Finding the Perfect Shade.

There are several differences between men and women in dentistry, many of which I have blogged about before.  However, one was brought to my attention the other day which is very interesting.  In case you didn’t know 7% of all men are colored blind, while only 0.4% of women are.  That is interesting as color blindness is encoded on the sex hormones and therefore many women are carriers but are not color blind.  But how does that interesting anomaly affect dentistry?  Well in my case, I am part of the 7%.   Specifically I can’t see many blues and reds.  Well let’s say I was doing a porcelain crown on your upper right central incisor and we need to match the shade to your upper left central incisor exactly.  When the laboratory technician is stacking the porcelain they use blue shades to mimic the translucency that many people have in their incisal edges of their central incisors.  Well if I can’t see the blue I can’t tell if the incisal edges match and it could look perfect to me but in actuality it is way off.  This is probably made worse with the fact that many teeth have orange or red tinges which I also cannot see.  Well, there is technology to the rescue.  We have used electronic shade matching computers for several years that can actually map several sections of your tooth to come up with a precise shade match on every portion of your tooth.  Is it perfect?  No, but with the help of an experienced and qualified laboratory technician we can get the shades really really close. And by the way, who are the best and most talented as techs at the laboratory to check shades?  Women of course.  Good Luck with those colors!  

Hi-tech

High tech is all the rage and it does affect dentistry.  If it weren’t for computers, iPhones, tablets and the internet, where would we all be?  Some love it, and others hate it.  I assume the difference is whether your “toys” are working or not.  But these are really more than “toys,” they have become part of our everyday life.  The one thing I have learned over the years however is that there is a place for technology, and other places where the old tried and true methods work better.  For example when my kids were little and they got a new hand held calculators that were available at the time, they thought that they were great.  But I would constantly drive them crazy by doing mathematics calculations on my old slide rule faster than they could push the buttons on their calculators.  Now to be honest, I have not used my old K + E Log Log Duplex slide rule for some years as I have learned to use computers just as they did.  But I believe the concepts of old versus new is still valid.  Now what does that have to do with dentistry?  I am sure you have heard advertisements for a new process in which they can do crowns (caps) in one visit.  It utilizes digital scanners, that we already use (Itero), with a milling machine attached  These offices can mill a new crown out of a solid "block" on the spot without having to send the impression off to a laboratory.  This means not having to deal with temporary crowns and need to return in a few weeks for a second appointment.  Sounds great doesn’t it?  But as always there must be a catch, and indeed there is.  You can only mill certain materials and today those materials fall into two categories.  The first one is one of the new “super composites” which are basically hardened plastic tooth colored filling material.  The second material is a new ceramic material called E-max, which does look great, but is not nearly as durable as many of the other materials that we have used for years.  Therefore, especially on the molars, you are risking cohesive failure of the material in a single visit crown just for the convenience of avoiding a temporary crown.  I don’t know how you feel about it, but I don’t like Novocaine shots that much.  So redoing a new crown because it broke is not my idea of fun.  Therefore, although we use the latest technology for scanning images for crowns, until the manufacturers develop new "blocks" with a wider range of restorative materials, in my opinion milling a crown on site is not the best option for the vast majority of our patients, especially on their molars, which take a tremendous amount of force and are prone to mechanical failure.  I will watch for continued improvements however and will jump on the band wagon if possible. 

Issues with Affordable Care Act, Part 2

In my opinion, as a medical care provider, the real issue with the Affordable Care Act is not the insurance aspect.  Single payer is single payer, it is obviously used widely in many developed countries throughout the world.  The real issue is the difficulty in getting quality medical care.  That has been a reported problem in many of these same countries.  So let’s get back to dentistry in California.  Before Covered California, Denti-Cal had the fourth lowest reimbursement rate for dental treatments of all the 50 states, despite our higher cost of living.  In fact, those rates for dental treatment have not seen any increases since the year 2000 and last year the legislature decreased funding for Denti-Cal additional 10%.  Obviously, as a dentist in California it is very difficult to see Denti-Cal  patients no matter how altruistic you are with such slow reimbursement rates and in fact fewer than 10% of us are currently seeing Denti-Cal patients.  I stopped seeing Denti-Cal in the late 90's as Sacramento and San Diego counties started an HMO style reimbursement program and in fact fewer than 40% of pediatric dental patients have access to their free dental care.  In California there are 5 counties that do not have a single dentist provider.   So how does the government plan to resolve this problem?  Well the Affordable Care Act raised the reimbursement rates for Pediatric Dentistry to the same level as Medi-Care rates for all Denti-Cal reimbursements.  Great, so now many more dentists can see these new Covered California pediatric patients.  Not so fast!  This supplemental reimbursement from the federal government is only until 2016 at which time it starts to phase out.  Well who is going to make up the difference?  Obviously the state of California will (i.e.we tax payers.)  Do we have the funds for that or do we have to cut back the program again?  Don’t hold your breath.  Because we could not afford the old, very low, reimbursement rates that served millions of fewer children.  So what will happen?  I don’t know.  But with past experience as a guide, it will not be pleasant.  And while I agree that many children will now have insurance, very few will be able to get adequate dental care, and isn’t that really what we are trying to accomplish?  Is this the right answer?  Once again we, the informed voting public, will make the final decision at the next election.  Thus the reason for the blog.  We need to make informed decisions and put children first and hopefully we can resolve some of the issues.    

             

Issues with Affordable Care Act, Part 1

I thought my next blog should be in 2 parts because of the complexity of the topic and my attempt to keep the blogs relatively short, so people will actually read them.  The topic we will be discussing today is the status of dentistry in California and how it is affected by the Affordable Care Act or Covered California.  Unlike Hilary Care in 1994 the ACA specifically left out dentistry to a large extent.  So why do I need to discuss it in a dental blog?  Well, while there is no federal dental funding mandate for the ACA, it does have a requirement for children’s dental healthcare coverage up to the age of 19 (no, not 18 or 26) for all insurance companies participating in the exchanges, including Covered California.  Obviously, from appearance that is certainly not a problem for California dentists and all Californians up to 19, who now will be covered by insurance.  After all that certainly boosts the demand for dental services and that is good for dentists and good for the patients that will benefit from our services with better oral health.  That certainly sounds like a win-win but unfortunately that is not the case.  The hidden problem is that Covered California in the ACA wants to increase patient care by subsidizing the cost of that increased patient access by putting millions of children into a single payer program paid for by the government.  In California, that huge figure translates to 5.1 million in 19 year olds and younger patients on Denti-Cal (the California version of dental Medicaid or Welfare).  Well what is the problem with that?  Let’s put it into perspective.  California is the 8^th largest economy in the world with a gross state production (GSP) of approximately 2.05 trillion dollars or 13.2% of the federal gross national product (GNP).  We currently have an unemployment rate of 7.4%, the fifth highest in the nation, which is certainly nothing to be proud of (but it is getting better).  The states demographics in the current census is 30.1% 19 year olds and younger of our total population of 37 million.  That means we have a total of 11,100,000 19 year olds and younger.  That translates to 46% of child population on welfare. Is that a problem?  Only you can decide, but it is certainly concerning to me that if we are such a great state, why almost half of our children on Welfare?

Disneyoholic

Just in case you have ever wondered why we have all the Disney memorabilia around the office there is a reason.  In 1968 when I was an undergraduate at UC Irvine, I needed a part time job to supplement my scholarships, grants and student loans so I went to Disneyland to get a job.  I was hired in the food services department and as a casual seasonal employee (Christmas, Easter, grad nights and summer) and eventually a permanent part time employee through 1972, when I was married to my wife Karen, and it was between my freshman and sophomore years at UCLA dental school when I started working as a dishwasher and moved up to line cook after the first summer and eventually to lead chef for the Tahitian Terrace restaurant (between the Tiki Room and the Jungle Cruise ride now known as Aladdin’s Oasis).  When I was working weekends as a part time employee I worked at the Plaza Pavilion on Main Street and Club 33 the private club above Pirates of the Caribbean in New Orleans Square.  During the winter months I would go in on Friday after classes and work 10 hours and then work 12 to 14 hours on Saturday and Sunday to pick up as many hours as I could.  I learned to work very hard and to be efficient, but most importantly I learned the Disney concepts of “host” and “guest.”  The concept is to treat both parties with respect and gratitude.  If you want to see a contemporary representation of that, watch the Disney film, “Saving Mr. Banks” with Tom Hanks as Walt Disney. That time frame is the time that I worked for Disney and I believe that it accurately betrays the Disney concept of how the “hosts” respect the needs of the “guest” P.L. Travers, no matter how she harasses them.  Although I never did meet Walt Disney as he passed away in 1964, I count his brother Roy as one of my friends.  In fact we watched the Armstrong Moon landing together on a 12 inch black and white TV set at “Station 13” at the Terrace.  Needless to say it is difficult to “outgrow” these types of experiences and training.  Thus I have been a Disneyoholic since then, as can be easily proven with my over 40 Mickey Mouse watches.  But what does this have to do with dentistry and our office?  Well I have utilized these Disney concepts in my practice with all of my staff (hosts) and patients (guests) trying to do the best that I could do for every one every day.  In the end you will have to forgive me for all the Disney stuff that I have around the office, but that is me.

Old vs. New

I am often asked whether it is better as a patient to be treated by a young dentist who has been trained in all the latest technology and is up on the latest trends and innovations in dentistry, or is it better to be treated by a seasoned dentist who has had life experiences and has done thousands of procedures like the one that you need to have accomplished.  It is an interesting dilemma, and a question not easily answered without some prejudices.  I believe it depends on the procedure that you need to have accomplished.  For example, I was taught at UCLA dental school in the early 70s to do gold crowns and silver fillings only.  And in fact the tooth-colored restorations as they are currently accomplished today were not even available until 1978, several years after I graduated.  On the other hand,  Dr. Naten who graduated 2 ½ years ago was raised on composites and ceramics, the bulk of our practice today, and is thus very comfortable with doing those procedures even though he has not done as many of them as I have.  I believe that the best method to even out this educational divide was derived in California many years ago with our continuing education requirements of over 50 hours of education each renewal period.  That certainly helps, but it is each individual dentist’s investment in their practice and care of their patients that is the real motivation to go beyond the minimum requirements and get as many continuing education units as possible.  In my case, our last office trip was to the Greater New York Dental Society meeting with over 55,000 other dental professionals all trying to get the most up-to-date techniques and bring them back to our practices to help our patients.  Our staff is committed to that education process otherwise they would not be here, and I am very proud of all of them for their dedication to improving dentistry and the health of our huge family of patients.  I believe this is the real answer.  Is the dentist happy with his or her work and do they look forward to going to work every day to try to help people?  If the answer is yes, I believe that is the dentist you want to see.   Fortunately in our office we offer treatment from both young and old dentists (Did I really say that?) so you get the best of both worlds.  As for those young dentists out there, watch out for us old guys and gals.  We are not necessarily behind you on the technology bandwagon.  You may have to look forward to find us rather than behind.