Emergency department visits for dental problems among adults with private dental insurance: A national observational study.

OBJECTIVE: Dental insurance may be a protective factor in reducing unnecessary emergency department (ED) use for nontraumatic dental pain. The purpose of this study was to 1) characterize patient demographics and identify risk factors associated with ED utilization for dental problems among individuals dually enrolled in medical and dental insurance and 2) investigate antibiotic and opioid prescription patterns among these patients following discharge. Further study of this unique population may provide insight into other causes of unmet dental need beyond lack of dental insurance. METHODS: Claims data from a large national managed health care plan from 2015 to 2018 were used to evaluate ED use for dental problems in patients with synchronous medical and dental insurance. National counts for ED visits, total visit costs, primary diagnoses, and outpatient treatments for antibiotics and opioids were assessed. Multivariable regression was used to assess any associated demographic and health-related variables. RESULTS: 1492 unique patients were admitted to the ED for dental pain and 429,376 unique patients presented for other symptoms. Utilization rates for nontraumatic dental pain were estimated to be 0.4% of all ED visits, with an average cost of $1487 per visit. Within three days following discharge from the ED, 58% of patients filled an opioid prescription and 38% filled an antibiotic prescription. Patients who presented for dental ED pain were more likely to be younger, live in a ZIP code with a lower median household income, have more medical comorbidities, and receive fewer preventive dental procedures within the prior year. CONCLUSION: Our findings demonstrate a low rate of ED utilization for nontraumatic dental pain among dentally insured patients and highlight the protective value of prior dental visits for reducing ED use. Given high rates of antibiotic and opioid prescription fill following discharge, comprehensive ED guidelines regarding appropriate antibiotic and opioid treatment pathways may be helpful to provide more definitive care to patients with dental insurance.

Bisphosphonates, healthcare professionals and oral health.

OBJECTIVE: General medical and dental practitioner and pharmacists all encounter patients on bisphosphonates and as such require adequate knowledge regarding osteonecrosis of the jaw, a potential complication associated with its use. The cross-sectional study investigated perceived implications of and attitudes towards bisphosphonate use in oral health among general medical and dental practitioners and pharmacists. MATERIALS AND METHODS: Medical and dental practitioners and pharmacists registered in Victoria, Australia, completed an online survey (SurveyMonkey©). Data analysis consisted of chi-square tests with significance as p < 0.05. RESULTS: One hundred and thirty six doctors (general medical practitioners, GMPs), 283 dentists (GDPs) and 26 pharmacists (PHs) participated. 70, 38 and 80%, respectively, reviewed patients prescribed bisphosphonates (BPs). GMPs (88%), GDPs (76%) and PHs (85%) were aware of osteonecrosis of the jaws (ONJ). GMPs (76%) and PHs (100%) advised patients to inform dentists. GMPs (45%) referred patients for dental assessments prior to commencing BPs with 71.9% of GDPs received such referrals. In terms of available information on oral health and BPs, GMPs (56%), GDPs (50%) and PH (53.8%) were either unsure any existed or reported receiving sufficient information. CONCLUSIONS: Discrepancies exist amongst different healthcare professionals in terms of BP use and oral health, and common consensus guidelines are warranted.

Knowledge, practices, and opinions of ontario dentists when treating patients receiving bisphosphonates.

PURPOSE: Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe but extremely rare complication of prolonged treatment with bisphosphonates (BPs). Improper treatment or misdiagnosis can have serious repercussions. In some cases, the treatment of BRONJ can require jaw resection, prolonged use of antibiotics, and long hospitalizations. This study aimed to measure the awareness of dentists in the Province of Ontario, Canada about BRONJ and to identify any gaps in their knowledge of the condition and its treatment. In particular, the study aimed to answer questions about the dentists' knowledge of the current guidelines and their opinions and practices related to performing surgical dental procedures in patients taking BPs. MATERIALS AND METHODS: The study involved sending a Web-based questionnaire to a random sample of dentists in Ontario, Canada (n = 1,579). Information about their awareness of BPs, their experiences treating patients presenting with ONJ, their experiences with different surgical procedures in patients taking intravenous or oral BPs, and their awareness of the BRONJ guidelines suggested by the American Association of Oral and Maxillofacial Surgeons was collected. RESULTS: A response rate of 30% was achieved. Sixty percent of responding dentists had a good knowledge of BP and BRONJ; however, only 23% followed the guidelines for surgical treatment of a patient taking BPs, and 63% would refer patients if they were taking BPs. Approximately 50% of responding Ontario dentists were not comfortable treating patients with BRONJ at their current knowledge. CONCLUSION: The finding shows that although 60% of Ontario general dentists and specialists have a good knowledge about BRONJ, most are not comfortable performing oral surgery in patients taking BPs. Those who are comfortable have higher knowledge scores, suggesting greater educational efforts should be made to promote the knowledge of dentists regarding BP, ONJ, and BRONJ.

PHARMACOTHERAPY FOR THE ELDERLY DENTAL PATIENT.

Current demographic data clearly show that the North American population is aging, and projections suggest that the percentage of older people will increase. The elderly often suffer from multiple chronic conditions that affect their quality of life, use of health services, morbidity and mortality. Also, in those of advanced age, the pharmacokinetics and pharmacodynamics of many drugs are altered. Polypharmacy increases the incidence of adverse drug reactions and drug interactions in this population. Thus, the dentist must be continually aware of the pharmacologic status of each patient and consider the likelihood of interactions between drugs prescribed by the dentist, drugs prescribed by the physician and drugs that are self-administered, including over-the-counter medications and natural supplements. In this article, we discuss pharmacokinetic and pharmacodynamic changes in the elderly patient, polypharmacy and the changes in prescribing for our dental patients. Specific emphasis is placed on the drugs commonly prescribed by dentists: local anesthetics, analgesics and antibiotics.

How concerns for bisphosphonate-induced osteonecrosis of the jaw affect clinical practice among dentists: a study from the South Texas Oral Health Network.

Bisphosphonate-induced osteonecrosis of the jaw (BONJ) represents a growing concern for dentists and patients in that it may alter clinical care. This study assessed the knowledge and perceptions of practicing dentists in relation to the risk of BONJ and how their knowledge and perceptions influence their decisions when developing treatment plans. For this study, a sample of dentists (n = 93) in South Texas completed a 38-item survey about BONJ knowledge and perception and their current clinical practices for patients undergoing bisphosphonate therapy. Knowledge score groupings reflected differences between low knowledge and high knowledge dentists in terms of their behavior concerning medical history, alternative treatments offered, and routine blood testing for patients on bisphosphonate therapy.

Survey on awareness and perceptions of bisphosphonate-related osteonecrosis of the jaw in dental hygienists in Seoul.

We investigated awareness in dental hygienists of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients with osteoporosis and cancer and assessed the situation in systemic history investigations to broaden the scope of the dental hygienists' BRONJ awareness as a basis for contributing to preventing this disease. The study was carried out through a survey; 217 dental hygienists responded to the survey. They worked at 12 university and general hospitals, 10 dental hospitals and 35 dental clinics, for a total of 57 institutions in Seoul. The survey consisted of 37 questions: general characteristics (J Oral Maxillofac Surg 65: 2007; 369), systemic history investigations (Ruggiero et al. J Oral Maxillofac Surg 62: 2004; 527) and awareness of BRONJ (Park et al. J Korean Dent Assoc 49: 2011; 389). Among them, 79.7% were aware of BRONJ. Recognition was highest among those from 25 to 35 years old (P < 0.05). In terms of work experience, those with 5-10 years experience showed the highest awareness (P < 0.05). In terms of institutions type, dental clinics showed lower awareness than general and dental hospitals (P < 0.05). It was found that 55.3% of the dental hygienists had been educated about BRONJ. Those aged 25-35 years were the most educated. In terms of institutions, dental clinic staff were the least educated. The degree of understanding about BRONJ was analysed with the average score of 6.14 points. According to these results, dental hygienists working in university hospitals and general hospitals had more opportunity to receive training than those working in dental clinics. Thus, it is considered that the development of professional training programs about BRONJ for all dental hygienists is necessary.

Looking for the Right Balance between Dentist as Manager and Dentist as Care Provider.

In the quest to understand the implications of separating management and treatment, we must first examine the forces driving management decisions. By defining ownership and equity interest, we are able to isolate a critical factor in the decision-making process. Evaluating the spectrum of the different models of dentistry gives us insight into potential advantages as well as disadvantages that can arise. In private practice, an owner typically wants to see the business grow over a lifetime, while, on the other end of the spectrum, corporate dental companies may be prioritizing dividends, investment returns through speedy packaged sales, or other means of reporting progress to investors. Interestingly, each model of dentistry has shown strength and growth, but there is no clear path to what is deemed ideal.

American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw--2014 update.

Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaw (MRONJ) were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007 and 2009. The position papers were developed by a special committee appointed by the board and composed of clinicians with extensive experience in caring for these patients and basic science researchers. The knowledge base and experience in addressing MRONJ has expanded, necessitating modifications and refinements to the previous position paper. This special committee met in September 2013 to appraise the current literature and revise the guidelines as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis, staging, and management strategies and highlights current research status. The AAOMS considers it vitally important that this information be disseminated to other relevant health care professionals and organizations.

Private practice of prosthodontists in the United States: results from the 2008 & 2011 surveys of prosthodontists.

PURPOSE: The purpose of this article is to review data and results from past surveys of prosthodontists sponsored and conducted by the American College of Prosthodontists. Surveys were conducted in 2002, 2005, 2008, and 2011. Selected survey results are examined for prosthodontists in private practice. MATERIALS AND METHODS: Results from past surveys of prosthodontists were statistically examined and used to estimate several characteristics of the current population of practicing prosthodontists. The selected characteristics included age, gender, number of patient visits, hours in the practice, employment of staff, referral sources, and financial conditions (e.g., gross receipts, expenses in the practice, and net income of prosthodontists). While the most recent survey was conducted in 2011, the results reported by respondents are for the previous year, 2010. RESULTS: The average age of a private practicing prosthodontist in 2010 reached 53 years; 26 years since graduation from dental school and 20 years since completion of residency; an average of 13 years in their current practice. Sixty percent were in solo practice. The mean number of hours per week in the practice was 35 hours, and practicing prosthodontists treated an average of 35 patient visits per week. The patient was the single largest source of referrals, while general practitioners were a close second. The largest percentage of time spent treating patients was for fixed prosthodontics (21%), which declined from a mean of 24.1% in 2007. The mean amount of gross billings in 2010 was $721,970, which was a decline from 2007. Average total practice expenses were $538,230, and the mean net earnings of prosthodontists in private practice were $238,010. CONCLUSION: Changes have occurred since the last survey of prosthodontists in 2008 (with results for the year 2007). The prosthodontist private practice industry, not unlike dentistry as a whole, has undergone economic challenges that have affected the private practice of prosthodontists.

[Bisphosphonate-related osteonecrosis of the jaw-after a decade has passed].

It has been passed 10 years since the first article of bisphosphonate-related osteonecrosis of the jaw (BRONJ) was reported in 2003. During this period of time, turmoil and confusion initially seen in physicians, dentists and patients in the management of BRONJ have been gradually and significantly settling and preventive methods for BRONJ have been developed to some extent due to the accumulation of substantial amounts of information and clinical experience. Further, Japanese version of position paper for BRONJ that suggests unified view of the pathophysiology of BRONJ and consistent treatments of BRONJ was published in 2010 and 2012. However, the mechanism and pathophysiology of BRONJ still remain elusive. The recognition for BRONJ is still inconsistent between physicians and dentists. It is also noted that a new anti-resorptive drug denosumab is associated with ONJ. Thus, there are still lots to learn and study. In this chapter current our understanding of BRONJ will be described.

Practice transition with intelligence and grace.

Viable practices change with the professional and personal needs of dentists and with trends in society. There is no single way for transitioning out of practice--concluding a direct sale, remaining as an associate, and even purchasing a new practice to better match one's more mature lifestyle and practiced preferences. Changing ratios of dentists to patients currently favor a seller's market and emergence of corporate models provide new options. An analysis is given of the Canadian practice market. Planning advice is also offered.

Practice transitions--past, present, and future.

Until the 1960s, the value of a practice upon the retirement of the dentist was considered to be nil. In the next several decades, the value of a practice as a going business concern was recognized and formulas based on productivity were used to establish the sales price of "walkaway" practice transitions. Increasingly creative means, such as pre-sale, deferred pre-sale, shareholder process, incremental practice sale, and practice mergers have been created to make practice transitions more flexible, thereby maximizing the financial value of transitions. Dentists at the beginning of their careers will have an increasing range of opportunities in the future, with various combinations of financial security, freedom from manage- ment concerns, control over the practice, and accumulation of equity. Those in the 45- to 55-year age range should be planning in detail for their transition. Those older than 55 should begin exercising their plans since the future will involve much longer transitions.

There are a lot of ways to go.

There is much more to transitioning well out of dentistry than maximizing the economic value of the practice. The full spectrum of professional and personal values, and where each dentist is in his or her life, must be considered. The same is true for the staff and the patients, especially for mature family-oriented practices. A case is worked out in detail, showing that the wisest thing to do in some cases is to gradually wind down a practice and stop without selling at all.

Desired characteristics of a potential oral and maxillofacial surgery practice associate: a Connecticut survey response.

PURPOSE: The goal of the survey was to identify the desired characteristics of recently graduated oral surgeons entering private practice in Connecticut and compare these results to a similar study conducted earlier in New Jersey. MATERIALS AND METHODS: An anonymous survey was mailed to all active members of the Connecticut Society of Oral and Maxillofacial Surgeons in February 2010. The response rate for the survey was 63%, with 69 of 110 surveys returned. CONCLUSIONS: The most valued characteristics of a new associate included board certification; clinical competence in dentoalveolar surgery, anesthesia, and implant surgery; and personal character. These results paralleled the results of the New Jersey survey.

What you need to know about bisphosphonates: an overview and general recommendations for orthodontic treatment.

The orthodontic treatment of patients on bisphosphonates is becoming an increasing aspect of contemporary practice. This article will draw attention to the chemical structure and effects of these drugs on bone and will provide the latest recommendations to avoid potential sequelae.

Dental ethics case 19: What are my ethical responsibilities when I suspect a colleague of substance abuse?

The situation described in this case scenario is an unwelcome one and can often lead to a breakdown in the relationship between professional colleagues. Many of these must be handled by scrupulous adherence to basic ethical principles. Where such conflicts do arise, every effort should be made to contain them in a manner which: avoids placing patients at risk; maintains the continuity of patient care and safeguards their rights and the quality of the dental care they receive; avoids bringing the profession into disrepute; maintains public confidence in the profession; treats professional colleagues as we would wish to be treated ourselves.

Writing off the copayment.

Three dentists who have been involved in teaching ethics comment on a case where an associate discovers that the 40% of collections she was expecting as compensation is being reduced because of the practice in the office of routinely writing off patient copays. The commentators note legal requirements and professional codes, but generally seek alternatives that do not require that patients pay the amount agreed by insurance contracts.

Motivational factors and future life plans of orthodontic residents in the United States.

INTRODUCTION: The purposes of this study were to investigate factors influencing career choice and identify future life plans of orthodontic residents in the United States. METHODS: Program chairs and directors of all 65 orthodontic residency programs in the United States were contacted by e-mail and telephone for permission to e-mail their residents and invite them to take part in on online survey. A total of 335 residents from 37 programs were invited to complete an anonymous 57-item questionnaire in May 2007. Data were categorized, and basic statistics including chi-square comparative analyses were performed. RESULTS: A total of 136 (40.60%) residents completed the survey. A "passion for orthodontics" emerged as the most important factor (20.29%) influencing the decision to pursue orthodontics as a career, followed by "intellectual stimulation or challenge" (18.12%). Most residents decided to become an orthodontist before they were in dental school (44.93%). Most residents (89.05%) plan to engage in private practice, and only 2 intend to pursue primarily an academic career. The average resident debt was $165,226 at the end of their program. CONCLUSIONS: The decision to become an orthodontist is often made early in life, before dental school, and a passion for orthodontics is the motivational factor. Residents plan to enter private practice and not pursue a career in academia. The current shortage of academics and orthodontic researchers will not be resolved from the current pool of orthodontic residents. A possible solution to the academic crisis is to change the selection criteria in programs to accept orthodontic residents who develop a passion for orthodontics while in dental school or to recruit primary researchers and teachers to the specialty. Residents plan to practice in an urban setting. Rural and underserviced areas will probably continue to experience shortages of orthodontists in the future.

Private practice of prosthodontists: current conditions of practice in the United States.

PURPOSE: The purpose of this article is to examine data and results from the 2008 Survey of Prosthodontists. Survey results are used to examine current trends and characteristics of prosthodontists in private practice. MATERIALS AND METHODS: Characteristics of prosthodontists and conditions of private practice are based on surveys conducted in 2002, 2005, and 2008 sponsored by the American College of Prosthodontists. Survey results are used to estimate several characteristics including age, gender, number of patient visits, hours in the practice, employment of staff, referral sources, and financial conditions (gross receipts, expenses of the practice, and net income of prosthodontists). RESULTS: The average age of a private-practicing prosthodontist reached 51 years in 2007; 12.3 is the number of years in the current practice; and most prosthodontists (71%) are solo private practitioners. The average amount of time per week by prosthodontists in the practice averaged 36.1 hours, and prosthodontists treated an average of 44.1 patient visits per week. The largest source of patient referrals is the patient themselves. The largest percentage of a prosthodontist's treatment time is spent rendering procedures in fixed prosthodontics, but this percentage has declined since 2001. In 2007, the average gross billings of a practicing prosthodontist reached $805,675; average total practice expenses were $518,255; the mean net earnings of practitioners were $268,930. CONCLUSION: In 2007, prosthodontists in private practice paid out about $1.4 billion in practice expenses to provide $2.2 billion dollars in prosthodontic care. Based on survey results from 2007 and the previous 6 years, specialization in prosthodontic care continues to be an economically attractive and productive healthcare profession in the United States.

Mapping dental establishments in New York State just before the recession.

Census Bureau data indicate a continuing increase in the number and size of dental establishments in the period just prior the recent recession. During this same period, the combination of a relatively limited increase of the population in New York State and increasing numbers of dentists and dental establishments resulted in decreases in population ratios, particularly in New York City. The usual favorable expectations of an economic upswing after a recession for dental establishments may need to be tempered given these developments.