New Soldiers in the Digital Revolution

In an era where computers are the cool yet serious tool of choice for the masses to access and send electronic information, it is no wonder that more and more dental professionals are joining the party.

Not long ago, only analog X-ray film was available. The practice computer's usefulness was limited to patient scheduling, data entry, and accounting. With the use of new forms of digital dentistry tools that enable dentists and their staffs to be more productive, while providing even better patient care, all that is changing.

The cost of entry or upgrading to higher digital standards is not inexpensive. Prices range from the hundreds of dollars for software, to the thousands for many types of equipment. But the rewards are worth the price, according to those who have paid it.

"I find that my staff and I benefit as much from new technology as our patients do because of the increased efficiency it provides, and the higher quality of service it allows," says Mark P. Miller, DDS, of Tustin, Calif. "But, of course, the primary reason for acquiring technology is always for the betterment of our patients."

The foundation for going digital is a late-model personal computer configured specifically to handle the demands of a busy practice. Beyond that, the correct type of practice management software is the key to successfully creating a modern digital office.

"Most Microsoft Windows-compatible practice management software programs currently available will integrate the other elements of a digital office successfully," says Bob Seawell, vice president of operations for D&S Video Warehouse, a Sacramento County-based operation specializing in high-tech dental components. Seawell says component compatibility arguably is the most important part of putting together a digital practice.

Of the new wave, digital radiographs enjoy popularity, and many dentists who use them sing their praises.

"It's where technology is headed, and it will probably be the standard of care in the future," says Dr. Adam E. Cortese, a general practitioner from Rio Linda, Calif. "It's cost-efficient, and it uses from 40 percent to 90 percent less radiation than the film system uses, so patients like it better.

"The images are almost instantly displayed on a computer screen, and we're able to e-mail them to another dentist for consultation, or print them out for the patient."

Cortese says the system is easy to operate, requiring him about an hour to train his staff. It also saves him and his staff time and money.

"I also no longer have to buy film and chemicals, don't have to pay staff to process the film, don't have to deal with a hazardous waste generator permit from the county or pay a contractor to haul away the waste, and it's also better for patient education," Cortese says. "They can look at a computer screen and easily see what we're seeing, rather than looking at the small standard film."

Delta Dental of California, the state's largest dental insurer, doesn't yet allow digital radiographs to accompany claims. But that's about to change.

"We're getting closer to being able to do that, and within two years we hope to start a pilot program to accept digital radiographs and evaluate the most efficient manner to incorporate them with a claim," says Debbie Keatley, Delta's Electronic Data Interchange manager.

While Delta doesn't yet have the capability to receive digital radiographs, a recently released survey of Delta dentists shows that electronic claims submissions rose 67 percent last year. Even so, Keatley says she thinks mandatory electronic claims submissions are a ways off.

"But some companies are starting to charge fees for filing paper claims to help cover their costs and promote electronic filing to force dentists to use the technology, because it's the most cost effective for everyone involved," she says.

Miller has gone head-long into the brave new digital world.

"We have intraoral cameras in each operatory, and digital radiography images are captured on a laptop, and it downloads radiographs into the patient's chart on the office PC along with the intraoral pictures," Miller says. "We also order most of our supplies online, and that's really handy. We use electronic claims filing, and we can make appointments from each operatory, update patient files, and input patient notes."

In each of Miller's four operatories patients or staff can watch an educational video, examine intraoral camera images, or watch a patient education video on an interactive compact disk. Patients can profit from the increased productivity digital dentistry offers, Miller says, because dentists have more time to spend on each case, resulting in better patient care. He says staff training is a key to successful utilization.

"Typically, doctors get hooked on the latest technology," Miller says. "I get jazzed by it, but it will collect dust unless I get staff involvement. . . . And get the advice of people who know what they're doing and know how to make it all work together. They're worth their weight in gold."

Adding his perspective on technology's usefulness in dentistry is the former chair of CDA's Council on Dental Research and Developments, Michael J. Danford, DDS.

"I think down the line we're looking at increased use of digital technology in increasing patient care, developing electronic patient records, and teledentistry to transmit images to someone else for consultation. By doing this, you can improve the overall care of the patient in a variety of ways. If I can do better dentistry with it, I'm interested."

Here are some suggested considerations for implementing new technologies:

* Define objectives. Envision how you want to practice with new technologies.

* Interview others. Talk to dentists who have implemented systems like the ones you're planning.

* Get it in writing. Ensure any guarantees of performance or system integration are in the contract.

* Go slowly. Integrate systems gradually to allow staff time to master new technologies.

* Have a back-up plan. Ensure that data is backed up daily. Secure the media in a separate location in case of fire or theft.

UCSF Helps the Disadvantaged Become Dentists

The University of California at San Francisco School of Dentistry has launched a program to help students from disadvantaged backgrounds get into dental school -- and to increase the number of dentists providing help to underserved populations.

The UCSF pilot program, called the Dental Post-Bac Program, is the first in the country designed to help students from a range of circumstances become successful dentists. Similar programs for potential medical students exist at University of California campuses in Davis, Irvine and San Diego. The dental and medical programs are funded through a grant from The California Endowment.

UCSF officials say the program is meant to give additional training to students who have been identified as possessing the potential to become successful dentists but have been hindered by educational, cultural or social disadvantages.

Program organizers hope to achieve a secondary goal of increasing the underserved populations' access to dental care. They say that can be achieved by admitting to the program students who have demonstrated commitment to working in their communities and a desire to continue doing so as a dentist.

"We have a strong sense that the students in the program are going to make a different kind of provider," says Harvey Brody, DDS, UCSF clinical professor of dentistry and the program's associate director. "These are wonderful, hard-working young men and women who want to go back and serve their communities."

Students, who must have completed their undergraduate education and recently been denied admission to dental school, must prove their ability to succeed in dental school academically. They also must show that an overriding factor contributed to their inability to previously gain dental school admission, says Charles Alexander, PhD, UCSF School of Dentistry assistant dean and the program's director.

Alexander says factors could include an applicant's lack of access to primary or second schools that didn't have high-enough academic standards or adequate educational resources. Other factors may include family circumstances such as financial hardship that interfered with an applicant's ability to focus solely on school. Those situations are explored through written statements, personal interviews and references.

Once accepted into the Dental Post-Bac Program, students spend a year honing their academic and learning skills so they are better prepared when they reapply to dental school. They also receive help in applying to the dental schools of their choice and improving interviewing skills.

USC Researchers Are Hard on Enamel's Trail

Researchers at the University of Southern California School of Dentistry are closing in on making tooth enamel. They have identified tiny spheres that regulate the formation and organization of tooth enamel by controlling the substance's crystalline growth.

Called nanospheres because they are only 20 nanometers in diameter, these structures are formed by a naturally occurring family of tooth-specific proteins known as amelogenins. These spheres are also a component of the synthetic amelogenin first cloned at the USC School of Dentistry's Center for Craniofacial Molecular Biology four years ago.

"More than 98 percent of tooth enamel consists of carbonated calcium hydroxy-apatite," says research professor A.G. Fincham, PhD. "Essentially, teeth are made of rock."

For two decades, researchers have studied tooth enamel with the goal of replacing mercury-based gold and silver fillings with restorations of man-made material identical or similar to natural tooth enamel.

"Beyond that, the same principles that nature uses to make enamel might also be applied to create novel synthetic materials," Fincham says.

Researchers first saw the spheres in 1994. A powerful microscope recently revealed that the spheres are uniformly 18 to 20 nanometers in diameter. Chemically, the mineral crystals in tooth enamel are a calcium hydroxy-apatite formed from calcium and phosphate ions, which are transported into the nanosphere matrix by ameloblast cells.

Apatite crystals grown in the lab by traditional methods are about one-hundredth the size of the crystals nature makes. They grow haphazardly, and the resulting material is considerably weaker than natural enamel.

Four years ago, the USC researchers took the gene for an amelogenin protein from a mouse, placed it in a bacterial cell, and then used the bacterial reproductive process to produce an identical recombinant amelogenin protein. This recombinant amelogenin protein, which the researchers can now produce in quantity, has since been shown to self-assemble to make nanosphere structures identical to those seen in mice and other animals, including humans.

Infectious Disease Deaths Increase in Late 20th Century

After an 80-year plunge, deaths from infectious diseases rose steadily for the first time this century beginning in 1981 because of the AIDS epidemic.

The rise demonstrates the need for vigilance over the threats posed by infectious agents, according to an article in the Jan. 6 issue of the Journal of the American Medical Association.

Gregory L. Armstrong, MD, and colleagues from the Centers for Disease Control and Prevention in Atlanta, researched the mortality tables for death rates for nine categories of common infectious causes of death for the years 1900 to 1996. The nine categories were pneumonia and influenza (considered a single category), tuberculosis, diphtheria, pertussis, measles, typhoid fever, dysentery, syphilis and AIDS.

The researchers found that while deaths from infectious causes dropped dramatically during the first 80 years of this century, deaths from infectious agents have risen recently. The researchers found that in 1900 there were 797 deaths per 100,000 caused by the original eight infectious agents tracked, but by 1980 that number had dropped dramatically to 36 deaths per 100,000.

"The disease categories that contributed most to this decline were pneumonia and influenza, which fell sharply from 1938 to 1950 and subsequently leveled off for several years, and tuberculosis, which fell abruptly from 1945 to 1954 and continued to fall until the mid-1980s," the authors write. "These declines coincided with the first clinical use of sulfonamides (1935), antibiotics (penicillin in 1941 and streptomycin in 1943), and antimycobacterials (streptomycin, first used against tuberculosis in 1944, para-aminosalicylic acid in 1944, and isoniazid in 1952)."

From 1981 to 1995 in the United States, the rate of deaths from infectious agents increased to a peak of 63 deaths per 100,000 in 1995 and declined to 59 deaths per 100,000 in 1996. Death from infectious diseases increased by 58 percent from 1980 to 1992. Research attributes a significant part of the increase to the emergence of acquired immunodeficiency syndrome in 25- to 64-year-olds and, to a lesser degree, to increases in pneumonia and influenza deaths among people 65 and older.

The authors note that deaths caused by infectious disease may again begin to decline again as the century ends; a 7 percent drop was recorded in 1996, largely due to a substantial decline in AIDS deaths.

Latest Dental Fee Survey Released

Dental Economics has released results of its 1998 dental procedure fee survey. Following are a few tidbits taken from the results. The entire report is available in the publication's December 1998 issue. (Figures shown are cost in dollars per procedure.)

Code Procedure Mid Atlantic W. N. Central S. Atlantic Pacific
00150 Comprehensive Exam 35 29 35 42
00210 X-rays (complete) 70 63 70 83
01110 Adult prophylaxis 52 43 46 64
02140 One-surface amalgam 60 54 63 80
03330 Molar root canal 595 460 535 605
Middle Atlantic: New Jersey, New York, Pennsylvania
West North Central: Iowa, Kansas, Minnesota, Missouri, New England, North Dakota, South Dakota
South Atlantic: Delaware, Washington, D.C., Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia
Pacific: Alaska, California, Hawaii, Oregon, Washington

Medicine Has Come a Long Way, Baby
Merck's Manual turns 100 years old this year, and as part of the commemoration, Merck & Co Inc. has reissued the first one.
While it's not as much fun as looking at the old Sears & Roebuck Catalog reissues (love those chaise longues for $7), a few chuckles may be found upon leafing through the 1899 manual.
Among somewhat humorous entries are the many suggested uses for tobacco as a medical treatment. The maladies it was said to heal and the ways to use it include:
* Asthma: "smoking is sometimes beneficial";
* Constipation: "5 minims of the wine at bedtime, or cigarette after breakfast";
* Hay fever: (application not specified);
* Hemorrhoids: (application not specified);
* Hiccough: "smoking";
* Excessive lactation: "as poultice"; and
* Nymphomania: "so as to cause nausea: effectual but depressing."
Also included in the 1899 manual are remedies for melancholia. They include:
* Alcohol;
* Arsenic: "in aged persons along with opium";
* Cocaine; and
* Gold.
It's hard to argue with that last one.

Honors

Jeff Morley, DDS, of San Francisco, has been appointed as an associate editor of the Journal of the American Dental Association. He will oversee articles pertaining to esthetic and cosmetic dentistry.

Upcoming Meetings

1999
April 8-11 CDA Scientific Session, Anaheim (916) 443-3382, Ext. 4470

April 13-17 International Dental Show, Cologne, Germany, http://www.koelnmesse.de/ids

April 15-17 International Congress on Reconstructive Preprosthetic Surgery, San Diego (310) 376-0752

April 21-25 American Association of Endodontists Annual Meeting, Atlanta (312) 266-7255, Ext. 3006

April 23-26 UOP/ADA National Conference on Over-the-Counter Dental Drugs and Products, San Francisco (415) 929-6486

April 27-May 1 The American Academy of Oral Medicine Annual Scientific Session (410) 602-8585

April 29-May 1 British Dental Association National Dental Conference, Torquay, England 0971 935 0875

Sept. 16-19 CDA Scientific Session, San Francisco (916) 443-3382, Ext. 4470

Sept. 17-18 Society for Advanced Dentistry Annual Meeting, New Orleans (317) 290-2613

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.