By:
Michael W. Davis, DDS
This is a guide for parents, government regulators and law enforcement. The American Academy of Pediatric Dentistry (AAPD) has issued a number of valuable guidelines, which illustrate methods and materials to gain the pediatric dental patient’s cooperation, in the child’s best interest for dental healthcare. This paper is not about that. The manner in which clinical care should be delivered in the child’s welfare is of minimal concern in the Medicaid mill environment.
Medicaid dental mills are clinics primarily focused on delivery of government funded dental services in the private sector. Their chief focus is maximal generation of dollar production. The interests of patients and parents are of minimal concern.
ThreatsParents often receive threats for not consenting to their child’s dental care at these types of Medicaid clinics. Threats come from office managers, doctors, and other staff, most of whom are operating under production bonus and quota programs, unknown to parents. The threats range from intimidation of reporting parents to state Child Protective Services, to reporting parents and children to “La Migra” (immigration authorities).
A “red flag” for parents is that when they ask questions about the need for their child’s dental treatment, there is never an offer for the parent to seek a second professional opinion or other optional treatment. The clinic representative usually ups the intimidation pressure, when the parent even hints at a desire for a second opinion.
Once the child is successfully isolated away from their parent, they are be frequently threatened to gain cooperation and compliance for clinical treatment. “If you don’t hold still, I promise you’ll NEVER see your mommy again.” “If you keep moving you head around, a needle will be going into your eyeball.” (Interestingly, I first heard that sick line from a dental educator.)
Keeping Children Isolated from ParentsMost children feel comforted and safe in the company of their parents. They generally enjoy a more positive overall dental experience in the presence of their trusted guardians. This is fully supported by AAPD Guidelines. However, the best interests of the child do not comport with maximizing clinic “Production per Patient” (PPP- a specific term used in the corporate training literature of Medicaid mill, Small Smiles Dental).
Isolation of the child is a method to break the child’s will, and employ further techniques to generate maximal production, at the patient’s psychological expense. In Medicaid mills, parents are often expressly forbidden to accompany their children in dental treatment areas. If there’s no parent to observe child abuses, abusive compliance techniques often ensue.
RestraintsThese devises may euphemistically be called “papoose boards”, “protective stabilization devises”, taco board, or “blanket wraps”. In reality, they represent child straightjackets. If the child is restrained, the doctor is more able to maximize clinical production (dollars generated). There is no longer a need to work within a child’s stamina or their individual understandings and ability to comprehend. It represents a seriously disturbing psychological trauma to a child. Again, usually no parents are allowed to provide their presence, with comfort and reassurance.
There are obvious clinical risks associated with child restraints. If the child is not properly monitored, which is often the case in busy Medicaid mills as dentists hop from patient to patient; the chest restraints inhibit a child’s breathing. This elevates risk of morbidity and mortality. The child may struggle to free oneself, with a potential for a restraining strap to compromise the carotid artery (blood flow to brain) or trachea (airway). At least one confirmed death (possibly more) has been attributed to the use of restraints.
Trying desperately to escape children struggle to the point of falling from a dental chair, while still secured in a restraining devise. They were subjected to needless contusions (bruises), lacerations (cuts), inclusive of head and neck trauma (potential for brain injury or nervous system damage). It should go without saying (and AAPD Guidelines do say so), the potential for a child’s psychological injury is also very real.
Due to wrist injuries being commonly reported by parents from the velcro bindings inside the restraint device, clinics are using socks to cover the hands and arms. If your child reports socks placed on their hands, it is a good indication of the child being restrained.
Hand Over Mouth and Nose Technique“Hand over mouth” (HOM) technique was formerly a mainstay in pediatric dental training. The dentist would place their hand over the mouth of a child, who might be screaming out inconsolably. The child maintained an airway through their nasal passages. Often the child would subsequently calm down. This was never designed to be a method of first resort. In fact, this specific technique is falling out of favor with increasing numbers of pediatric dental specialists.
Medicaid clinics take this technique to a new and highly disturbing level. The doctor will not only cover the child’s mouth with their hand, but use the thumb and first finger to pinch off the nasal airway. In very short order, the child must gasp for a breath. At that instant, the doctor inserts a Molt mouth ratchet, or a rubber bite block (instruments to forcibly hold a child’s mouth open). The child is no longer capable of free will of verbal communication at that point, for the remainder of the dental appointment.
Limiting Amount of Local AnestheticLocal anesthetic is commonly termed “Novocain”. In fact, Novocain is a generic term which might refer to a number of different forms of local anesthetic. This agent is essential for patient comfort, regardless of a dental patient’s age. Many elder patients have tooth nerves which regress, and little to no local anesthetic may be required for patient comfort. Children have relatively very large sized tooth nerves, and generally feel dental pain quite easily.
A child’s lower body weight often dictates a significantly reduced amount in delivery of local anesthetic by the doctor. If local anesthetic is overdosed to a child in particular, death can and does result.
Note: adults can safely receive far more local anesthetic. Therefore, dentists will often limit the amount of dental care they provide a child at a single dental visit, so only a safe and limited level of local anesthetic is given. The child may require several visits to complete planned dental care, in a safe and responsible manner. The child’s welfare should assume first priority.
The Medicaid dental clinic places dollar production ahead of all other concerns. Once the child is firmly secured in a restraining devise, and their mouth held in an open and locked position; dental drilling, pulpotomies (baby root canals) and extractions can proceed, regardless of adequate local anesthetic for patient comfort. Children will commonly generate screams from acute dental pain as the dentist drills on teeth with lack of anesthesia, while their tiny feet ceaselessly kick on the papoose board. The Medicaid clinic’s objective is to maximize PPP, regardless of the patient’s interest, pain and psychological damage.
Screaming in Child’s FaceScreaming in the face of a child by the doctor is a method to break the will and spirit of the child. This abhorrent technique is very similar to a Marine drill instructor screaming in the face of a raw enlisted recruit. Only this isn’t a young Marine, but a very young child. This is but one tool to bring the child into a psychological state of cognitive disassociation. Figuratively, the child leaves their body. The doctor is then free to invoke their more powerful will upon the child. Again, the goal is to maximize PPP, under the broken dental Medicaid program.
Physical AssaultA doctor punching, choking or slapping a child is another unacceptable method to gain a child’s compliance. Strikes may be to the abdomen (stomach), thorax (chest) or appendages (arms and legs), so bruising won’t immediately and as easily show. The doctor is frequently 3-5X the physical size and body weight of the patient. The concept is that with adequate physical intimidation, pain, and additional fear of pain, the child’s cooperation will be achieved. Again, often the patient is rendered into a state of cognitive disassociation, in order to generate maximal dental production.
WaterboardingMedicaid mills where this has been done don’t refer to this abuse as “waterboarding”, but that’s exactly what it is. This isn’t inflicted upon suspected Islamic terrorists, but on our nation’s disadvantaged children. Once again, the objective is to fully break a child’s will and spirit, to generate maximal dental Medicaid PPP. I’ll describe the two most common methods (One was common in Oklahoma City and the other in Albuquerque).
Oklahoma City Baby Waterboarding-
Initially, the child is firmly restrained in a papoose board and reclined in a dental chair. The feet are positioned higher than the head, to allow water to more easily flow up the nasal cavity from the mouth. A rubber mouth prop is firmly positioned between the child’s teeth, which will not allow them to close. The swallowing reflex is greatly inhibited, because the teeth aren’t allowed to close together. Next, the doctor fills the child’s mouth with water. The small patient can’t swallow and water flows up into their nasal passages. They experience a terrifying sensation of drowning, alone and without their parent. The concept is to break down the child, in order to maximize Medicaid dollar production.
Albuquerque Baby Waterboarding-This is similar to the Oklahoma City baby waterboarding method, but with a nasty twist. Instead of using a rubber bite block to hold open the child’s mouth, a paper patient bib is forcibly stuffed into the child’s mouth. These bibs are highly water absorbent. The doctor next will saturate the bib with water. The doctor may also elect to pinch off the child’s nose, so they have no ability to breath for a limited time. Other times, the doctor’s hand or a paper bib will also cover the child’s eyes. Again, the child is placed into a highly threatening position, with the sensation of imminent drowning. The spirit and will of the child is fairly easily broken. Maximal dental Medicaid production then ensues.
ConclusionOne will not find any of what I’ve described in the peer reviewed dental literature. It it far too threatening for dentistry’s leadership to face. Adults, who were dentally abused as children, under this toxic dental Medicaid program will have terrible memories surface. Many are suffering from dental post-traumatic stress disorder (dental PTSD). Please bring this article to your counselor or therapist to futher support your traumatic experience. What you faced as a child was horrendous and needless. I will absolutely validate the physical and psychological trauma you suffered.
Parents please do not blame yourself. You trusted a dental professional. You may have trusted what you assumed to be a reputable national chain of dental clinics. You were betrayed on many levels. Yes, doctors took advantage of your child, and cheated taxpayers. State and federal regulators have been hiding under their desks for decades. Leaders in my dental profession abandoned the public welfare. Wall Street bankers have even gotten in on the dishonest action. Politicians have also taken their cut. Those who cheated you and your child have high levels of formal education and are entrenched in our political and economic system. The game is rigged, and the fix is in.
People in law enforcement and government regulations, this should be a wake-up call. Many of our disadvantaged Medicaid kids are being abused by dental professionals. These children aren’t to be blamed for their financial circumstances or disabilities. It’s not their fault. Blaming victims is toxic thinking. Let’s get these kids the helping hand they need. Let’s give very serious attention towards filing criminal actions (not only civil actions) against doctor violators, and the corporate managers, who often pull the strings.
Finally, our dental Medicaid program is in complete disrepair. We need to place this sick program on the scrap pile, and rebuild a dental Medicaid system, which truly assists and honors patients it is intended to serve. Our current system is an out-of-control boondoggle of “welfare for the rich”. American taxpayers deserve better. Our nation’s disadvantaged children deserve better.*
In 2014 Dr. Davis sponsored a proposal to incorporate the AAPD Guidelines for the use of restraints into the New Mexico Dental Practice Act. Despite much opposition his efforts were successful and in 2015 the AAPD guidelines are no longer “suggestions” by rules in New Mexico. see
NMAC 16.5.2.27
16.5.1.27 PROTECTIVE PATIENT STABILIZATION: Unless otherwise stated in rules or statute, the board, licensees and certificate holders shall refer to the American academy of pediatric dentistry’s guidelines on protective patients stabilization. [16.5.1.27 NMAC - N, 01-15-15
Now the challenge is to prevent members at the AAPD from easing their guidelines. In these trying times the AAPD appears to be over run by members who are attempting to rewrite the guidelines that reflect less interest in treatment and more interest in speed and production per patient.
