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Wednesday, January 18, 2017

Dr. Jason Hirsch Talks Changing the Approach in the Treatment and Care of Childhood Caries

Interview with Dr. Jason Hirsch

By: Michael W. Davis, DDS

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Dr. Michael W. Davis maintains a private general practice in Santa Fe, NM. He also advocates for disadvantaged citizens, and provides expert legal work for numbers of attorney clients. His publications and lectures are on ethical and whistleblower issues within the dental profession, as well as numbers of clinical research papers. He may be contacted at: MWDavisDDS@comcast.net

 

 

Dr. Jason Hirsch(2)

Jason Hirsch DMD MPH maintains a private practice of Pediatric Dentistry in West Palm Beach, Florida. Dr Hirsch has degrees in Chemistry, Public Health, Dentistry and Pediatric Dentistry and has been a Dr. Jason Hirsch logolicensed dentist in his home State of Florida since 2002. Dr Hirsch's philosophy is simple, treat children like they were your own, treat the cause of the problem first and foremost and practice with principles of benevolence, non-maleficence and veracity.
Contact information: DrJ, 685 Royal Palm Beach Blvd, Suite 201, Royal Palm Beach, Florida, 33411. Phone: 561 795 7959 Email:jhirsch1971@gmail.com

Introduction

Dr. Jason Hirsch is at the vanguard of revolutionary changes in dental care for pediatric dental patients. This advancement goes far beyond progress in dental methods and materials. Dr. Hirsch examines dental disease in its totality, and arrests the causation and progression of dental caries (tooth decay). He has rejected the paradigm in restorative dentistry of continual drill-and-fill (or steel crowns), followed by pulpotomies (baby tooth root canals) and extractions. His emphasis is solidly on evidenced-based medicine and dentistry in treatment for the root causes of disease, and not simply the manifestations of disease (seemingly an endless cycle of tooth decay).

 

Question 1

Dr. Davis: Dr. Hirsch, I feel quite honored to provide this interview for our readers. Could you explain how our current mode of dental care for pediatric dental patients is irrational? We see endless cycles of restorative dental services for our nation’s children, especially disadvantaged Medicaid children. Costs to taxpayers are outrageous, with unsustainable deficit government spending. Too many parents are only given two options involving their child’s dental treatment; “juice them (sedation), or papoose them (restraints a/k/a- protective stabilization)”. Each venue has its own set of risks. How is your vision for children’s dental care different, in relation to immediate benefits for the youngster, associated cost of treatment, and the long-term wellbeing of the child into adulthood?

Dr. Hirsch: Pediatric Dentistry (or children’s dentistry) has become too focused on teeth treatments instead of disease Jason Hirsch pull quote 2treatments. I fully understand that dentists are trained to repair teeth. How can we achieve this lofty goal of incorporating dentistry/oral health into systemic health, if we are hypocrites and continue to myopically focus on teeth? I hear these oral-systemic connection buzzwords, but how are we supposed to connect the dots, if we don’t begin doing this in children?

You cannot take an adult in the middle of his/her life and try to convince them of the oral/systemic connection. It just won’t work. This has to be accomplished in pediatrics with mothers/moms as the gatekeepers to this paradigm change.

The care system is irrational because we have acute treatments for a chronic disease. If you look at diabetes management you will see some parallels that frankly pediatric dentistry needs to focus on. Diabetics’ needs daily insulin and a child with tooth decay in whatever stage, needs daily fluoride. I don’t see dentistry promoting fluoride as medicine and that is disturbing to me. The pharmaceutical industry has created longer lasting insulin, so we have created a longer lasting fluoride, silver diamine fluoride (SDF).

Jason Hirsch pull quote 5We have an opportunity to stop dental disease faster than ever before because of this SDF product and because of SDF; we can reduce the need to papoose children or sedate/ anesthetize them. What SDF buys is time, and we all know that the most precious and expensive commodity in life is time to ignore this therapy would be a great setback for children and dentistry in general.

We cannot talk out of both sides of our mouth. If we want to integrate oral health into systemic health, I’m telling you it starts and ends with this concept of care, and it starts with children. Period.

Question 2

Dr. Davis: I’d like to get into some of the “nuts and bolts” of your modalities of arresting the dental caries (tooth decay) process. Are you giving little children shots with needles, to numb teeth from pain of dental therapy? Do you generally require sedation of the child to gain patient cooperation? How long is the child sitting in a dental chair for these therapies?

Dr. Hirsch: SDF treatment requires skill, not in the delivery of the treatment, but in assessing whether or not the situation requires SDF treatment. We cannot think that we can just slather this medicine everywhere and we can sit back. On the contrary, we must identify the specific children that will benefit most from this therapy, and then we can slather it judiciously.

 

The skills of the pediatric dentist must change from being a morphological dentist Jason Hirsch pull quote 4exclusively, to being more of a diagnostician; which in my mind is part pediatrician, part radiologist, part pediatric dentist and part pharmacist. What made no sense to me about dental education was this emphasis for two years on systemic understanding and then two years of divorcing oneself from those concepts. I spent hours on end studying dental histology, only to literally incinerate that knowledge with a drill and a diamond cutting tip. I found this chasm between reality, which is the science, and irrationality that a human can cure/fix a microbiological problem by gluing parts onto teeth.

We take this science concept, and we bring it to life by using the microbiology of the problem and incorporating SDF, instead of drilling teeth and gluing parts onto teeth. What this therapy eliminates is the shots, the drill and the sedation/anesthesia; all of the time consuming and expensive details. We can literally scale this as far as we want, because this therapy matches the disease. It’s simple to apply and inexpensive. It’s topical fluoride, so hygienists can provide, multi-level practitioners (MLPs) can provide, and maybe even expanded dental assistants with training can provide.

It’s very hard to mess this up. The success of this comes from the Pediatric Dentist being the orchestra leader; much like the MD is in hospitals and private practices, as they orchestrate a lot of auxiliaries as well. The only thing that holds this back right now in my mind is a validation of payment. We have a billing code in place, ADA 1354- “Caries arrest by medicament”. Once the insurance companies and Health and Human Services (HHS) understand the way some of us do this, then it’s off to the races.

 

Question 3

Dr. Davis: With the tooth decay process stopped in its tracks by utilization of silver diamine fluoride (SDF), we see a downside of tooth discoloration (although probably less unsightly than metal nickel-chromium crowns). Please explain the use of modern glass ionomer restorative materials in conjunction with your restorative dental care. What factors do you find most beneficial with glass ionomer; aesthetics, localized fluoride release for decay protection and rechargeable with periodic fluoride varnish, ability to generate a true chemical bond to tooth structure regardless hyper-mineralization of tooth structure or quality of dentin substrate (i.e. carries-affected dentin), or a favorable coefficient of thermal conductivity (nearly identical to natural dentin) which insulates the pulp (nerve)?

Dr. Hirsch: When situations demand that a tooth needs to be restored to function so the child can masticate (chew) correctly, we can incorporate an additional treatment to satisfy that demand. We call the procedure SMART, silver modified atraumatic restorative technique.

Atraumatic restorative technique (ART) was developed in the field and proven in the field to treat children without access to a traditional dental office. Somewhere in the lexicon of dentistry, ART has been labeled non-definitive treatment, but that distortion of the lexicon is just because of money, not because the treatment is less than definitive. In fact, ART is quite successful over long-term study.

What we have created is a dual therapy of SDF and ART, to increase the effectiveness of these individual treatments simultaneously. We have seen very good early success using these two treatments together. We are using high viscosity self-curing Glass Ionomer to restore cavities following SDF treatment. This type of glass ionomer is the best material for this procedure because it seals (chemical cohesion), versus composites that are routinely used. Composite materials bond (micromechanical adhesion), and that is a huge difference. The second difference is that glass ionomers release fluoride ion into the tooth and the oral environment. Resin materials can do this to a lesser extent, but they cannot absorb fluoride and recharge themselves as glass ionomers can. The last difference is that glass ionomers are water based materials, and work in wet conditions, versus resin based materials that require an absence of moisture. We all know that is not possible in the mouth.

 

Question 4

Dr. Davis: I’m very troubled and frustrated by the arcane focus, administration, and structure of dental Medicaid. This government program is problematic on countless levels. Antiquated fee schedules are heavily weighted towards remuneration for restorative steel crowns and pulpotomies. Less invasive dental services, which conserve sound tooth structure as you’ve demonstrated here, are “red flagged” for denial of authorization. Procedure code submission for “application of a desensitizing medicament” (D9910), “medicaments by report” (D9630), and “application of fluoride” (D1208- if in excess of 2-3x per year) are routinely denied. Many public health dental clinics, which are operational primarily from grant money or funding outside of Medicaid, can afford to focus on the services in the child’s best interest. State dental Medicaid directors often lack a doctor’s degree in dentistry; much less have any background in dentistry what-so-ever. Do you have recommendations for state dental Medicaid programs, to implement care in the best interest of our nation’s disadvantaged children? Would this also carry over to bonafide insurance programs as well?Jason Hirsch pull quote 1

Dr. Hirsch: The first item I would require for Medicaid and HHS is to relearn what dental decay is, but more importantly what it isn’t. We have a society, including a large majority of dentists not keeping up with science still believing that tooth decay is some infectious disease. It’s not. Once we get over this “truth”, we will begin to emerge with valid understandings, and we can get a handle on this problem in the manner we are advocating.

Avoidance behavior and obstinate behavior by the dental profession must be overcome. The currently accepted science is not true and traditional and traditions of dentistry (i.e. drilling and filling) are failing methodologies to addressing an oral disease. We will not solve this problem with outmoded thinking.

We are prepared to fail, but if we don’t try then we will never get to a higher place. Dentistry must embrace risk taking but not on the level it is accustomed. Now, risk taking is all about risking the patient’s life for a non-life threatening disease. The current treatments are filled with risk. What we are saying is in order to eliminate the risks; one has to relearn what the problem really is. I think a lot of pediatric dentists believe that tooth decay is a life threatening condition and regardless of who told them that or where they acquired that belief, it is our duty to the public to inform them that children do not die from cavities in primary teeth. It’s just not observed. We also must relearn that the oral bacteria, that is innate in all of us is not an infection.

Jason Hirsch pull quote 3In many ways humans have learned to adapt to our bacterial guests. That’s why we are not walking around chronically inflamed despite erroneous concepts about systemic health.

For example, why is it ok to drink a probiotic of billions of tooth decay bacteria for intestinal health? Why have we embraced this concept for general health, but we deny that in order to drink these probiotics, we start them in our mouth? This is a major source of focus for the profession and oral systemic connections.

Pediatric dentistry education has no systematic approach to treating caries (tooth decay). Concurrently there is no system in place clinically, to treat patients chronically instead of acutely. Our most basic care system tells patients to show up every 6 months for polishing teeth and applying fluoride. I look from the patient’s perspective and if this is an out-of-pocket expense, I can see some moms reasoning that this is what they do every day, so what is special about visiting the dentist?

This is where changing the approach and implementing a system of care that matches the chronic nature of the disease for those that are affected makes a lot more sense. The sentiment behind it might just drive more people into the dental care system, which actually need this therapy. They are afraid of the traditional drill-and-fill, so they stay home and allow the disease to progress. This is what we must realize and tackle. Patients who need us don’t want what we have to offer

 

Question 5

Dr. Davis: What factors are barriers to implementation of the evidenced-based therapies, which you’ve so courageously embraced? We realize SDF dental therapies are highly effective on large sample population studies from other nations. Why aren’t we more routinely observing the benefits of SDF and glass ionomer restorative treatment for our nation’s children?

Dr. Hirsch: The major barriers to implementation are two fold, short term barriers and long-term barriers. The short term is the payment system is not in place for this type of care. I believe that this is easy to fix and should be a short term issue once the payers see the economic data overlaid against the efficacy and effectiveness data.

This is what insurance companies are supposed to do. They are supposed to analyze what is the more rational care model. Unfortunately, we use insurance companies as marketing tools for patient acquisition, and we fight them when they show us the data that we don’t want to see. This has to change for both parties, before patients just eliminate the utility of either.

The long-term problem I see is the utility of all this surgical dental training for pediatric dental residents. GV Black invented this care model and used it daily in practice. Dr. Black was a general practitioner, not a Pediatric Dentist. I am not sure in the long-term, if the stand-alone pediatric dental office concept is a viable model the way we are accustomed to. Much of the care we deliver routinely is a giant waste of time and money for the patient and the payer, but not for the pediatric dentist. It’s these conflicts of interest that will need to be understood and changed if there is a way forward.

In many respects you can do pediatric dentistry inside the pediatrician’s office now and that would be a truly integrated oral systemic care model. I am not sure that this concept will sit well with my colleagues, who have invested in these giant offices with the video games on the ceiling and their popcorn machines?

 

Conclusion

Dr. Davis: This has been a highly informative interview. A wide range of individuals will gain new perspectives and insights from your work. That list includes dental Medicaid and insurance administrators, state and federal legislators, the dental community as a whole, and caring responsible parents and guardians. Most importantly, your work will have a tremendously positive impact on our next generation of citizens. I can’t begin to thank you enough, for your pioneering efforts and being a national dental hero.

Dr. Hirsch: Dr. Davis, thanks for your insightful questions, I hope I presented the doctor reader with a challenge and the patient reader hope. Thanks for all that you do for patients.