Thursday, February 02, 2012

Time is money–ever wonder how much?

So why does your dentist strap your child in a papoose board as soon as they get their hands on them, instead of taking the time to go through the acceptable standards set out by the American Academy of Pediatric Dentistry? (Listed in detail below).

Answer - M.O.N.E.Y.

How much?

Every MINUTE saved is $6-$8.

For a Private Equity firm, or other Wall Street bank or investment firm, wasting $6-$8 a minute is UNACCEPTABLE!  For a greedy dentist who cares nothing about your child, only about his/her 5 million dollar home and private jet it’s also UNACCEPTABLE.  (see below about these numbers)

From the AAPD Guidelines for Behavioral Management

AAPD Guidelines Page 4 - Regardless of the behavior guidance techniques utilized by the individual practitioner, all guidance decisions must be based on a subjective evaluation weighing benefits and risks to the child. The need for treatment, consequences of deferred treatment, and potential physical/emotional trauma must be considered.

Decisions regarding the use of behavior guidance techniques other than communicative management cannot be made solely by the dentist. They must involve a parent and, if appropriate, the child. The dentist serves as the expert on dental care (i.e.,the timing and techniques by which treatment can be delivered). The parent shares with the practitioner the decision whether or not to treat and must be consulted regarding treatment strategies and potential risks. Therefore, the successful completion of diagnostic and therapeutic services.

Acceptable Techniques

1st – Tell-Show-Do Tell-show-do is a technique of behavior shaping used by many pediatric professionals. The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects
of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement.

2nd – Voice Control  Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient’s behavior. Parents unfamiliar with this possibly aversive technique may benefit from an explanation prior to its use to prevent misunderstanding.

3rd – Nonverbal Communication Nonverbal communication is the reinforcement and guidance of behavior through appropriate contact, posture, facial expression, and body language.

4th - Positive Reinforcement  In the process of establishing desirable patient behavior, it is essential to give appropriate feedback. Positive
reinforcement is an effective technique to reward desired behaviors and, thus, strengthen the recurrence of those behaviors. Social reinforcers include positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team. Nonsocial rein-forcers include tokens and toys.

5th - Distraction Distraction is the technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance techniques.

6th – Parental Presence/Absence The presence or absence of the parent sometimes can be used to gain cooperation for treatment. A wide diversity exists in practitioner philosophy and parental attitude regarding parents’ presence or absence during pediatric dental treatment. As establishment of a dental home by 12 months of age continues to grow in acceptance, parents will expect to be with their infants and young children during examinations as well as during treatment. Parental involvement, especially in their children’s health care, has changed dramatically in recent years. Parents’ desire to be present during their child’s treatment does not mean they intellectually distrust the dentist. It might mean they are uncomfortable if they visually cannot verify their child’s safety.

[In case you are missing it, this is saying if the parent is NOT with the child, trying bringing the parent in with the child before any further means of control should be used.]

7th – Nitrous Oxide  Nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia, and gag reflex reduction. The need to diagnose and treat, as well as the safety of the patient and practitioner, should be considered before the use of nitrous oxide/oxygen analgesia/anxiolysis.

Advanced Behavior Guidance

Most children can be managed effectively using the techniques outlined in basic behavior guidance. These basic behavior guidance techniques should form the foundation for all of the management activities provided by the dentist. Children, however, occasionally present with behavioral considerations that require more advanced techniques. These children often cannot cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability. The advanced behavior guidance techniques commonly used and taught in advanced pediatric dental training programs include protective stabilization, sedation, and general anesthesia.

Note this is number 8 on the list and under ADVANCED TECHNIQUES

8th – Protective Stabilization (Papoose Board) The use of any type of protective stabilization in the treatment of infants, children, adolescents, or patients with special health care needs is a topic that concerns health care providers, care givers, and the public.The broad definition of protective stabilization is the restriction of patient’s freedom of movement, with or without the patient’s permission,to decrease risk of injury while allowing safe completion of treatment. The restriction may involve another human(s), a patient stabilization device, or a combination thereof. The use of protective stabilization has the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, and violation of a patient’s rights. Stabilization devices placed around the chest may restrict respirations; they must be used with caution, especially for patients with respiratory compromise (e.g., asthma) and/or who will receive medications (i.e., local anesthetics, sedatives) that can depress respirations. Because of the associated risks and possible consequences of use, the dentist is encouraged to evaluate thoroughly its use on each patient and possible alternatives. Careful, continuous monitoring of the patient is mandatory during protective stabilization.

Partial or complete stabilization of the patient sometimes is necessary to protect the patient, practitioner, staff, or the parent from injury while providing dental care. Protective stabilization can be performed by the dentist, staff, or parent with or without the aid of a restrictive device.The dentist always should use the least restrictive, but safe and effective, protective stabilization.The use of a mouth prop in a compliant child is not considered protective stabilization. The need to diagnose, treat, and protect the safety of the patient, practitioner, staff, and parent should be considered prior to the use of protective stabilization.

Protective stabilization, with or without a restrictive device, performed by the dental team requires informed consent from a parent. Informed consent must be obtained and documented in the patient’s record prior to use of protective stabilization. Due to the possible aversive nature of the technique, informed consent also should be obtained prior to a parent’s performing protective stabilization during dental procedures. Furthermore, when appropriate, an explanation to the patient regarding the need for restraint, with an opportunity for the patient to respond, should occur.

[I suppose here is where the Superman Cape Technique recommended by the esteemed, Dr. Steven Adair fits.  This is NOT in the AAPD Guidlines]

8.2 - Superman Cape  Protective stabilization, broadly defined, is the restriction of a patient’s freedom of movement to decrease the likelihood of injury to the patient or the dental personnel while allowing safe completion of the dental procedure.

Protective stabilization may involve another human (dentist, dental team member, or parent), a stabilization device (protective wrap, mouth prop, towel), or a combination. Use of a mouth prop as an aid for a cooperative patient is not considered to be stabilization.

In your discussions with parents regarding protective stabilization, remind them that active stabilization - stabilization by the dentist and/or dental assistant – is described in the list of behavior management methods that they approved when they signed the health history form. Review this type of stabilization with the parent again, if necessary.

Dental staff who stabilize children should use their hands to limit the patient’s movement. Lying next to the child or partially on the child is not acceptable. The dental team should use the least restrictive stabilization that is safe and effective.

One example of a less restrictive form of stabilization is the use of a pillowcase to restrain hand and arm movements in a patient who is otherwise compliant.

The pillowcase is held open behind the patient; the child inserts his arms into the pillowcase, the pillowcase is pulled up to the child’s armpits, and he is then assisted into the dental chair. Once the patient is supine and lying on the pillowcase, his arms are stabilized.

Colorful children’s pillowcases are available, and can be described as a “Superman cape” or other child appropriate analogy.

9th – Sedation  Sedation can be used safely and effectively with patients unable to receive dental care for reasons of age or mental, physical, or medical condition. Background information and documentation for the use of sedation is detailed in the Guideline for Monitoring and Management of Pediatric
Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

10th – General Anesthesia  General anesthesia is a controlled state of un-
consciousness accompanied by a loss of protective reflexes,including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. The use of general anesthesia sometimes is necessary to provide quality dental care for the child. Depending on the patient, this can be done in a hospital or an ambulatory setting, including the dental office. Additional background information may be found in the Guideline on Use of Anesthesia Care Personnel in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patient.


The numbers

In an article published in the Ortho Tribune, by Dr. Edward Y. Lin in April  2009 about the speed of the “Cone-beam CT Scanner” verses , Dr. Lin stated “We calculated the value of each clinical minute at our practice at approximately $5,” he wrote.  And that using the cone beam instead of the camera cut each appointment by at least 30 minutes. “That’s $150 in savings,” he wrote. “For 1,000 possible new appointments for braces yearly, that’s $150,000 in savings.” 

In June 2011 an article published in Dentistry Today about the need for speed with dental impression materials, Dr. George Freedman, stated that “chairside time costs $6-$8 per minute.

November 2010 NYT article  - Radiation Concerns and Controversy over the Cone-beam CT