A Quick Review of Sedation Related Definitions
Anxiolysis – To mitigate anxiety. Usually accomplished in the clinical setting by administering a medication the night before and the morning of the procedure to reduce anxiety.
Minimal Sedation – Lightly depressing a patient’s level of consciousness with agents to produce a level of light or minimal sedation. The patient’s cognition level may be slightly impaired but respiration and cardiovascular functions should not be adversely changed or affected.
Moderate Sedation – Mildly depressing a patient’s level of consciousness with agents to produce a level of moderate sedation. The patient’s cognition level will be impaired but the patient should be able to respond to commands and light stimulation. The patient’s respiration and cardiovascular functions should not be adversely changed or affected.
Deep Sedation – Heavily depressing a patient’s level of consciousness with agents to produce a level of deep sedation. The patient’s cognition level will be greatly impaired and the patient will have great difficulty in responding to very simple commands or stimulation. The patient’s respiration and ability to maintain an airway may be adversely affected but cardiovascular functions should not be adversely changed or affected.
Level of consciousness from anxiolysis through sedation to general anesthesia needs to be thought of as a smoothly flowing continuum. The levels outlined for clinical and academic purposes are actually smoothly flowing and interconnected. A good source of information for this can be found in The Colorado Dental Practice Rule XIV, The Anesthesia Continuum.
Brent E. Virts, DDS
Prescribing of Controlled Substances
On April 8, 2019, Governor Jared Polis signed SB19-079 Electronic
Prescribing of Controlled Substances. This law requires that all podiatrists,
dentists, physicians, physician assistants, advanced practice nurses, and
optometrists that prescribe a schedule II, III, or IV controlled substance do
so electronically, with certain exceptions. The law does not require
pharmacists to verify the applicability of an exception to electronic
prescribing and pharmacists may dispense the controlled substance pursuant to
an order that is written, oral, or facsimile-transmitted that is valid and
consistent with current law. For most prescribers, the requirement begins July
1, 2021. For dentists and prescribers who work in a solo practice, or in a
rural area, the requirement begins July 1, 2023.
Cosmetic medicine is not an exact science, and patients occasionally have less than perfect outcomes with dermal fillers. Less experienced providers are more likely to make mistakes such as overfilling and asymmetry. Other side effects such as infection and allergic reactions can occur. Hyaluronic acid fillers such as Juvederm and Restylane products can be partially or completely removed with an enzyme called hyaluronidase. When injected into the affected areas, hyaluronidase dissolves the hyaluronic acid particles and may help in the event of vascular compromise, lumpy or irregular texture, infection in the treatment area, overfilling and dissatisfying results. Hyaluronidase isn’t perfect, and since products tend to be made from animal derivatives, certain patients may be at higher risk for allergic reaction and therefore not good candidates for the treatment. Make sure your patients know to call you immediately if they are experiencing pain, or unusual swelling, or the area feels warm to the touch. These are signs of infection that need to be addressed swiftly. Calcium based fillers can NOT be reversed with hyaluronidase. Each dermal filler product is unique and a wide variety of products are available. If this is a procedure you rarely provide, you might want to consider whether the possible complications are worth it. -Berkley Risk Complications with Dermal Filler Procedures. Is it worth it?
No Child under the age of 12 should snore. If they do, they
me be suffering from obstructive sleep apnea. Children can be misdiagnosed with
ADHD when in fact they have OSA. Common symptoms of OSA in children are: Sleep
in abnormal positions, snore loudly and often, stop breathing, sweat during
sleep, behavioral problems. Restless sleep. Headaches in the am and bed
wetting. As a dentist some of the oral signs you may notice are: mouth
breathing, chapped lips, exaggerated gag reflex and dark circles around their
eyes. We as dentists, see our patients more frequently than MD’s do so we can
screen and refer to sleep specialists. We can CURE KIDS with OSA with early
treatment (tonsillectomy and max expansion with forward maxillary growth) but
adults we can only treat. So, Keep your eyes open!!!
knew when I left school I needed a few necessities to practice dentistry. I
needed to have passed boards. Check. I needed to apply for my state license.
Check. I needed to have malpractice insurance. Sure? Maybe? Kinda?
and my classmates set out on the mad dash to get malpractice insurance, and
true to dental student fashion, I needed the best deal. The only problem was
that I had no idea what the words in the malpractice policy even meant.
Seriously! How could I have endured the trials and tribulations of dental
school and not know what the composition or the key terms in my malpractice
quote. Further, how am I going to judge if what’s in my policy is what I really
me simplify your life and give you the skinny on the components and meaning of
your malpractice insurance. First, don’t get caught up in terminology.
Malpractice insurance and professional liability insurance are the same thing.
It’s also the same as errors and omissions insurance. It protects you against a
claim that the dentistry you provided was done in error or an omission of
treatment. If a claim is made and brought to trial, it will pay for your
defense and damages whether the claim was unfounded or not. Keep your auto,
home, life, and umbrella insurance. These don’t overlap. It will only cover you
in civil matters in the practice of dentistry.
up are the really large numbers that the State Dental Board asks for you to
have covered. It looks like this: Effective
July 1, 2010, the law requires a minimum indemnity amount of $1,000,000 per
incident and $3,000,000 annual aggregate per year, or an acceptable alternative
as set forth in Board Rule 220.
Let’s break that down. Minimum
indemnity amount is the maximum amount an insurance company will pay out for
any one claim in one year. At this time, Colorado asks that you have $500,000
of minimum indemnity. An example of this would be if a patient claimed that you
failed to diagnose their periodontal disease and therefore they are losing all
their teeth. When the insurance company acts to defend you by retaining an
attorney and acquiring testimony and other needed items in a civil court case,
the most they will pay out is $1,000,000 per case.
Taking that a step further is the
annual aggregate per year. This is the total amount an insurance company will
spend on defending you in one year. So if you have multiple claims in one year,
the insurance company will stop covering the costs at $3 million. You may ask,
“What if legal fees are greater than $1 million for one case or $3 million in
one year?” In that situation you would then be responsible for the rest of the
As a new dentist myself, I have a
couple of words of advice despite the grim topic. Get malpractice insurance
from a company where you can talk to a real live person. If something were to
happen, you don’t want to be encouraged to send an email or chat online. You
will be panicked and you need a voice on the other end of the phone. Sign up
with a company that has dentists on their board and is run by dentists. Don’t
rely on statisticians and historians to comb through legal cases to see if your
claim can be won or not. Have a group of dentists that are on your side and
looking out for your ability to practice dentistry. Unfortunately we live in a
litigious society and some patients believe that a malpractice payout could
secure their financial future. Practice with confidence and only practice with
by Dr. Candace DeLapp
Texting has become more
common as a means of communication. It’s easy and convenient for all parties.
However, it is not without pitfalls. Below are a couple of situations you need
to know about texting and malpractice claims.
- A patient texts you or your office with “a quick question.” Avoid the quick answer back. Maybe have the patient in for a face-to-face conversation or let them know you want to investigate further and will get back with them. Patients can and will use text messages against you!
- Do not conduct business via texting. Your office should not be texting billing statements (balances due) or any private information via a text. A personal phone call or statement should be sent. Speak with the patient in person (don’t leave a detailed message) and ask them to return your call. HIPPA and privacy issues come in to play here. Have you ever dialed the wrong number?
- Appointment reminders are acceptable via texting, but no personal information should be included. Just the day and time of the dental appointment. No details as to what is to be performed. Again, this is a privacy issue. You don’t know who has access to the text.
It’s important to remember
that anything stored on a phone can be retrieved and used as evidence.
Be careful what you text!
By Dr. Todd Pickle
I am sure you have never had a situation
where two or more implants are either too close together or angled into each other
to the point that you cannot get the metal impression copings on at the same
time. But if this ever does happen, I
have found the best thing to do is use a plastic version of the impression
coping if your implant company makes one, which many do. This will allow you to cut the copings so
that they all fit and you can pick them up in one closed-tray impression.
Plastic impression copings are single-use
anyway, whereas metal copings that you have to cut are usually not usable
again. They are not accurate enough for
multi-use and the plastic components deform during use beyond their elastic
ability to accurately be used again. But
if you cannot find a plastic version of the impression coping, you should try
to find a plastic TEMPORARY coping.
These can be customized with resin ‘blobs’ so that they will pick-up in
the impression and serve the same purpose.
Make sure you decide if you need engaging
or non-engaging copings before you make the impression. Some companies call these parts “bridge
copings”. Only single unit crowns need
engaging copings, so stick with non-engaging components for everything else,
Use this tip to make a good impression!
By Dr. Todd Pickle
Polytetrafluoroethylene is a truly amazing
material used in many industries and has lots of uses in dentistry and everyday
The #1 best use in Dentistry: Closing screw access holes in implant
abutments, crowns and hybrids prostheses!
PTFE is very hydrophobic and does not collect microorganisms like cotton
pellets or retraction cords, or heaven forbid wax! It can be packed and condensed, and then
other restorative materials placed over it and they won’t stick to it. It will protect the implant screw so that
your implant components are retrievable, which is a prime benefit of dental
implants over teeth.
It is important to place the PTFE tape
starting in the deepest portion of the screw access hole directly on top of the
implant screw head. Then continue to
pack the tape (start with a long piece about 2 inches) until you have about
2-3mm remaining of the occlusal portion of the screw access hole. This will allow enough space for adequate
filling materials (interim or permanent) to be placed over the PTFE tape and
not always falling out and needing replaced.
But it also means you don’t have to dig very deep when you need to take
Other dental-related uses include: Using it
in endodontic access holes, blocking out undercuts or adjacent teeth around
composite placements, covering sutures while making impressions (instead of
rubber dams). “Gore-Tex” sutures are PTFE because they are strong, do not
attract microorganisms and do not resorb.
And of course, threading pipes for
plumbing! And best of all it is cheap
and you can get it at Home Depot!
By Dr. Sarah D. Parsons
Dentistry is personal. It’s
personal to us because we put our heart and soul into treating patients and
growing our business. We have dedicated
our life’s work to cultivate our dental practices.
But, there is a patient that
is unhappy. A variety of reasons can make a patient unhappy. There is a
miscommunication with a team member, a disagreement over finances, or a perceived
bad experience by the patient of some type. The patient calls or comes to the
office and they are unhappy, so how should you handle this?
First, it is important to
stay calm. We as clinicians take these situations very personal. But we must
put on our “doctor hat” and try to diffuse the situation in a professional
manner without bringing our personal feelings into the situation. We may feel
the patient does not understand the situation or does not have all the
information. This may be true; however, most unhappy patients just want to be
Invite them into a
consultation room or treatment room away from other patients. Hear them out.
Let them tell you in their own words why they are upset and unhappy. Your job
is to just LISTEN! Many times this diffuses the situation immediately; do not
interrupt or try to correct them. Let them tell their perceptions of the
situation from beginning to end. Let them know that your hear them and you
understand their frustrations. Reassure them that you will be taking the time
to review their grievances and that you will help find a way to make it right.
DOCUMENT, DOCUMENT, DOCUMENT!
Do not wait. Immediately document the situation with the patient and write
their exact words in quotes. Be sure to call Dr. Randy Kluender or Dr. Candace
DeLapp to discuss the situation and the best way to resolve your issue.
We know that your dental
practice is personal. That’s why we make it our mission to take these
situations as personal as you do. We have licensed dentists who have been in
private practice who understand your day to day business. We make it our
mission to always take your practice as personal.
By Dr. Candace DeLapp
Senate Bill 22 (SB18-22): Clinical Practice for Opioid Prescribing was signed in to law May 2018.
Briefly, its impact on the
practice of Dentistry is:
Initial prescription must be limited
to a seven-day supply if the prescriber has not written an opioid prescription
for the patient in the last 12 months.
The limits on initial prescribing do not apply if, in the judgement of the dentist, the patient:
chronic pain that lasts longer than 90 days or past the time of normal healing,
as determined by the dentist, or following transfer of care from another
dentist who prescribed an opioid for the patient;
been diagnosed with cancer and is experiencing cancer-related pain; or
- is experiencing
post-surgical pain that, because of the nature of the procedure, is expected to
last more than fourteen days.
The prescriber may exercise
discretion for a second seven-day prescription.
The prescriber must check the Prescription Drug Monitoring Program (PDMP) database except under specific requirements:
patient is experiencing post-surgical pain which routinely exceeds 14 days;
patient has cancer or cancer-related pain;
prescription is administered by an in-patient facility
- the patient
is in hospice or palliative care
For more information on opioid prescribing contact The Trust:
Dr. Kluender [email protected]erkleyrisk.com
Dr. DeLapp [email protected]
Or read the bill here.