We regularly see patients with multiple medical conditions, multiple medications, or other therapies. We are seeing an increase in the age of our patients, as well as seeing a greater population of patients with obstructed breathing disorders and diabetes. Understanding the complexities of these types of patients requires ongoing training and practice.
Thank you to Tara of Medic/First Aid, Inc. who led an intensive review
of lifesaving and first aid emergencies. She tailored our recertification
to the emergency protocols we encounter with our surgical, sedation,
and general dental patients.
Dr. Rafoth is trained in advanced cardiac life support (ACLS). He is a Dental Organization for Conscious Sedation provider, mentor, and member. Our team is trained and up-to-date on the current techniques for conscious sedation care as well as CPR, AED, and first aid services.
Thursday, March 28, 2013
Monday, March 18, 2013
Complicated Care Plans Require Flexibility in Treatment
Lately I have had several consultations regarding large-scale, complicated treatment plans to care for complex decay and periodontal disease. It's been pretty trying for me as I discuss the large costs of these treatments; my patients have developed these conditions over many, many years. To recommend the right kind of care for them, I have to walk a fine line between cost and care with them all. Most of the involved plans have a sticker price that is akin to a new car.
In order to make things affordable in dentistry, I have to find a way to create steps in care. I'm always using the simple (albeit sometimes oversimplified) analogy of building a house. At times I am proposing a remodel. Other times I am proposing a bulldozing and total rebuild. And when a house gets work done, it can happen in phases. No different in my line of work.
The reason it's important to share this? Twofold. First, everything in dentistry is expensive. It's important for me to keep that in mind as I propose care plans, because it's a real world we live in with lots of expenses from all angles in our lives. If I can create a situation where patients can start a project, have stability in the interim, and finish it within a reasonable time frame while on a budget, then I feel good about that.
Secondly, dentistry done right is time-consuming. I actually feel steps HAVE to happen in many of these cases. "Teeth InAn Hour" is bandied about these days, and I don't think that fits the majority of patients; it's practically unfair to doctors and patients alike to push that same-day tooth replacement option. Oral health doesn't blow up and fail in a day. So there's little chance that a quality result occurs in the same time frame.
Lastly, with financing, things can happen in steps with a flexible payment plan.
Give us a call to talk about your involved or complex care. I know we can find a way to make it happen in steps.
In order to make things affordable in dentistry, I have to find a way to create steps in care. I'm always using the simple (albeit sometimes oversimplified) analogy of building a house. At times I am proposing a remodel. Other times I am proposing a bulldozing and total rebuild. And when a house gets work done, it can happen in phases. No different in my line of work.
The reason it's important to share this? Twofold. First, everything in dentistry is expensive. It's important for me to keep that in mind as I propose care plans, because it's a real world we live in with lots of expenses from all angles in our lives. If I can create a situation where patients can start a project, have stability in the interim, and finish it within a reasonable time frame while on a budget, then I feel good about that.
Secondly, dentistry done right is time-consuming. I actually feel steps HAVE to happen in many of these cases. "Teeth InAn Hour" is bandied about these days, and I don't think that fits the majority of patients; it's practically unfair to doctors and patients alike to push that same-day tooth replacement option. Oral health doesn't blow up and fail in a day. So there's little chance that a quality result occurs in the same time frame.
Lastly, with financing, things can happen in steps with a flexible payment plan.
Give us a call to talk about your involved or complex care. I know we can find a way to make it happen in steps.
Thursday, February 28, 2013
Battling The Banes Of Our Existence: Inflammation AND Big Pharma
Inflammation is pervasive in the human body. It's likely that it is the primary cause for aging and our mortality. Hundreds of drugs have been brought to market to combat inflammatory diseases. It's likely thousands more will be introduced to treat inflammation at the genetic level, inhibit inflammatory enzymes and proteins; the list goes on.
One of the most influential drugs in the battle against periodontal disease is doxycycline. The popular brand name of this drug is called Periostat. But it is available in generic formulations. It is an antibiotic by design. But instead of using heavy-duty doses to kill bacteria associated with periodontitis, the drug has been wielded by researchers and clinicians in small amounts to suppress the body's inflammatory process, which is actually a reaction to bacterial toxins.
When the inflammatory process begins in periodontal disease, it is not the bacteria that create tissue destruction. It is the body's reaction to the toxins that trigger enzymes and bone- and gum-killing proteins to surge. So the low-levels of doxycycline suppress the enzymes released during inflammation, and the tissues are not destroyed as readily over time. The concept is called host modulation therapy.
Patients occasionally pipe up with concerns that they will not use the drug because they fear it will promote a bacterial super-infection when using doxycycline. But frankly, the doses are so small that they don't even kill bacteria, and do not promote the mutations responsible for bacteria to become more resistant to treatment. My opinion is that it should just be added to the water supply based on how effective it is for some patients with highly sensitive inflammatory reactions. It's one of the only good weapons I have seen sensitive patients use with success beyond good self-care to avoid surgical treatment and minimize the impact of periodontitis.
But there is now a greater challenge for patients to get access to this drug because of the decisions pharmaceutical companies and medical insurance companies are making. Not only are many drugs being taken off the shelf due to discontinuation of drug manufacturing, but insurers are also implementing increases in co-payments for patients who want to use drugs that are in short supply. So if you or others want to know the status of your drug of choice in the marketplace, go to the site managed by the American Society of Health Pharmacists.
One of the most influential drugs in the battle against periodontal disease is doxycycline. The popular brand name of this drug is called Periostat. But it is available in generic formulations. It is an antibiotic by design. But instead of using heavy-duty doses to kill bacteria associated with periodontitis, the drug has been wielded by researchers and clinicians in small amounts to suppress the body's inflammatory process, which is actually a reaction to bacterial toxins.
When the inflammatory process begins in periodontal disease, it is not the bacteria that create tissue destruction. It is the body's reaction to the toxins that trigger enzymes and bone- and gum-killing proteins to surge. So the low-levels of doxycycline suppress the enzymes released during inflammation, and the tissues are not destroyed as readily over time. The concept is called host modulation therapy.
Patients occasionally pipe up with concerns that they will not use the drug because they fear it will promote a bacterial super-infection when using doxycycline. But frankly, the doses are so small that they don't even kill bacteria, and do not promote the mutations responsible for bacteria to become more resistant to treatment. My opinion is that it should just be added to the water supply based on how effective it is for some patients with highly sensitive inflammatory reactions. It's one of the only good weapons I have seen sensitive patients use with success beyond good self-care to avoid surgical treatment and minimize the impact of periodontitis.
But there is now a greater challenge for patients to get access to this drug because of the decisions pharmaceutical companies and medical insurance companies are making. Not only are many drugs being taken off the shelf due to discontinuation of drug manufacturing, but insurers are also implementing increases in co-payments for patients who want to use drugs that are in short supply. So if you or others want to know the status of your drug of choice in the marketplace, go to the site managed by the American Society of Health Pharmacists.
Wednesday, February 13, 2013
New Beginnings
Old School is a favorite movie of mine. For some reason, Will Ferrell's voice resounded in my head as I was getting my day started with a dental assistant for a working interview. To me, "new beginnings" mean that my team gets a chance to find a great asset to add to the mix. And the theme of new beginnings are also important when any of our team is welcoming a patient into the practice.
One of the major tenets of our mission is as follows:
"Our patients are supported by a personable, approachable team concerned with building their trust and confidence. We provide a relaxed, open forum where you can consider or express a new desire for dental care."
I have always been associated with activities an interests that include people having fun together; making and performing music, hosting uniquely themed parties, skiing with a group, mountaineering, playing Scrabble and other games around the table with my family. So naturally I want to get to know somebody before I launch into dental care. And that's what I decided my team should be great at. Inviting guests into our house means we hang their coat, give them a tour, and sit down for a bit to share about each other. Then we can take the steps to plan treatment people want to pursue. Until that relationship is made, we don't do dentistry.
So call us! You can come in to meet us for a cup of coffee and a no-cost consultation, or book a visit for a cleaning and examination to get your dentistry done.
One of the major tenets of our mission is as follows:
"Our patients are supported by a personable, approachable team concerned with building their trust and confidence. We provide a relaxed, open forum where you can consider or express a new desire for dental care."
I have always been associated with activities an interests that include people having fun together; making and performing music, hosting uniquely themed parties, skiing with a group, mountaineering, playing Scrabble and other games around the table with my family. So naturally I want to get to know somebody before I launch into dental care. And that's what I decided my team should be great at. Inviting guests into our house means we hang their coat, give them a tour, and sit down for a bit to share about each other. Then we can take the steps to plan treatment people want to pursue. Until that relationship is made, we don't do dentistry.
So call us! You can come in to meet us for a cup of coffee and a no-cost consultation, or book a visit for a cleaning and examination to get your dentistry done.
Thursday, January 10, 2013
Treat Blood Pressure By Treating Apnea
A patient walked in to see me last week, middle aged gentleman, energetic, talkative, friendly. Not the least bit stressed-out from all outward appearances. But his blood pressure was 210/130! His readings came down modestly as we sat and talked. But I booked him a visit at his primar care doctor's office before he left. Upon examination, I recognized he had lots of risky physical characteristics and a positive history for sleep breathing obstruction. I told him he could manage his blood pressure by managing his breathing. His eyebrows went up.
It's true--blood pressures are reduced in patients treat their obstructive sleep apnea. The atricle I attached goes on to describe the study was performed with patients using oral appliance therapy.
I am a member of the AADSM--The American Academy of Dental Sleep Medicine. Call today to begin your treatment.
It's true--blood pressures are reduced in patients treat their obstructive sleep apnea. The atricle I attached goes on to describe the study was performed with patients using oral appliance therapy.
I am a member of the AADSM--The American Academy of Dental Sleep Medicine. Call today to begin your treatment.
Monday, January 7, 2013
Mid-Level Dental Providers--An Update
The idea of MLPs was introduced by advocacy groups to aid the most under-served portions of the population at large. MLPs have been suggested to work independently of dentists, possibly in their own clinics, and begin helping patients in geographic areas where providers are needed most. So with the unchanging tooth decay epidemic, the question is: are MLPs valuable for Washington State's future? The answer: not really. Over time we will likely see the value of MLPs diminish after they are introduced. The answer lies in the eventual failure of the economics behind the model for MLPs.
The American Dental Association (ADA) released a recent report about mid-level dental providers. (MLPs) The upshot is MLPs can perform valuable skills to improve patients' dental health. However, there is no obvious economic value in having MLPs incorporated into the dental industry. The ADA report states that regardless of how may providers treat dental decay, the population at large will not see a reduction in dental decay. Dental decay is an epidemic, and MLPs would not reduce the incidence of tooth decay.
If you recall, I have been against MLPs for a few reasons. MLPs could create catastrophic changes to our dental system for patients and dentists. The principles that I want you to consider were summed up nicely by an amazing colleague of mine, Dr. Christopher Jean, in a recent message:
"If independent mid-level providers have the capacity to operate a clinic independent of a dentist, the following will most likely occur:
1. The (midlevel providers) will apply for and eventually receive acknowledgement from insurance companies to perform many of the same clinical functions as Dentists. The reimbursement rate as set by the insurance companies will be the same. In fact if mid-level providers can operate clinics, they can now hire dentists to perform ancillary procedures in much the same manner as denturists currently do. Nothing will change, especially for the consumer. The equipment costs will remain the same and the costs of day to day operations will still be the same. Instead of a flood of midlevel providers going to areas to serve the poor, they will gravitate to where the money and jobs are.
2. The wages for midlevel providers can initially be set (at a certain level), but with several years of experience, the market will eventually dictate what they can make and that is usually productivity based. If a midlevel provider can produce what a dentist can produce, then they can make what a Dentist can make within a comparable scope of practice for how quickly they can turnover a chair...If hygienists can command (a higher wage) to go to an office for a day, but a midlevel provider can do so much more, it is doubtful that after several years the rate of pay for midlevel providers will be less than that of hygienists. The demand for hygienists will go down and the cost of midlevels will eventually exceed (the hygiene wage). The cost benefit ratio for becoming a therapist will exceed the motivation for becoming a hygienist. The quality of applicants for hygiene programs which is very high will drop. Therapists will have a broader focus of practice. This can be beneficial in certain instances, but nobody is better at the focus of prevention and maintenance than hygienists. There will be a drop off in quality of personal focus on this one key gate-keeping responsibility if there are fewer hygienists who practice as a proportion of the whole field. Studies have never decried the importance of hygienists, just their average hourly wage within the state of Washington as an economic obstacle to affordable healthcare for the working poor and to medicaid patients.
3. Public health clinics will restructure their personnel to take advantage of midlevels. Dentists will be more responsible for specialty procedures because there will be fewer of them. Their practice risk and stress will increase. Subsequently the retention rate will be more difficult and the turnover higher if salaries do not increase. If private practices pay more for Therapists, public health will need to up their payroll ante as well. The payroll savings will still be there but it won't be at (the same initial rate) after a few years. The real effect won't trickle down to underserved areas because it would take several years to construct new clinics in underserved areas and by the time they are ready to run and people start to access care which may take a few more years, the wage cost savings may diminish significantly to have any concrete impact upon the patients they were intended to serve.
4. The true beneficiary to the addition of a midlevel are corporations if they are heady enough to be opportunistic and take advantage of this. They can offer a fixed salary, benefits plus productivity bonuses that public health and Mom and Pop private offices either can not or are not accustomed to providing. Corporate chains already form a growing segment of the whole dental health field. Although many are not as efficiently run office to office, they play an important part in the whole economic landscape of the field that their presence and impact cannot be dismissed. They can draw upon that demographic that used to be the bread and butter of most dental practices. Yes, I'm referring to the trade unions who have traditionally had the best insurance benefits, the members who actually needed the most amount of care and who had the most amount of flexible time to access the care. If corporate offices strike a deal with unions that represent that majority demographic (for dentistry), it sets a precedent by lowering the value for services and treating the rendering of procedures as more of a product that is wholesale rather than treatment as part of a disease process.
And this is the whole point...we need to assess the impact of what this bill can really effect rather than what some advocacy groups hope it will effect.
The field is changing...the aspect of personalized care with a single doctor/ single hygienist model is becoming less of a standard. The common idea of addressing a patients dental/medical needs and putting them on preventive maintenance is gradually being replaced by a greater profit driven second tier of money management which typically focuses more on productivity and return as opposed to the relationship based doctor patient approach. Eventually the societal perception will slowly gravitate even more towards receiving dentistry as a product rather than a doctor-managed service. There is much more to being a good healthcare provider and a good doctor than just drilling, filling and cleaning. Every procedure that is done and every word of advice that is communicated bears a relevance to the overall totality of a patients general health and where that patient is or is not headed as they age and pertains directly to their quality of life."
Dental Health Day is this week in our state's capital, Olympia, Washington. There is still a possibility that the health bill to allow MLPs in Washington, HB13, may move into the legislature for more activity. Please show your support to cancel this bill. The economics of MLPs are too complex and not beneficial to the dental industry at this time.
The American Dental Association (ADA) released a recent report about mid-level dental providers. (MLPs) The upshot is MLPs can perform valuable skills to improve patients' dental health. However, there is no obvious economic value in having MLPs incorporated into the dental industry. The ADA report states that regardless of how may providers treat dental decay, the population at large will not see a reduction in dental decay. Dental decay is an epidemic, and MLPs would not reduce the incidence of tooth decay.
If you recall, I have been against MLPs for a few reasons. MLPs could create catastrophic changes to our dental system for patients and dentists. The principles that I want you to consider were summed up nicely by an amazing colleague of mine, Dr. Christopher Jean, in a recent message:
"If independent mid-level providers have the capacity to operate a clinic independent of a dentist, the following will most likely occur:
1. The (midlevel providers) will apply for and eventually receive acknowledgement from insurance companies to perform many of the same clinical functions as Dentists. The reimbursement rate as set by the insurance companies will be the same. In fact if mid-level providers can operate clinics, they can now hire dentists to perform ancillary procedures in much the same manner as denturists currently do. Nothing will change, especially for the consumer. The equipment costs will remain the same and the costs of day to day operations will still be the same. Instead of a flood of midlevel providers going to areas to serve the poor, they will gravitate to where the money and jobs are.
2. The wages for midlevel providers can initially be set (at a certain level), but with several years of experience, the market will eventually dictate what they can make and that is usually productivity based. If a midlevel provider can produce what a dentist can produce, then they can make what a Dentist can make within a comparable scope of practice for how quickly they can turnover a chair...If hygienists can command (a higher wage) to go to an office for a day, but a midlevel provider can do so much more, it is doubtful that after several years the rate of pay for midlevel providers will be less than that of hygienists. The demand for hygienists will go down and the cost of midlevels will eventually exceed (the hygiene wage). The cost benefit ratio for becoming a therapist will exceed the motivation for becoming a hygienist. The quality of applicants for hygiene programs which is very high will drop. Therapists will have a broader focus of practice. This can be beneficial in certain instances, but nobody is better at the focus of prevention and maintenance than hygienists. There will be a drop off in quality of personal focus on this one key gate-keeping responsibility if there are fewer hygienists who practice as a proportion of the whole field. Studies have never decried the importance of hygienists, just their average hourly wage within the state of Washington as an economic obstacle to affordable healthcare for the working poor and to medicaid patients.
3. Public health clinics will restructure their personnel to take advantage of midlevels. Dentists will be more responsible for specialty procedures because there will be fewer of them. Their practice risk and stress will increase. Subsequently the retention rate will be more difficult and the turnover higher if salaries do not increase. If private practices pay more for Therapists, public health will need to up their payroll ante as well. The payroll savings will still be there but it won't be at (the same initial rate) after a few years. The real effect won't trickle down to underserved areas because it would take several years to construct new clinics in underserved areas and by the time they are ready to run and people start to access care which may take a few more years, the wage cost savings may diminish significantly to have any concrete impact upon the patients they were intended to serve.
4. The true beneficiary to the addition of a midlevel are corporations if they are heady enough to be opportunistic and take advantage of this. They can offer a fixed salary, benefits plus productivity bonuses that public health and Mom and Pop private offices either can not or are not accustomed to providing. Corporate chains already form a growing segment of the whole dental health field. Although many are not as efficiently run office to office, they play an important part in the whole economic landscape of the field that their presence and impact cannot be dismissed. They can draw upon that demographic that used to be the bread and butter of most dental practices. Yes, I'm referring to the trade unions who have traditionally had the best insurance benefits, the members who actually needed the most amount of care and who had the most amount of flexible time to access the care. If corporate offices strike a deal with unions that represent that majority demographic (for dentistry), it sets a precedent by lowering the value for services and treating the rendering of procedures as more of a product that is wholesale rather than treatment as part of a disease process.
And this is the whole point...we need to assess the impact of what this bill can really effect rather than what some advocacy groups hope it will effect.
The field is changing...the aspect of personalized care with a single doctor/ single hygienist model is becoming less of a standard. The common idea of addressing a patients dental/medical needs and putting them on preventive maintenance is gradually being replaced by a greater profit driven second tier of money management which typically focuses more on productivity and return as opposed to the relationship based doctor patient approach. Eventually the societal perception will slowly gravitate even more towards receiving dentistry as a product rather than a doctor-managed service. There is much more to being a good healthcare provider and a good doctor than just drilling, filling and cleaning. Every procedure that is done and every word of advice that is communicated bears a relevance to the overall totality of a patients general health and where that patient is or is not headed as they age and pertains directly to their quality of life."
Dental Health Day is this week in our state's capital, Olympia, Washington. There is still a possibility that the health bill to allow MLPs in Washington, HB13, may move into the legislature for more activity. Please show your support to cancel this bill. The economics of MLPs are too complex and not beneficial to the dental industry at this time.
Thursday, December 27, 2012
No Big Deal...Just a Breathing Crisis.
Hanging out at the house last night, basking in the glow of the tree and feeling logy after the third full day of digesting mass quantities. And there's egg nog and candy in every corner of the house in case my blood sugar drops below 200. The kids are thrilled to be a part of it all, squirreling away candies and sneaking away to the play room. My 6-year old son is still buried in Lego kits, and my 2-year-old daughter is starting her journey as a performer, with a cute little drum set and a microphone sounding off at all hours.
It's a good thing she didn't get too far from Candy Mountain last night. Because she ended up lodging a Werther's in her airway. She was sitting on my grandmother's lap when my step dad threw an index finger in her direction, and furiously wagged it. "She's...she can't..."
I rolled my head in her direction, eyes at half-mast. Through my haze, I saw her reach for her throat. When my eyes locked on her face, turning from red to a dusky color. The hallmarks of choking were playing out exactly as they have been published. A tidal wave of adrenaline rushed through me, and I levitated out of the sofa. My instincts and first aid training took over.
In 2008, the American Heart Association published a survey about nationwide CPR training. Although 89% of respondents were willing to assist or step in to provide CPR for a victim, only 21% felt confident enough to perform it. Only 15% said they could utilize an AED in an emergency. The report added that most people were afraid they would screw something up, and/or suffer legal consequences.
I admit I was shocked, frozen, and completely surprised that my daughter would be the first victim that I saved from a choking emergency. I was scared that my training or my memory of the first aid algorithms would be accurate and effective enough to save her. I am trained in advanced cardiac life support, and my team undergoes routine training multiple times a year for CPR, AED, and first aid. But I was flat-out freaked I would fail. All of these thoughts went through my mind in a fraction of a second as I grabbed her and began the pediatric airway routines.
The outcome was positive. I had to beat up on her a bit, and had to institute a diaphragm maneuver. But the caramel popped out of her airway like a cork out of a bottle. Nothing but a scare for her, and she went to bed like an angel.
In reality, your family or friends will likely be the victims you have to save. And having the practice to save them is what it comes down to. Various sources place the length of time for brain death from lack of oxygen between 2 and 6 minutes. And that doesn't count the spectrum of brain damage during the time the brain has been deprived.
Being familiar with medical emergencies is easy to read about online; there are countless pages and sites. But rehearsing scenarios for heart attack, stroke, choking, and other common first aid situations is essential if anyone is to respond quickly enough to help a victim avoid brain damage, physical disability, or even death. Rehearsing at least once a quarter at home with your family or at work with your colleagues could mean the difference for those in trouble.
It's a good thing she didn't get too far from Candy Mountain last night. Because she ended up lodging a Werther's in her airway. She was sitting on my grandmother's lap when my step dad threw an index finger in her direction, and furiously wagged it. "She's...she can't..."
I rolled my head in her direction, eyes at half-mast. Through my haze, I saw her reach for her throat. When my eyes locked on her face, turning from red to a dusky color. The hallmarks of choking were playing out exactly as they have been published. A tidal wave of adrenaline rushed through me, and I levitated out of the sofa. My instincts and first aid training took over.
In 2008, the American Heart Association published a survey about nationwide CPR training. Although 89% of respondents were willing to assist or step in to provide CPR for a victim, only 21% felt confident enough to perform it. Only 15% said they could utilize an AED in an emergency. The report added that most people were afraid they would screw something up, and/or suffer legal consequences.
I admit I was shocked, frozen, and completely surprised that my daughter would be the first victim that I saved from a choking emergency. I was scared that my training or my memory of the first aid algorithms would be accurate and effective enough to save her. I am trained in advanced cardiac life support, and my team undergoes routine training multiple times a year for CPR, AED, and first aid. But I was flat-out freaked I would fail. All of these thoughts went through my mind in a fraction of a second as I grabbed her and began the pediatric airway routines.
The outcome was positive. I had to beat up on her a bit, and had to institute a diaphragm maneuver. But the caramel popped out of her airway like a cork out of a bottle. Nothing but a scare for her, and she went to bed like an angel.
In reality, your family or friends will likely be the victims you have to save. And having the practice to save them is what it comes down to. Various sources place the length of time for brain death from lack of oxygen between 2 and 6 minutes. And that doesn't count the spectrum of brain damage during the time the brain has been deprived.
Being familiar with medical emergencies is easy to read about online; there are countless pages and sites. But rehearsing scenarios for heart attack, stroke, choking, and other common first aid situations is essential if anyone is to respond quickly enough to help a victim avoid brain damage, physical disability, or even death. Rehearsing at least once a quarter at home with your family or at work with your colleagues could mean the difference for those in trouble.
Subscribe to:
Posts (Atom)