Doctor Eclectic

Doctor Eclectic
Doctor Eclectic

Saturday, June 29, 2013

Squamous Shamus

Once a year my church has a blood drive and I used to be a regular donor.  Then I had Prostate cancer and took a forced five-year hiatus that ended last year.  This year I was prepared to continue a habit started when I was a Naval Officer and a four-times-a-year donor.  After I completed the paperwork I was interviewed and told that I could not donate until next February.

Because I had been operated for a Squamous Cell cancerous lesion on my left ear.  Twice.

The operation was self-directed because I had virtually stopped going to Dermatologists because they rarely operated and generally just used Cryosurgery to take off dozens of spots on my balding dome.  But two lesions: one on my ear and one on my chest, had recurring scabs that peeled away at four to six month intervals.

So I asked my Primary Care Physician for an opinion and he suggested a referral for evaluation.  The ear was a candidate for Mohs surgery: a procedure that allows evaluation of borders immediately.  One corrective procedure and a follow-up cleanup procedure and I was pronounced cancer free.  The chest was treated with his freeze-gun.

An interesting article by friend and columnist, David Whiting in the OC Register this June discusses his experience with squamous cell cancer.  He had a lesion on his knee that didn’t heal and eventually was sent to a dermatologist who referred him to an Orthopedic surgeon because of the location of the lesion.  The Orthopedist sent him to a Plastic Surgeon who diagnosed it as an embedded thorn.  Mr. Whiting is a researcher and visited the Mayo Clinic website and the website for skin cancer and self-referred to a pathologist who diagnosed the Squamous Cell lesion on the knee and three other areas of his body.  David’s message?  Be your own advocate.

Mary, my wife is currently healing from 40 sites, treated by her dermatologist by Cryosurgery.  Perhaps it is my bias as a trained dentist, but I find it unusual that so many lesions be so treated without a biopsy of at least one.

My suspicious nature wonders if this is yet another treatment decision driven by the fact that we pay for services rather than for care.

One wonders also why there are so many restrictions about donating blood?  Some examples?  Malaria, five years (Mary and Tim, having contacted malaria on a Philippine Naval Base in 1983 have yet to donate); Travel to Europe during the time of mad-cow disease, forever; sex with a single male partner if you are also male, forever; and my squamous cell operation one year.

When I went in for my Prostate surgery I was encouraged to bank my own blood.  I think if asked I would have as soon tried some blood from a restricted donor.  Again, my skeptical self wonders if the logic is driven by liability risk rather than medical.

As I write this my 80 year-old brother in law is being treated for a radiation cystitis.  His problem?  In his home town, Freeport, there is not a medical facility or physician who has treated his condition.  I have another relative and friends who are in serious stages of dementia with limited resources to treat the condition.  All this at a time when we are preparing to expand healthcare to millions of people without access to the limited resources we have.

Which brings me to considering the subject of my next post.  With student loan rates scheduled to double in interest in two days, I think I’ll weigh in on the subject of financing post-high school education.

You might find my comments interesting.

Friday, June 21, 2013

2x a Day



A recent article, printed in the Journal of Dental Research caught the attention of the prestigious New York Times and consequently the attention of the American Dental Association.  Although the article brought forth no information not known to those in the profession who are abreast of outcome analysis, it caught public attention because it challenged advice deeply ingrained in the public’s minds.

Namely:  Brush your teeth twice a day and see your dentist twice a year.

The brushing twice a day is a relatively new mantra, having been part of a marketing campaign for Ipana toothpaste in the late 1940s.  Actually toothpaste manufacturers would like you to brush when you wake, after each meal, and before you go to bed, but twice a day had a nice ring to it because dentists, even today are preaching “brush twotimes a day for two minutes” to instill a habit from the time you are a child.

The public tends to believe that the reason for brushing is to remove plaque and the bacteria that live in plaque, and in fact that does happen.  But plaque comes back with remarkable speed, so brushing is limited in its role to prevent decay and maintain healthy gums.  It does provide an efficient mechanism to deliver fluoride to the teeth to make them decay resistant and it will lengthen the time for plaque to mature, which means the dangerous bacteria are not around to convert sugars and starches into acid and it lessens the likelihood that plaque will gravitate below the gums to break down the collagen in the gum tissue.
 
The article, which surveyed some 5,000 patients, concluded that unless a patient had one or more of three risk factors for periodontal disease: smoking, diabetes, or interleukin-1 genotype, there was no value in having a professional cleaning more than once a year.  Furthermore it concluded that those patients with one of more risk factors should have their teeth professionally cleaned more than twice year.

The ADA couldn’t agree more.

This points out some interesting changes in the delivery of dental services.  The ADA is struggling with the best way to identify patients by risk: for caries, periodontal disease and oral cancer.  And third-party payers are designing benefits to encompass personal health management in both general and oral healthcare.  There is even one non-profit (The Continua Alliance) dedicated to embracing developing technology to improve this system.

For several years the ADA has been preaching prescriptive use of services; e.g., x-rays, recall intervals, and staging of treatment plans.  However, hungry dentists, public expectations and benefit design have often impeded acceptance of this philosophy.  There is hope that the adoption of an electronic Health Record, and the need to better allocate limited healthcare dollars and providers, will force better acceptance and move compensation for health services from Volume to Value.

In the meantime we should all get to know our bodies better and seek remedies consistent with our needs and desires.

While I am on a roll about health, I think my next post will be about a friend and columnist, David Whiting who wrote a piece telling of his bout with cancer.  I think you will find it interesting.

Monday, June 17, 2013

Telehealth

As so often happens, about three things happened recently to make me think about where Telemedicine and more particularly, teledentistry have developed.  The first was a story on NPR describing a recent robotic venture by USC that allows interpretation of reactions from a remote site by accumulating data and forwarding it for review by an off-site Psychologist or Psychiatrist.  The incentive for developing the robot came because of the increasing disparate distribution of service personnel suffering from Post-Traumatic Stress Disorder or other complications of battle fatigue.  I placed a link to the story here.

The second was a series of references I came across while preparing a presentation to the American Association of Dental Consultants recently.  My subject was an explanation of those skill sets that need to be developed for a Dental Director to be effective in improving efficiencies in healthcare delivery.  One that caught my attention was what has happened recently to improve evaluation and delivery of needed services in geographically underserved areas.

The third sprang from the second when I heard a presentation on what the University of the Pacific School of Dentistry has been doing with Grant money in a program they title the Virtual Dental Home, delivered by Paul Glassman to the quarterly meeting of the Oral Health Access Council.  Dr. Glassman summarized his two-year Grant program with an excellent synopsis that directly countered the two major arguments against using expanded function: that it would establish a two-tiered system of healthcare and that it doesn’t save any money.

The breakthrough came from a surprising direction.  I had thought that using mid-level providers, in the UOP case hygienists specially trained to collect data by camera, computer, and mobile radiographs, would translate into monetary savings.  Not so much.  The training itself is a limiting factor in cost savings, as it takes a limited resource (hygienists) who generate a good income from their normal activities (cleaning teeth) and places them in remote areas performing tasks that, for the most part, are unreimbursed.

But aren’t preventive services cost saving in the long run?  In today’s world of  “if you can’t measure it, it doesn’t count”, the answer is essentially “No”.

It turns out that the savings come from a ten-year study that tracked literally thousands of teeth that were intentionally filled with a bonded composite material over active carious lesions.  This is termed Interim Therapeutic Restoration or sometimes Atraumatic Restorative Treatment (ART).  The acceptance of the science and wisdom of treating both primary and permanent teeth in this manner and following the restored teeth over time to evaluate the need for further treatment allows successful intervention for much larger populations.

As the dental codes for the 2015 Current Dental Terminology are being discussed a code for this treatment is a strong contender and is likely to be a reimbursable procedure.

I hope that Dr. Glassman is successful in spreading the word of how his model allows for full control of the patient by the dentist and limiting the need for patients in remote areas to travel for their needed treatment.  Perhaps then we can move this “mid-level provider” conversation from rhetoric to reason.
Having found my dental footing, I believe I’ll address another dental issue in my next post: going to the dentist twice a year.  Please join me as there is a recent study that has the dental world buzzing.