain radiating in the arm, which is why it was such a surprising event.
Training, training, training – that is why you take CPR training repeatedly so that in an actual emergency, you know what to do almost automatically, and you don’t even have to think about it. I have been privileged to have performed CPR now on five people and thankfully they all lived. Some have suggested that maybe it’s me – maybe people just like to drop around me. I don’t know what it is, but it sure is good to be prepared and trained.
Now it is kick in the pants time. When was the last time you checked your emergency medical kit? Do you even know where it is? Are the medications expired? What is in it and do you know how to use it? I have always been of the opinion that you don’t need a complex medical emergency kit unless you have had advanced training. A basic kit with some common easy to use medications is the right fit for most dental offices. Does your office have an AED? In some states, it is now mandatory for dental offices to have one on site and it is a good idea for every dental office to have one and for every team member to know how to use it. It has been said (only half-jokingly) that if the dentist in the office is a middle age male, an AED is essential because chances are the dentist may be the primary beneficiary of this piece of equipment. All joking aside, it is time to treat the dental office as a primary healthcare facility that is properly equipped for emergencies.
Because of this experience, I had our team find one of the best AED’s on the market at the best price available, please visit the American Academy of Facial Esthetics store at www.FacialEsthetics.org for more information. Get an AED for your office today!
The exact same concept can be applied to our careers in dentistry as well. The key to a happy and successful dental practice is training and education on new techniques so that you can produce successful patient outcomes over and over again. Certainly a lecture atmosphere can be a wonderful learning experience but nothing replaces hands-on training, whether it is on models or live patients. Can you imagine doing a CPR training by lecture only? Hands-on training where you physically go through the movements whether it is for CPR or any kind of dental related training like restorative, implants Botox and dermal fillers, removable prosthodontics, exodontia, etc., is essential to train your hands to perform the procedures so that when it comes to crunch time, you are ready to go. Your brain runs through the procedure and guides your hands to properly carry it out.
I thoroughly enjoy all of my teaching activities whether it is lecture or hands-on. Here is the way I look at it – if I can motivate attendees at a lecture to add new things to their office and improve their practices, then I have accomplished my goal as a teacher. When I teach one of my hottest topics hands-on courses, then attendees learn how to actually perform new techniques which they can instantly integrate to their office - then I have accomplished my goal as a teacher and a dental professional.
Hands-on training is what made you a dentist. Hands-on training in CPR is what prepares you and your entire dental team for emergencies, make sure your training is up to date. That same lesson applies to your dental career – get yourself some hands-on training and make sure you are up to date with the latest techniques, products and technology in dentistry that will directly benefit your patients.
Dr. Louis Malcmacher maintains a cosmetic and general practice in Bay Village, Ohio. He is an internationally recognized lecturer and author, known for his entertaining and comprehensive teaching style. He has vast experience in total facial esthetics and has taught tens of thousands of healthcare professionals in the areas of smile design esthetics and facial injectable therapy. He has also lectured at many major medical and dental meetings throughout the US, Canada, Europe, and the Middle East. Dr. Malcmacher has also been extensively featured in the general media. His interviews have been seen on CNN, Fox, ABC, CBS, NBC, 20/20, Wall Street Journal, New York Times, Jane, Shape, Washington Post, Cleveland Plain Dealer, Detroit Free Press, GQ, Edge, Newsweek, Reader’s Digest, and Men’s Health. Dr. Malcmacher is a master of the Academy of General Dentistry, a fellow of the International Association of Dental Facial Esthetics, a fellow of the World Clinical Laser Institute, and a visiting lecturer at a number of universities.
