Tuesday, December 20, 2011

The Negative Impact of Dental Insurance

In the mid 1980's dental insurance came into vogue, dramatically changing the way dentists do dentistry. Prior to dental insurance a visit to the dentist was simple: he would tell you what you needed, you would get the work done and then pay for his services out of pocket. With the introduction of dental insurance suddenly a third party was making decisions about how much services should cost, what services each individual was eligible for, and how many services that individual could have done. Dental insurance became a huge business! One that has had a lot of negative impact. Because of insurance companies, patients would no longer have proper treatment if their insurance refused to contribute toward those services. Often patients wouldn't complete treatment because an insurance maximum was reached and there would be no more benefits. 

In the 1990's along came the invention of the HMO (Health Maintenance Organization) in both medicine and dentistry. HMO's were new and no consumer really understood how they worked. All the consumer knew was that they paid a lot less in premiums and received a lot of services for free. What the consumer didn't know hurt them: when you join an HMO you have been put on a list that has been assigned to a specific dentist. Most likely this meant that you had to change from your usual dental provider to one that was also on a list. The dentist is paid a monthly amount to see the patients on his or her list. 

There are many problems with trying to provide dentistry this way. The first is the list, which is usually out of date. If a patient has selected an office but has not yet appeared on their insurance company's list then the dentist is not obligated to see the patient. The second is that the provider list is always out of date. Dentists who appear as providers on the list may have dropped their participation or are no longer accepting any new assigned patients. The lack of organization within the insurance companies hurts the patients: they are paying huge monthly fees but are no longer able to get services rendered in a timely fashion or at an office nearby. 

Then there was the invention of the DMO (Dental Maintenance Organization). This is similar to an HMO, but instead the dentist charges a percentage of their usual fees to patient's with DMOs. To counter this, dentists began raising their fees for most services, many times doubling their fees so they wouldn't lose money to DMOs. Patients without dental insurance would have to pay extraordinary amounts for certain services. This caused a ripple effect throughout dentistry because dentists' fees were rising 10% to 25% per year when inflation was less than 5%. Dentistry became much more expensive because of HMOs and DMOs. For example: a crown in 1990 would go for around $500, but by 2000 a crown cost over $1000. 

When I opened my office in 2001 we accepted several HMO/DMO programs. By 2005 we had become so overwhelmed by the same programs and decided to discontinue our participation. We still accept hundreds of insurance programs: Delta Dental is the creme de la creme of dental insurance companies on my hate list. This company has not raised the amount they pay dentists for certain services in over eight years! They are so difficult to work with that many Delta Dental members can no longer find participating dentists nearby. This is unfair to the dentists and unfair to patients who are now, thanks to insurance companies, forced to pay exorbitant amounts of money for dental work regardless of whether or not they have insurance. 

So we came up with our Family Plan- a reduced fee plan available only at my practice. The patient pays us a yearly fee, usually less than the premiums for an HMO/DMO, and in exchange receives cleanings, exams, and x-rays for free. They also receive a substantial discount on our other services. We have been able to provide the same program with no increase in per year membership ever. It's still just $99/ year! 

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

Tuesday, December 13, 2011

The Evolution of Dental Implants

In 1982 I saw a television program about the exciting use of dental implants. The program suggested that dental implants would be placed by every dentist within the next few years. Ten years later I entered dental school excited to learn about dental implants and... nothing. Although dental implants were around and were successful, they were not taught to general dentists. It was felt that only specialists, such as oral surgeons, should be placing dental implants. We were taught that there were so many risks involved with placing a dental implant that we would be foolish to try. So I let the subject of dental implants sit on the wayside until 2005.

In 2005 I got sued. A hockey player was hit in the face and his two front teeth were sheered off at the gum line. I attempted to heroically save the teeth and they subsequently failed two years later. After two years of legal process I was found not negligent as the plaintiff ignored my statement to "immediately have the teeth removed and implants placed at the first sign of failure." The lesson I learned was to stop beating around the bush and start placing implants. I realized that placing dental implants is usually very simple once you get over the overwhelming technology of each system. Now I have developed my own surgical techniques that allow an implant to be placed in less than five minutes. I hold classes in my practice a couple times a year to teach these techniques to other general dentists.

Hiossen Dental Implants
To get to this point, I began by taking hundreds of hours of continuing education, including hands on and hands off surgical courses. I realized that my initial thought 15 years earlier was absolutely correct, implants are very easy to place and are very successful. So why aren't more dentists placing them? Cost and time. There are dozens of FDA approved implant systems in the United States. Each system uses its own set of instruments and components. Every time we select a new system it may cost $50,000-$100,000 in monetary investment, and the dentist is required to be educated in proper use of the implant system. This means taking more hours of continuing education, up to 100 hours for each system. We currently employ three systems in our office, plus a state-of-the-art digital radiograph.

The technology for dental implants is constantly evolving. Dental implants can now replace the need of almost any bridge, denture or partial denture and can be used to replace one or all of a patient's teeth. They are comfortable, natural in appearance, and can last a lifetime. We have now moved implants into our daily routine in our office, and we currently use a "non-surgical" technique. This new technique eliminates any cutting and stitching of the area. Healing times have also dramatically decreased from 16 weeks to 6 weeks, and in many cases we can place a tooth on the implant immediately. Now we routinely place hundreds of dental implants in our office every year with a 96% success rate.

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

Tuesday, December 6, 2011

Waiter! There's a zombie in my soup!

I like food. I like good food, fancy food, and I really like theme food. You know the restaurant with flaming tiki torches and a pig rotating over a spit? That's my kind of place.

There's a well known restaurateur in Philadelphia that has a dozen or so themed restaurants, and every restaurant, although different, has the same cloned waitstaff. I swear there is a blood sucking zombie in the back biting each one until they get that glassy stare. Every waiter gives the same introduction, announces the specials with no enthusiasm, and proceeds to serve in a robotic fashion throughout the night. I like to break the cycle by listening to the table service behind us, and when the waiter comes to our table I stop him before he has a chance to deliver his table-side performance by preempting him. Yes, I fully understand the theme of this restaurant from its inception to the imprisonment of the chef to the stove, and the overall environmental impact this locally grown meal will have. Yes, I know each special and how it is prepared. And no, I would not like to order the Chilean sparkling water that has been passed through the gills of a shark and then blessed by a shaman while performing a head shrinking ceremony.

This always stops the waiter. Then I get the stare. They don't know how to handle it; the script they have been made to memorize and have been quizzed ad nauseam by upper management has fallen apart! I am in my glory!

What does this have to do with dentistry? Scripting! The same management technique used to provide identical service in restaurants has been adopted for use in dentistry. Now we can have zombies in the dental office.

You can always tell when you have contacted a scripted office. They are much like the zombie waitstaff: always starting with the same introduction, a little meaningless information about the dentist, and ending with a "how may we help you today?" Usually I can spy these offices from a mile away just by looking at the dentist's credentials. There is always a mention of attending a world-renowned institution of post-graduate education that teaches a life-changing, advanced technique. Some of this "prestigious" education is about learning new and advanced ways to treat a patient's teeth, but a good part of it is about how to treat a patient's journey through a dental practice. All patients are treated the same by each member of the staff who are all zombies reading off of a cue card.

There is a massive amount of articles on the internet guiding dental offices toward scripting. They include exact phrases to use under every circumstance so each patient can have an identical experience. In my opinion, scripting like this sucks the life out of the practice. It creates an impersonal atmosphere, making each patient feel like a number and not an individual. It denys the employees the freedom to flaunt their colorful personalities and takes away from any element of fun in the office. I like to keep my office fun, unique and interesting so I say no to the zombifying effects of scripting!

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

Monday, November 28, 2011

An Art Gallery in a Dental Office

An original landscape painting by Virginia Kilpatrick.

I am a firm believer in the idea that artwork is the gateway to the soul, and my office reflects that belief. In addition to being a dental practice, my office is also a gallery of original artworks of all mediums ranging from photography to paintings to hand-drawn pictures. Every wall features unique and beautiful artwork that is handpicked by me, and each piece has a unique story attached to it. 
I believe that the artwork of an office represents the doctor. A stodgy office covered in unoriginal, mass produced prints lacks character and is hardly comforting. Who wants to look at the same Andy Warhol print every time they visit? It's boring to be stuck staring at some poster while sitting in a dental chair, anyone would rather be engaged in an interesting and original piece of art. I like that my patients have something new and entertaining to see and think about while they wait.

A lot of the artwork hanging in the office is of abstract organic images of flowers, nature, and landscapes. Abstract art is always interesting and thought provoking, and since patients often have to come back multiple times for procedures these abstract pieces give them something new to think about every time they visit. Another reoccurring theme in my office is "flowers". Besides being generally aesthetically pleasing, flower artwork always changes in the way it is perceived depending on the mood of the viewer. They also create a calming atmosphere, which is important in a dental office. 
The Money Tree- an original painting.
Decorating like this doesn't have to be expensive. The majority of the decor in my office is created by extraordinary local artists that I've discovered over the years, and some of them are happy to hang their work for free just to get recognition. Alan Allum is a local artist that I have most recently discovered. He is a fine art photographer who creates exactly the kind of artwork that I prefer- organic shapes, flowers, and nature. He is currently working on a few pieces to feature in our office: cool old automobiles with pictures etched into their big front ends. 
Pencil-drawn tree, NYC Street Art
Auctions, Ebay, museums, and city streets are a few other ways that I obtain our office art. Every piece of art has a unique story attached to it, often in how I discovered it. "The Money Tree," a beautiful and very colorful painting, was bought for only 58cents at an auction. On Ebay, I discovered a very talented artist from Tennessee named Virginia Kilpatrick. Many of her original paintings of beautiful landscapes are hanging in our office gallery. While walking the streets of New York City I stumbled upon a man trying to sell his pencil-drawn artwork, I bought two pictures of trees for $25 to help him out. These pictures are featured in our waiting room. 
To view more of the art in our unique office click here to see a slideshow.

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

Tuesday, November 15, 2011

An Inconvenient Truth About... Gum Disease

Cool Star Wars lightsabers- not the same kind of lasers
we use in dentistry. 

When I was first entering dentistry, lasers were already in use in most areas of medicine. I wanted one. Every boy who ever saw Star Wars wanted one- they're really cool! While lasers are a wonderful tool, they have limitations.
After looking into lasers it seemed to me that here was a great widget, with lots of cool buttons and such, that had no real use in my daily routine. Many of my peers have invested thousands of dollars in the latest and greatest laser just to have a really expensive place to pile stuff, kind of like that treadmill in your basement. But lasers just seem so great! And they are... just not in dentistry. They can be used for contouring the gums, root canal treatments, whitening, and even removing decay. However, there are other more efficient and less painful ways to do the same tasks. Lasers work by precision burning, which is essentially third degree burning. This means they are really great tools in other areas of medicine because they can stop bleeding with minimal damage to surrounding tissue. While this is a great advancement in medical technology, dentistry can't really benefit because teeth hate heat, it kills them. Inside every tooth is a nerve, artery, and vein. When you heat a tooth up too much, or come too near this area, the tooth will die, causing a lot of pain. 
One caveat that I have to no lasers in dentistry is for their use in gum disease. Lasers are great for treating some forms of gum disease, but only in conjunction with other treatments. The laser can remove gum diseased tissue around the teeth and kill the bacteria hiding below the gums that are causing the disease. With proper maintenance and other therapy this can help reduce gum disease in certain patients. We refer to several gum specialists who offer these services. 
Gum disease, or periodontitis, affects millions of people every day. Unfortunately for these people, gum disease never goes away. It is a chronic condition that has no cure, only treatments to lessen the damage. This is the same problem encountered by diabetics; there are treatments for diabetes like insulin, but no cure. Once you are diabetic, you will be diabetic for life and the same is true for gum disease. Once you have gum disease, you will have it for life. Sorry.
Blame your parents or blame your significant other. Gum disease is caused by bacteria and your body's failure to resist that bacteria. If you have gum disease you weren't born with the bacteria that causes it, either your parents or significant other passed the bad bugs to you. But the bad bugs alone do not cause gum disease, you need a bad gene pool as well. You get the picture: blame those around you. 
Gum disease is communicable, which means that we can pass the bacteria that causes gum disease from one person to another through intimate contact or even through food. For example: mom blows on baby's food or tests the food to see if it is cool enough and BLAM! Baby now has gotten the bacteria for gum disease. All adults carry the bacteria that cause gum disease, but not all adults get gum disease because some of us are resistant to it or have taken superb care of our gums and teeth.
So what do you do if you are diagnosed with gum disease? The first step is to get the bacteria at bay and reduce their numbers so that your body's defenses can get a foothold. This is done by having a gum treatment: the patient is numbed up and the teeth and gums are given a thorough cleaning. After the gum treatment(s) a light antibiotic, like Periostat, is prescribed that will be taken twice a day, along with a mouth rinse to be used twice as day. In addition to the prescriptions, using an electric toothbrush is always a good idea to help control and prevent gum disease. 
After initial treatment, the gums will need to be checked at regular intervals and cleanings will need to be scheduled at least four times a year. If there is advanced damage, or if the gums do not respond well to the treatments, we will refer the patient to a gum specialist for further evaluation. Remember, even though your gums have been treated and you may have no symptoms of gum disease you will always have gum disease and must continue with treatment. The day you decide not to continue with treatment is the day your gum disease will pick up where it left off and destroy your gums and teeth at an accelerated rate. 

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

Are Amalgam Fillings Really That Bad?

An amalgam filling.

When I entered dentistry in 1998 I thought that the demise of silver fillings was surely at hand. They were ugly, contained mercury, and were sometimes difficult to place well. Some of these points still remain true today, but I have a new-found respect for this old material. Yes, it is ugly and contains mercury, but it can be a long lasting restorative material that is not as finicky as most of the tooth colored materials today. My rant? Amalgam material is being phased out of dentistry through fear and force, both political and social. 
I will start with some background information on mercury containing fillings. Mercury is a metal found in nature as a liquid which, when heated, enters a vapor state. This happens in dentistry through the use of friction from our hand-pieces. Most mercury that is found as a contaminant was released as a vapor from industrial and commercial release. This is when problems occur because the vapor is very toxic and readily absorbed. This becomes a huge problem when silver fillings, which can be up to 50% mercury, are removed. The dentist must protect the patient, himself, and his staff from this volatile vapor. One of the ways that we help protect everyone is through the use of a dental dam which fits snugly over the tooth and keeps the patient from swallowing or inhaling any freed up particles. 
Alleged smoking tooth- a 50 year old amalgam filling.
Biased articles against amalgam fillings will scare you, claiming that simply chewing gum and brushing teeth can release vapors and increase the risk of mercury poisoning. There are even horrifying pictures and videos on the internet showing mercury vapor smoking out of teeth. In truth, the temperature at which mercury vaporizes is about 673 degrees Fahrenheit, which is three times the boiling point of water. I have yet to meet a food or liquid that I could consume that is that hot!
In the mid '90s, some dentists discovered the "fear factor" and tried to deter patients from amalgam fillings by calling them "silver mercury fillings." They were even able to convince their patients that "those silver mercury fillings are bad for you and should be removed. We only use tooth colored materials which are not a health risk." This was an outrageous statement, but I actually witnessed it firsthand in several offices. It was an easy way to convince a patient to have their amalgam fillings replaced when they were probably fine. This was also a dark time in dentistry when dentists discovered that a recently introduced material, pressable ceramics, could be "bonded" into teeth. Even worse was the use of chair side millable ceramics such as CEREC, which was introduced in the mid-1980s. This material was very interesting because the dentist would prepare the tooth similarly to a filling, then take an impression and have a lab, or CEREC unit, fabricate a tooth colored filling which could then be "bonded" into the tooth. I call it a dark time because thousands upon thousands of these restorations were placed and many of them failed in a very short time because the bonding technology was not there to keep the filling material from leaking and allowing new decay to form. Believe it or not, there are dentists still using this technique today. 
Amalgam is...okay? Yes, according to the government and... no, according to the government. California tried to encourage the reduction of amalgam by mandating that any office that uses it must have approved devices and means for dealing with amalgam waste, including water that may be contaminated with amalgam particles. This is a very expensive proposition and caused many offices to go amalgam free just to avoid government regulation. Additionally, the transportation of mercury and mercury containing compounds is now regulated all over the US under the Hazardous Materials Transporation Act. On the flip side, the government has made many statements touting the safety and efficacy of amalgam fillings, with little or no risk to the public. In fact, there are laws that prohibit a dentist from recommending the removal and replacement of amalgam fillings, just for the sake of reducing a health risk. 
How about my office? We are essentially amalgam free, and only out of convenience. Amalgam contains silver, mercury, tin, and other materials. It contaminates all the instruments it touches with a "silver" residue. If those instruments are accidentally used with other materials, it can impart a grey hue, which is unsightly and unexpected. We have invested thousands of dollars and hundreds of continuing education hours to make all tooth colored restorations in our office as attractive and successful as possible. We strive to stay on top of technological advances in materials and equipment to make every restoration as good as it can be. We have never recommended the removal of amalgam fillings just for the sake of doing so. If an amalgam is failing we will replace it with a tooth colored material. 
Of course I've checked my facts on all this, but as always this blog is strictly an expression of my opinions based on years of dental experience. As such, none of this should be taken as a direct fact- unless you see my logic and agree with me. 

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

Patient #906

Where y'all from? Pennsylvania.
Rosen... is that Jewish? Yup, but non-practicing.
Well I gotta get all my teeth out while I can... ya know, fer free. 
I heard this same sentiment over and over again. I was in hell. I was in Wise, Virginia. Where is Wise, Virginia? In the middle of nowhere. You don't want to be there even for a day. I was stuck there for three days. I flew in to what I thought was the nearest airport. After I landed and went to the only car rental counter, I discovered I was over 100 miles away from my destination. I was in another state all together and I wasn't getting a good feeling about all this. How did I get here?
It all started with a great new report by 60 MinutesRemote Area Medical is a volunteer-operated organization started to provide treatment to those without access to medical and dental care. Initially, it was intended only to provide for remote areas of the world without any direct access to care. After it was discovered that there is a tremendous domestic need for this service, Mission of Mercy was formed to provide medical and dental care to those without adequate access to care in America. Doctors and dentists volunteer to provide care at no cost. I decided that this was exactly the cause that I wished to support. 
I arranged for a Virginia dental license, airfare, hotel and rental car. The dental care that I could provide far outweighed my out-of-pocket expense. I was excited to begin volunteering, that is until I got a stern warning not to go outside of the fairgrounds where the event was taking place. Some of the locals had devised a new way to make methamphetamine, called a "slow cook". They put all the chemicals in a soda bottle and leave it out to form methamphetamine over several days. Unfortunately, the soda bottles are unstable and tend to explode. This gave a whole new meaning to "minefield."
Wise, Virginia was central to the methamphetamine belt. We saw it when the patients opened their mouths: melted teeth. Every patient was the same story – we were in town pulling teeth for free and they wanted in. The first patient of the day was the eye-opener, followed by hundreds of identical cases. We stood extracting teeth for 12 hours at a time and for three days straight. At the end of the three days I returned home exhausted. I did this for four years and I extracted over 1500 teeth. This was not the way to be a dentist, or to treat a patient. They were all just numbers. 
This year I traveled to a new site that was closer to home. Cumberland, Maryland started a Mission of Mercy last year, just as I completed my last Virginia clinic. I could drive there instead of flying and the clinic only lasted two days. I signed up. 
I drove in to Cumberland, Maryland after a full eight-hour day of work. After three and a half hours more in the car, I was already tired for the next morning's work, which started at 5am. The day began much the same as Virginia – a blur of tooth extractions. At the bottom of every patient's sheet was a number marking their arrival: 75, 126, 229, 378, finally we hit the 500s! We had seen over 500 patients in the first day. I couldn't remember any of their names and their faces were a blur. I was dreading day two, which started with a rare October snowstorm. 
Day two began as I arrived at my chair and started the whirlwind of extractions. We were shorthanded because of the impending snow, so I took over two chairs. I would numb up one patient and then go extract the other patient's teeth, back and forth all day. At noon, more doctors left to get ahead of the snowstorm, leaving me with triple duty. Numb, extract, interview, clean up... the numbers started to blur: 705, 812, 900!
I decided to take a break and walked outside to check out the snow. As I passed the line of patients waiting for their turn one of them quipped, "Where are all these dentists going?! I've been waiting here all day!" A small woman behind him slapped the back of his head. He smiled. I smiled. He apologized. I sat down next to him and we talked for a bit about the town and where he was from. I explained that I had been working for two entire days without a break and that if I didn't get one I would probably be on the floor, which wouldn't do anyone any good. He apologized again.
I walked back in to the battle before me. The day continued where it left off, except that I recognized a patient! #906 and I even knew her name – Corrine! She had been at the clinic the day before to have a tooth removed. She had another broken tooth that needed to be extracted but decided to come back to have it removed because so many other people were waiting. She was the woman who slapped the man from behind and she understood what this was all about. Now I did too.
I extracted her tooth. She thanked me a hundred times and gave me a hug. She was no longer #906, she was Corrine. Corrine works in a hotel up the street cleaning rooms. She has two daughters, one of which just had her first grandbaby, Lillianna, and they were coming for dinner tomorrow. 
That was all I needed to know. I will be back next year. 

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403

The Tooth Fairy a.k.a The International Tooth Repossessors

I am a general family dentist in Norristown. I am also the father of three boys. As soon as I entered my children in school I began to get bombarded with questions about how much the Tooth Fairy gives for each baby tooth. Before I was a parent the answer was simple...I have no idea ask other parents. Now I am a parent. Now I am on a budget. I started to ask other parents what they thought was a fair amount for each baby tooth. The answer was astonishing; as much as $20 per tooth! As a parent that seems fair, but as a dentist it is highway robbery because there are 20 baby teeth, and I have three children. That means I'm expected to shell out $1200!!! So I came up with an alternative plan and it is even educational.
There are children all over the world. The Tooth Fairy must travel all over the world collecting their teeth and giving them money. Therefore the Tooth Fairy is an international traveler and gives out coins from all over the world from all the countries she has visited. 
Now replace that crisp $20 with a few coins from around the world. You can buy them on ebay for pennies. Put them in a little sack that you will reuse for future teeth. Now, when your child awakens with his/her new found treasure you can take the opportunity to look up where the coins come from and a little history on each country. We put a world map on the wall and mark where each coin came from.
Alternatively, you could use a variety of United States state quarters. Then you can use a map of the U.S. and show them where the coins came from and a bit of history about each state. 

A Family Dental Care Center: Dr. Seth Rosen
2030 West Main St. Norristown, PA 19403