Dental fraud. A dental consultant's view

Since most plans today are based on "cost plus", employers and unions, whose plans were negotiated a long time ago, cannot afford to pay an increase of $13 per amalgam as they were asked to do when new codes for bonded amalgams were added to the provincial fee schedule. Similarly, demanding strains were placed on drug plans when a $16 per tablet medication for migraine headaches was placed on the market. The plan says that if a physician prescribed it, it will be covered. But by whom? And for how long? Dental insurance is not, and has not been for a very long time, a source of profit for the insurance carriers. One large company, for whom I worked for a number of years, just sold all their group dental insurance to a large carrier. Another well-known company has placed their group insurance on the market and is anxiously seeking a purchaser. It is too much to ask of a dental plan (and let's face it, without the plan, the patient may not seek dental treatment) to pay $100 or more for an "examination and one periapical radiograph resulting from the referral of a patient by a general practitioner to a specialist for endodontic treatment." In the case of a difficult diagnosis, this might be entertained, but why charge this fee in every case, even when the patient is holding a radiograph? I am not suggesting that fraud is being committed by a large number of practitioners on a regular basis. At the same time, I think that we must realize that this type of activity may result in the removal of dental "insurance" from the benefits provided by companies to their employees. Most dentists are extremely honest, but the backlash produced by the few who are involved in fraudulent practices is disturbing.     

Unusual nasal foreign body detected on routine dental radiography: case report

This report describes an unusual nasal foreign body in a 4-year-old boy discovered incidentally in a routine dental radiograph. A small piece of rubber eraser was lodged in the right nasal cavity, causing unilateral nasal obstruction and discharge, sneezing, snoring and breathing difficulty. In this case, discovery of unknown intranasal object was diagnostic for a condition suspected of pathological origin. Dentists may play a significant role in the diagnosis of intranasal foreign objects in children, through careful clinical examination and interpretation of dental radiographs. Early diagnosis is emphasized in order to avoid complications.     

The dentist and preventive dental health information

Patients receive differing amounts of preventive dental health information from their dentist. What factors affect the amount of preventive information a patient receives? Many possible reasons which have been advanced for this difference are discussed in this paper. Using the clues presented in the literature, and results of a presurvey, some factors thought to influence the amount of preventive dental health information the patient receives were investigated. Specifically, the research problem was, "What is the relationship between the amount of preventive dental health information a patient receives from the dentist in his private office and the following factors: patient's appearance, interest-responsiveness, nervousness, need for dental care, request for service, orientation to dentistry, and dentist's liking for the patient?" The hypothesized relationships of amount of preventive dental information delivered to dentist's perception of patient's characteristics were not upheld. The paper tentatively concludes that the characteristics of the dentist and his dental practice affect the preventive information delivered more significantly than patient characteristics.     

Reconstruction of an atrophic edentulous maxilla with unilateral cleft lip and palate (UCLP) using sub-antral augmentation and osseointegrated implants: case report and 3-year follow-up

With the current sophisticated, multidisciplinary approach to the treatment of cleft palate, it is anticipated that most patients with this deformity will enjoy good dental health and function. However, due to the number of older adults who were not treated with primary bone grafting and orthodontic therapy, there remains a significant number of potential candidates who may benefit from dental implants and implant-supported prostheses. Although it was not necessary in this case, a pharyngeal extension may be added to the maxillary denture to further improve speech and deglutition. This case report presents a three-year follow-up of a complex reconstruction of a highly compromised, edentulous patient. Stable fixation of the maxillary prosthesis results in a complete return to function in an individual for whom traditional dental prosthetics had resulted in ten years of failure and frustration. Combining the disciplines of reconstructive surgery and implant prosthetics enables the clinician to achieve a predictable result (Figures 12 and 13). While this case represents an extreme example, there are millions of patients for whom implant dentistry can provide life-changing benefits.     

The prevalence of preferential nasal breathing in adults

The prevalence of preferential nasal breathing was studied in an awake adult population. One hundred and ninety-four people consented to gentle manual compression of the nostrils. They were advised to 'breathe in and out', but no further information regarding breathing was given to avoid influencing the patient. One hundred and eighty patients (92.8%) commenced immediate regular relaxed breathing. Fourteen patients (7.2%) had difficulty with oral breathing which ranged from irregular mouth breathing associated with distress to no spontaneous respiration. The prevalence of preferential nasal breathing was strongly associated with increasing age (chi 2 for trend, P = 0.007). In addition, a weakly significant association was demonstrated between a history of asthma and this phenomenon (P = 0.047). These findings suggest a tendency for the elderly person to revert to the infant pattern of obligate nasal breathing. Physicians should be aware of this possibility in the elderly patient, especially prior to any procedure which may induce nasal obstruction.     

The effects of visual surround eccentricity and size on manual and postural control

The aim of this study was to compare two different modes of behaviorally-oriented therapies for dental fear. The subjects were chosen consecutively from the waiting-list of a Dental Fears Research and Treatment Clinic. In addition, a control group was selected from patients treated under general anesthesia to compare levels of dental and general fear with the experimental groups. Twenty-two women, with a mean age of 31.8 yr, were included and randomly assigned to two groups. The median time of avoidance of dental care was 9.5 yr. One group received hypnotherapy (HT) and one group a behavioral treatment based on psychophysiological principles (PP). Both therapies included eight sessions followed by standardized conventional dental test treatments. Pre- and posttreatment measures were dental fear, general fear, mood, and patient behavior. Nine patients were not able to conclude the treatment sessions (6 HT and 3 PP); these patients did not differ significantly from the remaining patients before treatment. The PP group reported a statistically significant decrease in dental fear as well as a rise in mood during dental situations, as opposed to the HT group. General fear levels decreased but not significantly. Eleven patients completed conventional dental treatment according to a dentist's behavioral rating scale, indicating that they were relaxed, and no problems occurred during the treatments. These patients were referred to general practitioners within the community dental service. In conclusion, this small size study showed that a majority of the patients, who accomplished the behavioral therapy and the dental test treatments, became less fearful of dental care and were able to manage conventional dental care, including changing dentist.     

Prevention of contamination with a heat-and-moisture-exchanger (HME) and bacterial filter during clinical anesthesia

Although the use of HME and bacterial filter is a common practice to protect the anesthesia machine as well as the patients from bacterial contaminants, there is no report demonstrating the effectiveness of this filter in clinical anesthesia setting. We evaluated the actual effectiveness of the filter during clinical use. While the anesthesia breathing circuit, two bacterial filters (BB 50 T, Nihon PALL) and anesthesia bag, which were sterilized with ethylen oxide gas (EOG), were connected to the anesthesia machine and used continuously for one week, EOG sterilized HME and bacterial filter (BB 25 A, Nihon PALL) were changed before each anesthesia. Culture samples were taken from the BB 25 A, the breathing circuit and the machine side of the BB 50 T. Of the 117 BB 25 A samples taken, 6 were positive for Micrococcus, alpha-Streptococcus, Bacillus, and Staphylococcus epidermidis. From 21 breathing circuit "internal" samples, one was positive for Bacillus, Staphylococcus epidermidis. But the contamination from outside sources was suspected, since all the BB 25 as used with this circuit were negative. Use of BB 25 A prevents contamination of the breathing circuit for a period of one week. If we use BB 25 A in every anesthesia case, the changing of the breathing circuit is unnecessary, reducing the cost and simplifying procedures during clinical practice.     

Sleep and breathing disorders in patients with brain stem lesions

Most information about the structures within the brain stem that modulate respiration and sleep are gathered from animal experiments. Therefore we examined 10 patients several weeks after an infarction of the brain stem by means of polysomnography and tested the chemosensitive drives of respiration. None of these patients complained about symptoms of sleep disordered breathing. In each case polysomnographic measurements and ventilatory response curves revealed pathologic findings. The respiratory response to CO2 was diminished or completely abolished in each patient. In some cases hypoventilation or disturbances of the respiratory rhythmicity could be seen. In several cases missing REM sleep, sleep fragmentation or the reduction of slow wave sleep were observed. The study indicates that on the base of results from animal research the comparison of morphological and pathophysiological data is helpful to gain a better understanding on the coupling of the respiratory system with sleep at the brain stem level as well as on the pathomechanism of sleep related breathing disorder.     

Clinical interview skills and identification of emotional disorders in primary care

BACKGROUND: This study focuses on the detection of medically compromised dental patients in the Netherlands by means of a validated patient-administered medical risk-related history (MRRH). Due to social changes and scientific innovations in the past decade, more medically compromised patients will be needing special dental treatment. METHODS: The medical problems of 29,424 dental patients (age 18 years and over) from 50 dental practices in the Netherlands were registered by means of the MRRH. The patients were classified according to the ASA risk-score system, which was modified for dental treatment. An inventory of the number and nature of medical problems and the modified ASA risk score was drawn up in relation to dental treatment and age. RESULTS: The average age of the patients was 37.1 +/- 13.5 years. According to the current guidelines, dental treatment must be modified if the patient has an ASA score of III or IV. A relatively high percentage of patients ages 65-74 (23.9%) and 75 or over (34.9%) did have an ASA score of III or IV. Furthermore, the medical problems were classified into 10 categories, and the relationship to age was examined. The conditions that increased with age were hypertension and cardiovascular, neurological, endocrinological, infectious, and blood diseases. CONCLUSIONS: For the dental practice, these results mean that the MRRH can play an important role in adapting dental treatment to the specific needs of patients. This is especially important in the case of elderly patients.     

Potential role of the peroxynitrate-poly(ADP-ribose) synthetase pathway in a rat model of severe hemorrhagic shock

PURPOSE: The purpose of this study was to assess the performance of sealants placed by senior dental students as part of a comprehensive dental care program that included periodic patient recall. METHODS: The dental records of 100 patients ranging in age from 6 to 13 years were selected for review to determine the treatments provided for first permanent molars over time. Criteria for inclusion were: 1) at least five documented recall examinations and 2) all four first permanent molars had to have been treated with an occlusal pit and fissure sealant. The data collected included: 1) the age of the patient at the time of initial sealant placement; 2) the subsequent treatment provided to the first permanent molars, including retreatment with sealant or restoration and the date the services were provided; 3) the last date of follow-up examination in the pediatric dental program. RESULTS: A total of 400 molars were followed for an average of 54 months. Fifty-two percent of all molars received no further treatment after initial placement of sealant. Approximately 35% received retreatment with sealant only. The total number of molars receiving sealant material only was 343 (86%). The total number of teeth that were judged to require restoration was 57 (14%). No relationship was noted between the patient's age at placement of the occlusal sealant and sealant performance. CONCLUSION: In a dental school clinic, occlusal sealants were effective at preventing caries in a comprehensive care program that included periodic recall.     

Bruxism after brain injury: successful treatment with botulinum toxin-A

Bruxism, the rhythmic grinding of teeth--usually during sleep--is not an infrequent complication of traumatic brain injury. Its prevalence in the general population is 21%, but its incidence after brain injury is unknown. Untreated, bruxism causes masseter hypertrophy, headache, temporomandibular joint destruction, and total dental wear. We report a case of complete resolution of postanoxic bruxism after treatment with botulinum toxin-A (BTX-A). The patient was a 28-year-old man with no history of bruxism who sustained an anoxic brain injury secondary to cardiac arrest of unknown etiology. On admission to our rehabilitation unit 2 months after the injury, the patient presented with severe bruxism and heavy dental wear. The patient was injected with a total of 200 units of BTX-A to each masseter and temporalis. There was total resolution of bruxism 2 days after injection, with no complications. On follow-up 3 months after injection, the patient remained free of bruxism. We propose that botulinum toxin be considered as a treatment for bruxism secondary to anoxic brain injury. Further studies regarding muscle selection and medication dosage are warranted to elucidate the toxin's efficacy in this condition.     

Morquio's syndrome. A case report and review of clinical findings

Morquio's syndrome is a genetic disorder caused by the lack of the enzyme responsible for the breakdown of the mucopolysaccharide keratin sulfate. The resulting buildup of keratin sulfate causes a specific pattern of abnormalities, including short stature, spinal deformity, cardiac abnormalities, corneal opacities, deafness and dental abnormalities. The specific dental findings in the patient described here are as follows: the posterior teeth were tapered and had pointed. cusps; the maxillary anterior teeth were spaced and flared, and on radiographs, the enamel was less than 25 percent of normal thickness but of normal radiodensity. Despite these findings, the patient exhibited a low rate of caries. This paper is a review of medical and dental findings in the Morquio's patient and how this may affect dental management.     

Electrospray ionization and collision-induced dissociation of antibiotic polyether ionophores

The hypothesis of the present study was that previous experience of caries may serve as an indicator for individualised bitewing examinations in 15-19-old adolescents. One hundred adolescents, all 19 years old, were randomly selected from the files of public dental clinics in the County of Orebro. For 93 adolescents the total number of radiographs were summed for every patient from the age of 3 to 19 by assessing the files of public dental clinics and by assessing the files of the dental radiology department. All sets of bitewing radiographs from 14 up to and including the age of 19 were assessed with respect to approximal caries. The average number of intraoral radiographs exposed in a patient from the age of 3 through 19 was 24.4. It was shown that 70 to 80% of 14-19-year-old-adolescents had had a bitewing examination every year. The decision to perform a bite-wing examination in a 15-year-old was significantly correlated to the number of surfaces with initial caries at the age of 14. In the other age groups, none of the investigated variables was found to be significantly correlated to the performance of radiographic examinations.     

Oral and systemic effects of prolonged minocycline therapy

The following case report shows the unfortunate side effects of minocycline therapy used in the management of facial acne. All three features of discoloration affecting the skin, bone and dentition were found. A 46-year-old patient presented with adult onset discoloration of the dentition following prolonged minocycline therapy. In addition, oral and cutaneous pigmentation were noted. Unfortunately, the undesirable cosmetic appearance of facial acne was exchanged for permanent discoloration of the dentition. When considering prolonged minocycline therapy, patients would benefit from dialogue between the medical and dental practitioners, so that the risk of this potential side effect can be assessed in a more informed way.     

Osteodysplasty (Melnick-Needles syndrome) (author's transl)

Authors report a new case of osteodisplasty (Melnick-Needles syndrome) and describe radiological findings that are typical of this entity: bony sclerosis of base structures, abnormal dental alignment, sclerosis and irregularity of clavicles and ribs, described as "band-like" deformity, cortical irregularity of tubular bones with metaphyseal flaring and diaphyseal bowing. Flat bones are broadened, particularly iliac crest and vertebral bones. Facial features described by the majority of authors in this entity are present in our patient in an incomplete form: craniofacial disproportion, micrognatia, depressed temples, exophthalmus (not in our patient) and broadened forehead. The paper is intended to gather clinical data of already reported cases in order to facilitate clinical research in the future from the immunological, genetical and biochemical points of view. Our patient has the same clinical history as the patient studied in the original paper. Dr. Melnick was kind enough to send us clinical data and autopsy findings.     

Oral management of the cancer patient. Part II: chemotherapy

This second of a three-part series reviews chemotherapy treatment and the responsibilities dental care providers have for patients in all phases of this type of cancer treatment. The goals of dental care are to maintain the integrity of the oral mucosa, prevent secondary infection, provide relief, and assist in maintaining dietary intake. The dental hygienist plays a key role in the recognition, treatment or monitoring of dental conditions that could cause complications to the patient during and post chemotherapy, as well as in educating and motivating the patient in optimal oral self-care.     

Acute maxillary sinusitis from a dental implant: an unusual case report

In this case report, we present an unusual complication of a previously inserted dental implant leading to maxillary sinusitis. The implant was removed and the patient postoperatively prescribed antibiotic medication. At the follow-up examination, healing was observed without any complications.     

Periodontal, implant, and prosthetic treatment for advanced periodontal disease

This article reports a case that involved a challenge in multidisciplinary decision making. A patient presented with severe periodontal disease and the need for prosthetic rehabilitation for purposes of tooth replacement and the stabilization of periodontally compromised teeth. The initial diagnosis revealed that the treatment regimen would require periodontic, endodontic, and orthodontic treatment, as well as dental implants. This case report demonstrates teamwork and a sequential approach to a complex case in a postgraduate clinical setting.     

An experimental test of adolescents' compliance with dental appointments

This study assessed factors associated with adolescents' compliance with dental appointments. Patients (n = 162) attending an adolescent clinic were administered a pretest questionnaire assessing health locus of control, self-esteem, and beliefs and attitudes about dental health from the Health Belief Model. Adolescents needing dental care were randomly assigned to groups for whom their dental appointment was made by a health professional or one in which the patient made his or her own appointment and to groups receiving an appointment reminder card versus not receiving a reminder card. Dental records were then reviewed to examine previous experiences with dental treatment. Neither the method used for making the appointment nor the use of reminder cards had a significant effect on compliance with the dental appointments. Also, compliance was not associated with health locus of control, self-esteem, or variables from the Health Belief Model. Older patients were more noncompliant than younger patients (tau = 0.14). Noncompliance was negatively correlated with the number of previous dental visits and previous dental procedures, oral hygiene instruction, and x-rays. Number of previous x-rays and previous broken appointments explained 5.1% of the variation in noncompliance. The Health Belief Model was not successful in predicting compliance behavior in this sample of adolescents.     

The importance of dentistry in the differential diagnosis of a medical disorder

This is a case report of a patient presenting to our clinic with a chief complaint of occlusal changes, but no clear-cut diagnosis of local origin could be found. The patient later was diagnosed with acromegaly. This rare systemic disease, caused by a slow-developing tumor of the pituitary gland, induces changes in various vital organs. Among them is a change in occlusion that can bring the patient to the dentist first. Dental professionals may be the first health care providers to see the signs and symptoms of acromegaly, and thus have the first opportunity to correctly diagnose this serious disease. This case demonstrates the importance of taking a thorough medical history and making a careful diagnosis before any dental treatment is recommended or undertaken.