Wednesday, November 27, 2019

Clinical Trial of VOCO Admira Fusion X-Tra

 



I’m really excited about the future of operative dentistry.  In the last couple of years, we have seen tremendous progress in the development of highly aesthetic composite materials that require very little effort to create a nice shade match.

As composite technology has evolved, the industry has seen composites evolve in leaps and bounds.  Composites are a combination of resin and filler particles.  These fillers are what contribute to the aesthetics, polish-ability, and wear resistance.  Companies have been experimenting with these fillers, types, and ratios for years and have found several different combinations that work well in different circumstances.

The latest development has been spherical fillers.  In the past, fillers, when viewed under an electron microscope, looked like tiny pieces of gravel.  When light hit these particles, their shape caused the light to bounce around at all kinds of crazy angles and that meant that the resin holding the particles had to be embedded with a shaded material.  This meant that multiple shades were needed and sometimes shade matching was a challenge.

Spherical fillers do not have the same reaction when light hits them.  They allow the light to pass through the material and to then illuminate the surrounding tooth structure.  The reflection of the tooth structure is what gives the composite its shade… not some type of coloration added at the factory.  This allows for one material to handle every shade.  The other advantage of these materials is that since the light passes easily through them, the depth of cure is better.  Photons are not stopped by the color embedded in the resin so the light penetrates deeper into the composite.

A week ago I started to work with VOCO’s Admira Fusion X-tra which has spherical particles between 20-40nm.  While I have only been using the material for a few days, my overall impressions are extremely good.  The clinical case shown in the photos above are my second uses of the material.  The cases consists of a traditional MO on #4 (FDI 1-5) and a DO slot prep on #5 (FDI 1-4).  The margins were beveled using a #4 course round diamond.  Bonding was accomplished by using a 5th Generation Total Etch Technique with Ultra-Etch and Ultradent Peak Universal Bonding Agent.  Under normal testing circumstances I would have used a VOCO product, but I didn’t happen to have any available.  However, this also shows the variability of Admira Fusion X-tra as it is compatible with all conventional bonding agents.  

The matrix used was a Triodent Super Curvey band, held with a standard Triodent V3 Ring, and a Garrison Composi-Tight 3D Fusion Wedge.  The restorations were polished with an Ultradent Jiffy Original Composite System array of polishers.  

The material looked incredible immediately after placement.  Finishing was quick and easy because the aesthetics were so good.  I’m also impressed with Admira Fusion X-tra for a few other reasons as well.  The material has a depth of cure of 4mm (due to the lack of shading and the spherical fillers).  It also has a flat out incredible volumetric shrinkage of 1.25%.  This means that the margins stay intact; there are no “white lines” along the margins due to polymerization shrinkage.  

Since this is the first time I’ve worked with the material I’m going to be monitoring the restorations for the foreseeable future.  Any time I use a new material I’m always cognizant of the fact that I don’t know *for sure* how well they will wear and hold up to the everyday wear and tear that dental materials undergo.  However, I’m optimistic about the wear because the filler is ceramic-based which should allow for it to easily withstand occlusal forces without excessive material wear.

I’m just starting to work with Admira Fusion X-tra so you can expect to see more posts on it in the future.  At this point in my work I’m excited about the material.  I am really excited about the future of materials such as this and their ability to provide almost undetectable shade matching.  Any product that can provide gorgeous results that benefits the patient is something I’ll gladly do testing on...

Tuesday, November 26, 2019

Airway Summit at 2019 Greater New York Dental Meeting

 


Foundation for Airway Health returns to GNYDM for Third Consecutive Year


Are you attending the Greater New York Dental Meeting?  If so my organization The Foundation for Airway Health will be holding their third consecutive airway centered education program.

Screening for Airway and Sleep-Related Breathing Disorders is becoming the standard of practice for dentistry. In October 2017, the ADA approved a policy statement emphasizing dentistry’s role in screening for sleep-related breathing disorders. Learn what you need to know to meet this new standard of care or to exceed it and provide more for your patients and practice. Whatever your goal this presentation is for you and your entire team.
For the third year in a row, the Foundation for Airway Health will present a full day of airway-centered education. On Saturday, November 30, leading dental educators, scientific academy representatives, allied health organizations, representatives from industry and members of the public will offer information about what the dental team must know and can do to impact positive health change for patients. Learn from not one but 18 expert presenters. This is an excellent place to begin your sleep education as well as to expand it to new levels.
If you are a dentist, you should attend! If you practice in a different discipline or are a member of the public, encourage your dentist to attend. Every dentist who can screen for airway problems can affect the lives of hundreds each year.

To Register for the Airway Summit, visit the Greater New York Dental Meeting site.

Our presenters and topics:


Michael Gelb, Overview Airway Centric

Steve Lamberg, Screening

Steve Carstensen, Airway: The New Paradigm

Cyndee Johnson, Hygienist

Jeff Hindin, Physiological Dentistry

Richard Klein, TMD & Airway

Ben Miraglia, Early Intervention

Jill Meyer, Orthophics

Leslie Stevens, Early Airway Intervention

William Hang, Airway Orthodontics

Philip Neal, Readiness: The Army Sleep Initiative

Ben Waldman, Public Health Crisis

Barry Raphael, Airway Orthodontics

Mark Murphy, Scanning

Jerald Simmons, Medical Dental Connection

Payam Ataii, Clear Aligner for Airway Tx

Marc Moeller, Airway & Myofunctional Therapy

Vijay Parashar, The Role of Imaging in Airway Treatment

Julia Worrall, Airway Advocate Workshop

Monday, November 25, 2019

Security - Simply Put - Is Worth It

 


When you are running a business, costs have to be taken into consideration.  There is always a balance between costs and benefits.  Heck, that’s why there is a term referred to as “cost/benefit analysis” in the business world.

However, sometimes in healthcare the situation can devolve into the old adage of being “penny wise and pound foolish”.  Often doctors are not well trained in business practices and certainly not trained in the “Best Practices” of IT, and because of that sometimes poor business decisions are made.  The potentially bad part of poor IT choices is that saving money on the front end could very well create problems that might, in the long run, cause greater expenditures.

Unfortunately in recent history, some of these mistakes have been made in the security sector.  Products such as reliable offsite backups, network security, and reliable antivirus systems have all been overlooked in an effort to save money.  This violates a rule that has been referred to as The Common Law of Business Balance.  This law is the basic demonstration of cost vs. benefit or even an explanation of the ancient idea of Yin and Yang.  For every positive there is a negative, for every plus there is a minus, in business for every benefit there is a cost.

The secret to business success is to find and maintain that balance!!!   The problem with this rule is that many people feel they can violate it and still find success.  In other words there is a segment that thinks “I can pay a tiny amount and get a huge benefit which all of my competitors are paying a huge amount for the same thing.”  One thing I love about physics is that math works every time.  Shooting it to you straight, this truly can’t be done.

There is a famous quote attributed to a British man named John Ruskin that goes like this, “There is hardly anything in the world that someone cannot make a little worse and sell a little cheaper, and the people who consider price alone are that person’s lawful prey. It’s unwise to pay too much, but it’s worse to pay too little. When you pay too much, you lose a little money — that is all. When you pay too little, you sometimes lose everything, because the thing you bought was incapable of doing the thing it was bought to do. The common law of business balance prohibits paying a little and getting a lot — it can’t be done. If you deal with the lowest bidder, it is well to add something for the risk you run, and if you do that you will have enough to pay for something better.”

Anyone want a great deal on a parachute or a lifeboat?  i just got done with having my IT team replace every computer in my office.  We’ve got over 20 workstations so you can imagine that this wasn’t something I paid for with change from the couch cushions.  I also upgraded my AntiVirus system with Emsisoft.  After doing my research, I knew I needed to have a more robust A/V system running to maintain security and I looked at some others.  I settled on Emsisoft for a number of reasons, but one that I did NOT consider was the price.  

I had a buddy recommend a much cheaper solution to me.  He thought I was crazy to spend around $450 U.S. for A/V protection.  My reply was "If malware takes over my office and/or my network, the money I saved would be quickly consumed by all the work expended and paid for to get me back online."

Between those costs and potential fines if my data is stolen, the money I paid was small… and well worth it.  In today’s threat landscape you cannot be too careful.  Having the best protection for the different aspects of your data is important.  Don’t skimp in areas where you need the best.

Thursday, November 21, 2019

Evaluation of CheckUp from BlueLight Analytics

 
Dentistry is a continually evolving field and one of the major parts of it is the branch referred to as “restorative”.  This is science of taking the existing teeth and “restoring” them to state of health when they are broken, decayed, etc.
As far as actual time spent, the average dentist spends more of their time performing restorative procedures than anything else.  Restorative has evolved and changed greatly in the last 10-15 years.  Today the majority of fillings that are placed in the U.S. and Europe and “white fillings” which are done using a composite resin material.  While studies have failed to prove that silver amalgam fillings are detrimental to patient health, they do have the negatives of polluting the environment and not being aesthetically pleasing.  Composites, on the other hand, don’t contain any mercury and are tooth colored. One of the other big positives for composite is that it chemically bonds to tooth structure which means that less tooth structure needs to be removed during restorative procedures.
However, everything has plusses and minuses… advantages and disadvantages.  For composite, the minus is mainly due to the fact that it is technique sensitive which means a dentists needs to be pretty meticulous while performing the procedures.  Paying close attention to details such as eliminating contamination and not over-drying are easy to replicate.  Yet since their invention over 30 years ago there has been one problem that has been difficult to overcome because it couldn’t be evaluated.
That one step is what it referred to as “photo polymerization”.  Composites contain a chemical which, when exposed to a certain wavelength of light, causes the material to rapidly polymerize or harden.  The advantages of this are obvious since patients can leave the office and eat on the fillings immediately without worrying about damaging them.  Yet, the process of polymerization was impossible to measure in a clinical environment because it was impossible to measure the output of the the light that causes the reaction. 
Measuring the light output precisely requires a rather expensive piece of hardware called a radiometer and they really haven’t been available for use in a clinical setting.
Now, however, that is all about to change thanks to a company named BlueLight Analytics and their product called CheckUp.  Now, for the first time, a doctor has the capacity to test their curing lights on a state of the art device that can provide the data necessary to ensure your curing light is operating properly.  The CheckUp device is a combination of a small piece of hardware (the CheckUp device) and an app that runs on your smartphone.  When the app is downloaded your phone will connect to the CheckUp hardware via a BlueTooth connection.  The app allows the user to select which curing lights they are using as well as what composites are in the office inventory.
In addition to CheckUp providing a digital readout of the intensity of the light, it also provides information on the composites being used by the doctor.  One of the amazing and problematic things about composites is that different materials (and even different shades of the *same* material) will absorb the photons of the light differently.  This means that even though your light may be incredibly bright you cannot use an approach of “one cure fits all”.  For example, a very light shade such as B-1 might only take 5 seconds whereas a much darker shade such as A-3.5 might require a 20 second cure.  But how would you know this?
Utilizing the CheckUp database of curing lights as well as the database of materials, the app tells you specifically the output of the light being tested and the recommended curing times of each brand and shade of composite.
CheckUp is now on the market and I really think you need to take a good look at it.  You can got all the info you need by following this link.  
I have been using the device for about 60 days now and have been very impressed with what I’ve learned from it.  I’ll be reporting back here in future posts with more info.  .  This is truly the only way to be able to ensure the light is performing as it should.

Wednesday, November 20, 2019

Dentsply Sirona’s First US installation of State-of-the-Art Student Simulator Units Starts at University of Missouri-Kansas City School of Dentistry


 


Here’s some exciting news from Dentsply/Sirona and my alma mater the University of Missouri - Kansas City School of Dentistry.  When I received my training we worked with desktop Tensor lamps and simple airlines that powered high speed handpieces.  The upgrades now in place will allow students to learn in the most advanced environment possible and to simulate real world working environments.

Over 100 new and modern Dentsply Sirona simulator units were fitted at University of Missouri-Kansas City (UMKC) School of Dentistry in a groundbreaking USD 4-million project, making UMKC dental training labs one of the country’s largest and most advanced education facility.

Charlotte/Salzburg, November 19th, 2019. Leading manufacturer of digital dental equipment and education systems Dentsply Sirona continues to shape young dentists of tomorrow with the successful installation of a simulation and technology lab for pre-clinical education at University of Missouri Kansas City Dental School (UMKC).The installation, led by Dentsply Sirona’s International Special Clinic Solutions (ISCS) division, introduced more than a hundred new and ergonomically accurate simulator units which enable UMKC dental students to practice on ‘close to real life’ models.

A realistic environment to train future dentists

Last month, two UMKC training laboratories were equipped with 109 Intego student simulator units and two instructor units for its School of Dentistry students. The upgraded training labs now allow students to learn and practice in a realistic clinical setting from the very start as all dental procedures can be simulated under ergonomic conditions with correct instrumentation technique. The configuration of the workstations allows utmost flexibility, such as easy switching from right-handed treatments to left-handed. Thanks to its modular concept, the units are also suitable for both UMKC dental and dental hygiene curricula and include the option to add further functions and technological updates in digital dentistry in the future.

"The planning and research process were crucial to the success of this project at UMKC. Working closely with the university leaders to map their ideas and visions for the upcoming years allowed us to deliver an individually tailored product and training portfolio from start to finish,” says Peter Rössling, Dentsply Sirona Sales Director of International Special Clinic Solutions USA/Canada. “This is our first simulator installation of its kind in the U.S., and we look forward to bringing our technology to more students in the country.”

Universities and large clinics all around the globe from Germany to South Africa and New Zealand trust the long-term expertise of Dentsply Sirona’s ISCS division and its comprehensive approach. From consultation and planning to training and global support, ISCS ensures each customer’s unique vision is brought to life.

The high-quality equipment at UMKC has been designed and produced in Germany using particularly robust materials ideal for university settings.

UMKC – A world-class institution for excellence in oral healthcare education

Since 1881, UMKC School of Dentistry has been offering a varied and complete range of educational experiences for students of dentistry and dental hygiene, as well as students for Advanced Education and continuing education. The faculty comprises scholars, scientists and specialists – all dedicated to providing a high quality and comprehensive education, which is now enhanced by the new modern dental equipment from Dentsply Sirona. “The lab is spectacular. This will give our students more real-life experiences before performing dental care on people,” says Marsha Pyle, Dean of the UMKC School of Dentistry.

Tuesday, November 19, 2019

Vaping Illness Continuing to Be Reported - Death Toll Rising

 


The bad news on ENDS (Electronic Nicotine Delivery Systems or e-cigarettes) continues to grow.  As you regular readers know, yesterday I provided some info on a study that shows ENDS decrease the immune response of the lungs, and today I’ve got another post that deals with the dangers of vaping.

An article that was posted by Reuters on November 14, 2019 reports that lung problems associated with vaping continue to rise.  According to the CDC (Centers for Disease Control) the most recent statistics show 2172 cases of lung problems/infections have been reported as well as 42 confirmed deaths.

The condition has become so widespread that it now has a name.  It is being referred to as EVALI (e-cigarette Vaping Aassociated Ling Injury) 

About Patient Exposure:
All EVALI patients have reported a history of using e-cigarette, or vaping, products.Vitamin E acetate has been identified as a chemical of concern among people with e-cigarette, or vaping, product use associated lung injury (EVALI).


THC is present in most of the samples tested by FDA to date, and most patients report a history of using THC-containing e-cigarette, or vaping, products.


The latest national and state findings suggest products containing THC, particularly from informal sources like friends, or family, or in-person or online dealers, are linked to most of the cases and play a major role in the outbreak.

The information from the CDC is updated every Thursday.  To access the CDC webpage with all of the most current info, bookmark this link.

Monday, November 18, 2019

Electronic Cigarettes Disrupt Lung Lipid Homeostasis and Innate Immunity Independent of Nicotine

 


The US has seen a vaping crisis lately.  The problem began showing up around med-summer and continues to today.  The documented cases show that greater than 200 patients have been affected so far.

One of the frightening things about this problem is that it is showing up in young people who are normally expected to be in the prime of physical health.  The numbers are probably trending to youth simply because the vaping fad is heaviest in that demographic.  Current stats are showing that around 20 percent of high school students are vaping.

The disease/problem presents as a “pneumonia-type” situation.  Patients who are otherwise healthy are suddenly having trouble breathing.  Some are having chest pain, vomiting, and diarrhea.  The patients present with these problems and yet they test negative for bacterial and virus infections.  The only thing these cases seem to have in common is that every patient reported having recently used an e-cigarette.

Now a study published in The Journal of Clinical Investigation is showing that the body’s way of protecting the lungs is damaged by the contents of vape pods; even those that do not contain nicotine.

Here is the abstract:

Electronic nicotine delivery systems (ENDS) or e-cigarettes have emerged as a popular recreational tool among adolescents and adults. Although the use of ENDS is often promoted as a safer alternative to conventional cigarettes, few comprehensive studies have assessed the long-term effects of vaporized nicotine and its associated solvents, propylene glycol (PG) and vegetable glycerin (VG). Here, we show that compared with smoke exposure, mice receiving ENDS vapor for 4 months failed to develop pulmonary inflammation or emphysema. However, ENDS exposure, independent of nicotine, altered lung lipid homeostasis in alveolar macrophages and epithelial cells. Comprehensive lipidomic and structural analyses of the lungs revealed aberrant phospholipids in alveolar macrophages and increased surfactant-associated phospholipids in the airway. In addition to ENDS-induced lipid deposition, chronic ENDS vapor exposure downregulated innate immunity against viral pathogens in resident macrophages. Moreover, independent of nicotine, ENDS-exposed mice infected with influenza demonstrated enhanced lung inflammation and tissue damage. Together, our findings reveal that chronic e-cigarette vapor aberrantly alters the physiology of lung epithelial cells and resident immune cells and promotes poor response to infectious challenge. Notably, alterations in lipid homeostasis and immune impairment are independent of nicotine, thereby warranting more extensive investigations of the vehicle solvents used in e-cigarettes.

The study is a pretty fascinating read for those of you with a science or healthcare background.  The entire study can be accessed with this link.  

Thursday, November 14, 2019

BMC Oral Health Report on Dental Care During Pregnancy

 


As those of us in dentistry have been preaching for quite some time now, the mouth is connected to the rest of the body and what happens in the mouth can definitely have an affect on overall systemic health.

That’s why I was interested to see a study published by BMC Oral Health titled "Dental care during pregnancy based on the pregnancy risk assessment monitoring system in Utah”.  Problems and diseases of the oral cavity have been shown to have an affect on pregnant women and also on their unborn children.  Things like periodontal disease can lead to low birth weight and premature deliveries.  Those are just two of the reasons it’s important for pregnant women to seek out dental care.  It’s good for the health of the mom and also good for the health of the child.

Here’s a little of what the study had to say:

Poor dental hygiene and gum disease can increase the risk of heart attack, stroke, and adverse pregnancy outcomes. During pregnancy, a woman’s body goes through several changes that can cause oral health problems, including hormonal changes, fluctuation in oral hygiene practices and eating patterns. A 2012 national experts’ consensus statement concluded that dental care is both safe and effective throughout pregnancy, and that women should continue receiving treatment during their pregnancy. Research supports that routine preventive, diagnostic, and restorative dental therapy, and periodontal treatment, among pregnant women does not increase the risk of adverse pregnancy outcomes. Continued dental care during pregnancy is particularly important to avoid periodontal diseases  and subsequent risk of pre-eclampsia, preterm birth, and low birth weight infants.

Few studies have reported on the level of dental care received during pregnancy. However, those studies have shown lower levels of dental care during pregnancy. For example, in a study involving 2009–11 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) in Hawaii, 50% had their teeth regularly cleaned before pregnancy compared with 33.4% during pregnancy. In a study involving 1998 data for four states from the PRAMS, 23 to 35% of pregnant women went to the dentist during pregnancy, 12 to 25% suffered from an oral health problem, and, of those with a problem, only 45 to 55% received care. The study further found that some women thought poor oral health during pregnancy was normal, believing that some types of dental care could harm their fetus. In a study involving 2004–08 data from PRAMS in Michigan, 26.0% reported that they needed dental care during their pregnancy, of which only 58.4% sought care. Low levels of care may be because of concern among patients, dentists, and obstetricians regarding the safety of dental care during pregnancy. Lack of dental insurance may also play an important role. A better understanding is needed as to how these factors contribute to the use of dental care during pregnancy, according to specific subgroups of the population.

Research shows that some dentists and obstetricians contribute to the low use of dental care among pregnant women. In one study, only 40% of pregnant women were advised by their obstetric provider to seek dental care during pregnancy, and 10% were refused care during pregnancy by their dentist. A recent survey of gynecologists found that they often mistakenly believed that dental x-rays (73%) and local anesthesia (59%) were unsafe for pregnant women.

Some healthcare workers are simply not counseling their patients about the importance of receiving dental care during pregnancy. In a study involving PRAMS data for 10 states in 2004–06, only 41% of pregnant women received oral health counseling [19]. A better understanding is needed of how such counseling impacts the use of dental care during pregnancy. Many dental and obstetrics workers may simply be unaware of the prenatal oral health guidelines, thereby causing them to not recommend dental care during pregnancy and to be less likely to talk with their patients about how to care for their teeth and gums during pregnancy. In a survey conducted in the United States of 60 dental school deans and 240 obstetrics and gynecology residency program directors 65% of deans and 45% of residencies were aware of prenatal oral health guidelines and 39% of residencies taught prenatal oral health [20]. In addition, it has been recommended that pregnant women should receive education on the importance of oral health care and safe medications during pregnancy in order to encourage home oral hygiene care.

Not having insurance coverage can limit dental care during pregnancy. Pregnant women with either private or Medicaid insurance are less likely to receive dental care during pregnancy than their non-pregnant counterparts. The type of insurance has also been associated with use of dental care during pregnancy. In a PRAMS study, pregnant women with Medicaid insurance were 24 to 53% less likely to receive dental care than those covered by private insurance . This is particularly concerning since Medicaid insurance for dental care during pregnancy, as it is available in most states, only provides coverage during their pregnancy and for 2 months postpartum, such that if dental care is delayed because of pregnancy, there may not be insurance to cover treatment later on.

Certain demographic characteristics and smoking and alcohol behaviors have been associated with failure to receive dental care during pregnancy. Research has shown that pregnant women are less likely to receive dental care during pregnancy if they are younger, a minority, not married, and have lower income and education. Women who smoke cigarettes or drink alcohol also have lower use of dental care during pregnancy.

From this previous research we can conclude that dental services are less frequently used among pregnant women, and that certain demographic groups, smokers, alcohol drinkers, and uninsured or publically insured pregnant women are least likely to use dental services. However, we know little about how knowledge of the importance of care during pregnancy and having a dental or health care worker talk with pregnant women about dental care influences whether dental care is received. In addition, we know little about the characteristics of pregnant women who are most likely to have dental insurance. The purpose of the current study is to identify the prevalence of dental services received (teeth cleaning and seeing a dentist for a dental problem) and factors related to receiving dental care (knowledge of the importance of care, having a dental or other health care worker talk with them about the importance of dental care, and insurance) among a group of women who completed the PRAMS survey in Utah. The impact of knowing the importance of receiving continued dental care during pregnancy, having a dental or other health care worker talk with them about such care, and insurance on actually receiving dental care during pregnancy will also be assessed.


To read the entire paper follow this link.

Wednesday, November 13, 2019

Omnichroma Results Continue to Impress

 


In Chicago this past spring (2019) Tokuyama introduced OmniChroma composite.  This has been a game changing restorative material for a lot of doctors.

I was fortunate enough to be able to beta test the material and I am now approaching about 13-14 months of clinical cases.  What I am seeing clinically is cases that are holding up well.  Margins are intact, material wear is minimal, they are still highly polished, and the shade match is still “spot on”.

For those of you who don’t know the details of Omnichroma, it is a composite resin that is designed to be a single shade to match all clinical situations.  The company accomplishes this through a pretty unique filler particle system.  Composites are normally resin with a mix of filler particles for strength and polishability.  Most composites use a variety of sizes of these particles, larger ones for strength and smaller ones for polish and under high magnification, these particles look like tiny pieces of gravel.

Because of the non-uniform shapes of these particles, light is bounced around at a myriad of different angles. 

What Tokuyama managed to do was to figure out a way to make filler particles that are round spheres.  These spheres cause the light the reflect and refract in uniform ways that allow the composite to pick up the shade of the surrounding tooth structure.  This means that Omnichroma comes in a single shade and, when the material is polymerized, that single shade picks up the nuances of the surrounding tooth structure to create a near perfect match.

When Tokuyama approached me about the product, I must admit I was a bit skeptical.  However some experimental time testing it on extracted teeth showed me that my concerns were unfounded.  Now 13-14 months into my usage of the material, I continue to be impressed with it.

If you are looking for way to simplify your restorative procedures, I definitely feel you should give Omnichroma a try.

Tuesday, November 12, 2019

In the World of Clinical Dentistry - Knowledge Is Power

 


I'm not sure who came up with the expression "Knowledge is Power" but whoever thought of it was a genius. Those three simple words are true in many different ways. By bringing knowledge into the equation, we become much more powerful in ways we never considered.
Research and development in a myriad of subjects is rapidly increasing the “bottom line” of our knowledge base. Now that we have computers and machine learning, the curve continues to accelerate.

According to Industry Tap Into News, Buckminster Fuller created the Knowledge Doubling Curve. He noticed that until 1900, human knowledge doubled approximately every century. By the end of World War II, knowledge was doubling every 25 years. Today things are not as simple, as different types of knowledge have different rates of growth.

For example, nanotechnology knowledge is doubling every two years and clinical knowledge every 18 months. But on average, human knowledge is doubling every 13 months. According to IBM, the build out of the “internet of things” will lead to the doubling of knowledge every 12 hours. Now, this may seem daunting at first, but if you think about it, having access to all of that knowledge can open doors and let us do things we would never have dreamed of.

In the beginning

It used to be that the general practice was sort of a “clearing house” of sorts for procedures. The GP performed basic restorative procedures and simple procedures such as basic extractions and easy one-canal endodontics. Anything more complicated ended up in the hands of one of the local specialists.
Back then, fluoride was not yet in all the places and substances it is now. Restorative needs of the patients was the “bread and butter” of most general practices. Doctors were so busy restoring large carious lesions they didn’t have the time to learn and implement other procedures into their practices. If the patient’s teeth were misaligned, a referral to the local orthodontist. Impacted third molars? A referral to a local oral surgeon.

As time passed, fluoride began to work its magic and the scope of the general practice began to change. Restorative procedures changed from amalgam and “bombed out teeth” to slot preps and conservative composite procedures, and doctors began to look at ways to expand their services.
The rapid proliferation of internet connections in the late 1990s allowed doctors to connect with other doctors as well as digital databases of research that previously were only available to university or government-based researchers.

This allowed “in the trenches” practitioners to gain access to tremendous amounts of data and leading-edge techniques which allowed them to operate more efficiently and with more predictability. Now a doctor could learn a new technique while eating breakfast and perform the procedure twice before lunch that same day.

This created a feedback loop that greatly changed the way we practice. Whether an online database, an email chain from friends, or one of many other sources of information, the knowledge base of clinical dentistry expanded rapidly.

Sharing
As all of this knowledge expanded, the ability of the general practitioner to treat complicated cases also expanded. Because this expansion of knowledge was stored in a digital format, the ability to share and access that data became a simple matter of “point, click, learn.”

In truth, the doctor had the ability to not only learn, but to then provide immediate feedback to others. This allowed other doctors and educators to quickly evaluate and change procedures so everyone who was “in the loop” could quickly change protocols for the better.

As the operatory computer became the hub of the clinical technology wheel, doctors used their digital integrations to rapidly and reliably share clinical information. Procedures with complications could be tracked and solutions could be advised and attempted in practically real time. Sharing photographs, radiographs and clinical notes with others allowed for the rapid dissemination of clinical information.

For the full article, head on over to the Dental Products Report website.

Monday, November 11, 2019

Sleep and Pregnancy in the United States

 


I find it fascinating how citizens in the United States take for granted the amazing aspects of the statistics in our healthcare system.  We simply don’t even think about things like survival rates for procedures  or how predictable amazingly difficult procedures have become.  Recently a friend of mine had a hip replacement procedure performed.  Ten to fifteen years ago, this surgery would have required a hospital stay of a week or longer.  My friend also would have been flat on their back for several days before the staff even considered getting the patient mobile.  

Now by friend was gently gotten to his feet hours after the surgery.  Add onto that the fact that the surgery was done at 06:00 and my friend was released to go home that afternoon.  You read that right.  A weight bearing joint relationship surgery is now considered outpatient surgery!!!

So what does joint replacement surgery have to do with sleep and pregnancy?  Well just like outpatient hip replacement, we tend to take for granted how simple pregnancy and delivery can be.  

As I have become more and more interested in sleep and the affects it has on myriad aspects of our health, I’ve come across some pretty incredible statistics dealing with sleep and fertility.

Here are just a few of the things that have been noted regarding the differences in sleep between females and males:

Examples of sex and gender differences in sleep
A. Epidemiology of normal sleep in general population
 1. Sleep latency is longer in women than men;2
 2. Women <55 years report more sleepiness than men;2
 3. Older women report 20 minutes less sleep than men;2
 4. Women have more (106%) SWS and less NREM stage 1 sleep than men;3
 5. Men have more NREM stage 1 and stage 2 sleep than women;3
 6. Normalized delta activity in older women is lower than in older men.4
B. Normal sleep in animal models
 1. Female mice spend more time awake and less time in NREM than male mice;5
 2. Female rats show ∼50% decrease in REM sleep compared with male rats;6
 3. Slow wave activity during recovery dissipates more quickly in gonadectomized male rats compared female rats;5
 4. Restraint stress produces increase in REM sleep which is greater in male mice than females;7
 5. Sex-steroid modulation is greater in females than in male rats;6
 6. Young male fruit flies have bimodal (middle of the day and night) sleep and young female flies sleep mostly at night.8
C. Epidemiology of sleep disorders
 1. Women are at 40% increased risk for developing insomnia compared with men;9
 2. Women are at twice the risk for RLS compared with men;10
 3. Women with RLS are at higher risk for comorbid problems compared with men;11
 4. Antidepressant use is more strongly associated with RLS in men than in women;12
 5. Men are at twice the risk for OSA than women;13
 6. REM sleep disordered breathing is more prevalent in women and men (<55 years);14
 7. Depression is more strongly associated with apnea in women (OR 5.2) than in men (OR 3.4).15
D. OSA symptoms and presentation
 1. Women report different OSA symptoms than men;16,17
 2. Men consistently have higher apnea-hypopnea index compared to women across all ages;18
 3. Waist-to-hip ratio is more predictive of severity of OSA in men than in women;19
 4. Women have more partial obstructions compared with men;20
 5. Women have lower scores than men on Epworth Sleepiness Scale, which maybe be more sensitive to subjective sleepiness in men than in women;17
 6. Central nervous system white matter changes are more likely to occur in women with OSA than men.21
E. Treatment
 1. Women may require less CPAP pressure for OSA treatment of similar severity in men;22
 2. Women metabolize zolpidem 50% slower than men.23

Sex and gender differences exist in normal sleep and sleep disorders. Some examples discussed during the roundtable are listed.

CPAP, continuous positive airway pressure; NREM, non-rapid eye movement; OR, odds ratio; OSA, obstructive sleep apnea; REM, rapid eye movement; RLS, restless legs syndrome; SWS, slow wave sleep.

There is now very little doubt that the rest our bodies receive during sleep is incredibly important to how our bodies function.  Now we are seeing that even things such as fertility can be seriously affected.

Thursday, November 7, 2019

The Goetze Dental Family Celebrates 135 Yearswith New Fifth Generation Leadership!

 


Our world has changed a lot in the pst 20-30 years.  And it hasn’t just been the continuing extension and penetration of technology into every nook and cranny of our existence.  Unfortunately it has also been about the changes in business.  It seems that the small business environment has also suffered as “mom and pop” operations are forced out by large corporations that undercut on wholesale costs & put smaller competitors out of the landscape.

This has been apparent, not only in “normal” consumer brick and mortar businesses, but also in dentistry as well.  From a clinical standpoint the industry has seen a huge influx of corporate dentistry devouring or crippling the solo practice.  However, it’s also become commonplace on the supply side of the equation as well.  At one point in time small local solo practices in medicine and dentistry were supported by small local suppliers that were family owned and worked synergistically with each other for the good of the customer (the patient).

Yet, just as we’ve witnessed WalMart move into a town and quickly put local merchants out of business or buying them up, there has also been a tidal wave of small independent dental supply companies being purchased and absorbed by large supply companies.  These same large supply companies are also selling to corporate dental offices, but the prices they offer these corporate clinics are at a much lower price than those offered to the small traditional practice.

How does a smaller company like Goetze Dental manage to stay viable in today’s climate?  It’s a simple process really.  Goetze Dental realized that they are a 5th generation family owned company and that they owe this longevity to small family owned dental practices.  Because of that, they have chosen not to sell to corporate clinics and instead to support the customers that have supported them for 135 years.  Loyalty and treating customers like friends has been the secret to their continued success.

The good folks at Goetze Dental have a tremendous record of success that has come by treating their customers the way their customers deserve to be treated.  They also have an incredible team of dedicated employees that have incredible numbers of years of service and those numbers are just one more indicator of how their corporate culture extends from the customer to every employee.

Although I doubt I will be practicing when they celebrate their 270th anniversary, I hope they are still around to do so!  Congratulations Goetze, you deserve to celebrate a bit!

Goetze Dental turned 135 years old on September 24, 2019! We are so grateful to you and our entire Goetze Dental community for your trust and support over the years.

Marking the occasion, the fifth generation of leadership stepped into executive management with Ben Brunker named president and David Brunker named chief operating officer.  Owners and fourth generation family members, Don and Janet Brunker, will remain active in the business, with Don continuing on as chief executive officer and Janet as senior vice president, finance.

Ben Brunker joined the company in 2004 as a business analyst and in 2008 moved into the role of vice president of marketing.  He became vice president of sales and marketing in 2013.  Ben holds a bachelor's degree in finance from Missouri State University and an MBA in finance from The University of Missouri - Kansas City.

David Brunker began his career as a business analyst with Goetze Dental in 2014 and in 2015 he was named vice president of service.  David holds bachelor's degree in management and leadership from The University of Kansas.

Other leadership changes include role changes for longtime Goetze Dental employees Larry Dalrymple and Keith Lister. Dalrymple becomes vice president of merchandise and Lister becomes vice president of information technology and warehouse logistics.

It's been an exciting 135 years so far, and now the Goetze Dental family is sure the next are the best to come!

Wednesday, November 6, 2019

Healthcare Data Breaches Will Cost $4 Billion by End of 2019

 


Here’s some more interesting news on the entire IT problem that is faced by the healthcare sector these days.  I happen to love Black Book Market Research.  The company does a great job of staying on the leading edge of healthcare IT.  They recently released the following information which I think anyone involved with healthcare should read.  It doesn’t matter if you are a provider or an IT person, what Black Book has to say is pretty incredible… 

Read on:

Black Book Market Research LLC surveyed over 2,876 security professionals from 733 provider organizations to identify gaps, vulnerabilities and deficiencies that persist in keeping hospitals and physicians proverbial sitting ducks for data breaches and cyberattacks. 96% of IT professionals agreed with the sentiments that data attackers are outpacing their medical enterprises, holding providers at a disadvantage in responding to vulnerabilities.

A fragmented mix of 415 vendors offering data security services, core products and solutions, software, consulting and outsourcing received user feedback including large IT companies, mid and small security vendors and start-ups in the polling period Q4 2018 to Q3 2019.

Thus far in 2019, healthcare providers continued to be the most targeted organizations for industry cybersecurity breaches with nearly 4 out of 5 breaches, whereas successful attacks on health insurers and plans maintained with more sophisticated information security solutions with little change year to year. Over half (53%) of all provider breaches were caused by external hacking according to respondents.

Over 93% of healthcare organizations have experienced a data breach since Q3 2016 and 57% have had more than five data breaches during the same timeframe. Not only has the number of attacks increased; more than 300 million records have been stolen since 2015, affecting about one in every 10 healthcare consumers.

The dramatic rise in successful attacks by both criminal and nation-state-backed hackers illustrates how attractive and vulnerable these healthcare enterprises are to exploitation. Despite these wake-up calls, the provider sector remains exceedingly susceptible to ongoing breaches.

Budget constraints have encumbered the practice of replacing legacy software and devices, leaving enterprises more susceptible to attacks. “It is becoming increasingly difficult for hospitals to find the dollars to invest in an area that does not produce revenue,” said Doug Brown, founder of Black Book. According to 90% of hospital representatives surveyed, IT security budgets have remained level since 2016. As a percentage of IT health systems and hospital organizational budgets, cybersecurity has increased to about 6% of the total annual IT spend for CY 2020, however, physician organizations and groups report a decrease in actual cybersecurity expense allocated, with less than 1% of their IT budgets earmarked for cybersecurity in 2020.

A third of hospital executives that purchased cybersecurity solutions between 2016 and 2018 report they did so blindly without much vision or discernment. 92% of the data security product or service decisions since 2016 were made at the C level and failed to include any users or affected department managers in the cybersecurity purchasing decision. Only 4% of organizations had a steering committee to evaluate the impact of the cybersecurity investment.

“The situation did not improve in 2019 and dilemma with cybersecurity budgeting and forecasting is the lack of reliable historical data,” said Brown. “Cybersecurity is a newer line item for hospitals and physician enterprises and budgets have not evolved to cover the true scope of human capital and technology requirements yet, including AI.”

Last year’s Black Book cybersecurity survey revealed 84% of hospitals were operating without a dedicated security executive. As a solution to unsuccessfully recruiting a qualified healthcare chief information security officer, 21% of organizations opted for security outsourcing to partners and consultants or selected security-as-a-service options as a stop-gap measure.

In 2019, 21% of hospitals surveyed report having a dedicated security executive, although only 6% identified that individual as a Chief Information Security Officer or CISO. Only 1.5% of physician groups with over ten clinicians in the practice report having a dedicated CISO.

The estimated cost of a data breach by the respondent hospital organizations with actual breaches in 2019 averaged $423 per record.

In a separate Q3 2019 survey of 58 health system marketing leaders with organizational breaches in the past 18 months report expending between 51k and 100k dollars of unbudgeted marketing expense to fight any negative impressions on the hospital brand cast from data breaches and theft. Still, no marketing executive surveyed reported allocating 2020 budget funds to combat the consequences of patient privacy or record breaches.

That shortage of healthcare cybersecurity professionals is forcing a rush to acquire services and outsourcing at a pace six times more than cybersecurity products and software solutions, increased 40% from last year. Cybersecurity companies are responding to the labor crunch by offering healthcare providers and hospitals with a growing portfolio of managed services.

“The key place to start when choosing a cybersecurity vendor is to understand your threat landscape, understanding the type of services vendors offer and comparing that to your organization’s risk framework to select your best-suited vendor,” said Brown. “Healthcare organizations are also more prone to attacks than other industries because they persist at managing through breaches reactively and not proactively.”

The ability of non-CISO executives in healthcare organizations is not improving either. 70% of IT management respondents report their operations are not aware of the full variety of cybersecurity solution sets that exist, particularly mobile security environments, intrusion detection, attack prevention, forensics and testing. Last year 57% reported not having a good understanding of the cybersecurity product and service landscape.

58% of hospitals did not select their current security vendor in advance of a cybersecurity incident. 94% have not augmented their cybersecurity protections since their last breach. 35% of healthcare organizations did not scan for vulnerabilities before an attack.

“Providers are at a severe disadvantage when they are forced to hastily retain a cybersecurity firm in the midst of an ongoing incident as the ability to conduct the necessary due diligence is especially limited,” said Brown.

20% of healthcare organizations reported they felt intimidated by a vendor to retain services when the vendor identified a vulnerability or security flaw. “While the intrinsic nature of cybersecurity radiates pressures and urgency, hospitals shouldn’t let this dictate the vendor selection process,” said Brown.

On a positive note, 41% of healthcare enterprises have not formally identified specific security objectives and requirements in a strategic and tactical plan, improving from 60% in 2018. “Without a clear set of security goals, providers are operating in the dark and it's impossible to measure results,” said Brown.

87% of healthcare organizations have not had a cybersecurity drill with an incident response process, despite the skyrocketing cases of data breaches in the healthcare industry, and as of Q3 2019, 84% of hospitals and 65% of payer organizations did not have full-time cybersecurity employees.

27% of hospitals (up from 12% in 2018) believe that a Q3 2020 assessment of their cybersecurity will show improvement. 29% of hospital leaders believe their cybersecurity position will worsen and 79% of physician groups foresee increased cyber-attacks, as compared to 4% in other industries.

In 2019, 40% of providers surveyed still do not carry out measurable assessments of their cybersecurity status. Of those that did, 19% used an objective third-party service to benchmark their cybersecurity status, 7% used an objective software solution to benchmark their cybersecurity status and 73% self-assessed with their own criteria.

26% of hospital respondents and 93% of physician organizations currently report they do not have an adequate solution to instantly detect and respond to an organizational attack.

60% of surveyed CIOs did not evaluate the total cost of ownership (TCO) before making a commitment to sign their current cybersecurity solution or service contract. 91% reported they bought their cybersecurity solution to be compliant, not necessarily to reduce risk when the IT decision was made.

Healthcare organizations are hyper-focused on patient care and reimbursement. “Cybersecurity risks are not at the forefront of executives’ minds,” said Brown. “Medical and financial leaders also wield more influence over organizational budgets making it difficult for IT management to implement needed cybersecurity practices despite the existing environment.”

Tuesday, November 5, 2019

Medical Device Software VxWorks is Open to Hackers

 


One of the security problems we have in healthcare is the danger of proprietary or legacy software running devices that have a direct impact on patient care.  One of those systems that has come into the spotlight in 2019 is VxWorks which is developed by Wind River.  The software is something that runs in the background of many of the devices in our lives, however unlike major operating systems like iOS, Windows, or Android, many of us have never heard of it.  However, just because it manages things we don’t really pay much attention to doesn’t mean it is any less serious if it is engaged by hackers.

In this case VxWorks is currently running on 200 million (you read that right) devices and many of them are in the healthcare sector.  The company has stated it "can be found in surgical robots, infusion pumps, dialysis machines, pace maker programmers, assisted ventilators, etc. When critical Class III devices are being developed, and lives are at stake, medical device manufacturers have turned to Wind River. "

However, recently VxWorks has been in the news because of network vulnerabilities that could allow nefarious hacker types to break into it.  Because the code is used in so many specific devices, fixing it isn’t a simple matter.  Basically each device that uses it must be patched and it isn’t just a matter of a company setting up a patch which is then automatically downloaded and installed by every user.  In cases such as this, each unique end user would have to tell their devices to download and install the patch.  You can imagine the struggles of a company that manufactures surgical robots suddenly needing to update their operating system.  It could very well cause operational problems and/or affect patient care; and that is just one example.  Add to that the potential for FDA involvement and it is easy to see how big a problem something like this could turn out to be.

That sad part of this is that we have already seen that criminals don’t really care if patients and their lives are affected.  The Ransomware blitzkrieg we’ve seen in 2019 has shown in no uncertain terms that in the quest for money lives are not important to cyber criminals.

This isn’t meant to be an indictment of VxWorks, but it’s an example of how sideways things could potentially go with our dependency on life centric hardware.  I’m not currently aware of any dental devices affected, but that doesn’t mean there aren’t any.

If you would like to read more about the concerns the U.S. Government has on this situation, take a look at this page from the U.S. Department of Homeland Security.  

Monday, November 4, 2019

Coupled Electrophysiological, Hemodynamic, and Cerebrospinal Fluid Oscillations in Human Sleep

 


As someone who was diagnosed as a sufferer of Obstructive Sleep Apnea (OSA), I’ve become passionate about the importance of sleep and what a good night’s sleep can do for our bodies.

I’ve always been a Type A person and have pushed myself harder than necessary when it comes to sleep.  When I was younger, it was not uncommon for me to run on 4 to 6 hours of sleep on a regular basis.  My motto was a the ever popular “I’ll sleep when I’m dead”.  Unfortunately my ignorance of proper sleep eventually caught up with me.  This was especially true when I discovered that I had a genetically narrow airway.  Combining lack of proper sleep with the fact that even when I WAS sleeping I wasn’t getting restful sleep became a recipe for health problems later on.

Since I was diagnosed, I’ve taken a great interest in sleep and the importance of it for our overall health.

I recently came across a pretty interesting study about the movement of cerebrospinal fluid (CSF) during sleep.  It seems that while we sleep, our brain allows CSF to circulate more readily around the brain  and this allows different types of chemicals to be removed.  Many of these chemicals are one associated with memory problems.  The point being that even more information about sleep and its relation to health is being discovered.

The study is pretty fascinating reading.  It can be found at this link.