Journal CDA Journal Volume 30, Number 9 september 2002 departments 643 The Editor/Good Acronyms 655 Impressions/Clowning Around in the Dental Office 706 Dr. Bob/Placebo Surgery features 665 Dentist Hero Finally awarDeD Congressional MeD al oF Honor It took a five-year campaign, but Robert West, DDS, made sure Capt. Ben Salomon, DDS, was finally honored for his heroism during World War II. Collette Knittel 671 Prevention oF CuMulative trauMa injury -- CarP al tunnel synDroMe The REST program offers dentists a way to avoid a common injury. Randy Q. Ligh, DDS 681 tHe aCCura Cy oF tHe neosono ultiMa eZ aPex l oCator using Files oF DiFFerent alloys: an in vitro stuDy This study found that the accuracy of the Neosono-Ultima EZ apex locator in wet conditions exceeded 90 percent. M.H. Nekoofar; K. Sadeghi; E. Sadighi Akha; M. Sadegh Namazikhah, DMD Edhietaod r cda journal, vol 30, nº9 good acronyms Jack F. Conley, DDS an acronym, by definition, is a lawsuits, could reach as much as $200,000 word formed from the initial or more annually for some physicians, letter of each of the successive such as surgeons or obstetricians. The parts of a compound term AMA president noted that as insurance (or name). Many have been becomes unavailable or unaffordable, used in dentistry, including such common physicians would either be forced to limit abbreviations such as DDS (doctor of their services or to leave practice. The dental surgery), DA (dental assistant), and release further states that several firms RDH (registered dental hygienist), which have either failed or have stopped writing refer to members of the dental team. malpractice insurance. In our experience, acronyms have Of particular interest is that in often been associated with regulations, medicine, only 5 percent of malpractice regulatory bodies, or health care cases are taken to trial. Physicians and delivery systems. Terms such as OSHA hospitals apparently want to avoid the (Occupational Safety and Health negative publicity or expense of lawsuits Administration), DMFS (Dental Materials and trial preparation that they fear would Fact Sheet), PPO (preferred provider occur if they take cases to trial. organization), FFS (fee for service) and That brings us back to dentistry, and HMO (health maintenance organization) dentistry in California to be specific. Are are among the most frequently utilized. we likely to be faced with a similar danger Sometimes these acronyms have a to that faced by medicine? While we need negative connotation to dentists. Those to be extremely careful in assuming what applied to the delivery systems have the future may hold for fear of setting additionally been referred to as “alphabet up a jinx, at the moment, it appears soup.” that California dentists are in a very Our present purpose is to focus on fortunate position for two very important a couple of acronyms that without any reasons. We must remember that in doubt have been extremely positive the 1970s and early 1980s California for dentistry in California, MICRA and dentistry experienced its own crisis of TDIC. Let us explain. In a news release rising malpractice costs. While we didn’t dated mid-June, the American Medical experience a crisis of the same magnitude Association released the results of a as that currently faced by medicine, it 50-state analysis showing that “medical brought forth some committed visionary liability has reached crisis proportions minds to forge some solutions that we in 12 states, with more than 30 others continue to benefit from today. seeing problem signs.” The AMA said The first part of our solution was medical liability insurance (premium), MICRA (Medical Injury Compensation which insures doctors against malpractice Reform Act of 1975), which placed a cap september 2002 643 editor cda journal, vol 30, nº9 on non-economic damages of $250,000. reducing liability claims. We have the hard work of our association Not only has the company to thank for being a major participant, provided a stable insurance product along with TDIC, in the coalition for policyholders, but it has provided (Californians Allied for Patient Protection financial benefit to policyholders, CDA, -- CAPP), which continues to lobby to and the CDA Foundation, in the form of maintain the cap. The California MICRA dividends and charitable contributions. law is currently being discussed by the The most recent TDIC support is AMA as a model, in their campaign to extremely impressive and worthy of urge Congress to develop a Health Act of mention. Policyholders have received 2002 to resolve the current malpractice $39 million in dividends since 1989. crisis. Policyholder dividends have been declared MICRA’s limit on pain and suffering in each of the past five years, including awards has kept malpractice premium the sum of $4.9 million this year alone. costs down. As a result, it has obviously The company made a recent charitable resulted in keeping all health care costs donation to the CDA Foundation, down, helped to maintain access to bringing its total contribution to the care, places a limit on attorney fees and foundation to almost $1.4 million. These contingency fees, and removed the trial funds assist the foundation in raising lawyers financial incentive to take on awareness of dental disease, improving nonmeritorious cases. access to care, and providing scholarships In our view however, the bigger story to students seeking dental careers. These here has been The Dentists Insurance contributions to the public and to our Company. In the first years after TDIC’s future professionals are achievements incorporation in 1980, no one could of which all members of the California have imagined the impact and benefit Dental Association should be extremely it would eventually have for its dentist proud. It is a positive accomplishment shareholders in California. The early that contributes to the image of the years were difficult, but visionary leaders profession and should not go unnoticed. and supportive policyholders nursed The next time we engage in the company through the difficult years. conversation about the negatives that we As the first dentist-owned professional must endure in our professional world, we liability carrier in the country, it helped must at the same time remember the two eliminate the unfair premium practices acronyms that do so much to protect our that CDA members were being subjected liability interests here in California, TDIC to by commercial carriers at the time. and MICRA. This summer, TDIC announced that it had retained an A.M.Best rating of “A” for 2002. Best cited the company for remaining “dedicated to its policyholders through claims and risk management.” In addition to good company management, unquestionably, the many quality educational programs launched by TDIC for the profession and for students has been a major factor in managing risk and 644 september 2002 Imprheesadsions cda journal, vol 30, nº9 speaker suggests Clowning around in at tickling funny bones, she said that it is your mood for the rest of the day because the office a skill anyone can acquire. you’ve created it as such.” By Collette Knittel “It’s possible to be humorous and The Secret Mission technique works If you’re cruising down the highway light-hearted, even if it’s not in your particularly well when an office staff and see a woman driving beside you nature,” she said. “People don’t try it member is stressed out or aggravated by a wearing a red foam clown nose, it may be because it’s a bit of a risk, but the benefits difficult patient. Holton-Cashen suggests Fall Scientific Session speaker Christine are on many levels.” you carry a file or something in your hand Holton-Cashen. No, she’s not late for her “It doesn’t have to be anything major,” so that you look busy, or like you are on next circus appearance; she just believes she added. “Humor is not about telling a mission. Take two minutes and walk in making people smile. jokes. You can be childlike without being around briskly, even though you have “People have a need for stress relief childish. It’s a matter of looking at things nowhere to go. now more than ever before,” she ex- a different way. It’s keeping your stress “Shifting from mental to physical plained. “It’s impossible to feel stressed gauge on low and your fun gauge on makes a big difference,” she explained. out or angry while wearing a clown nose.” high.” “Act very serious, like you have something An award-winning speaker, Holton- In her presentations, Holton-Cashen’s important on your mind, even though it’ll Cashen will give two presentations at the goal is to get everyone laughing to the make you laugh on the inside. I call it a fall Session on how dentists can incor- point of tears. She explained that the en- two-minute stress buster.” porate humor into the workplace and dorphin release that accompanies a good At the upcoming Scientific Session in how it aids overall office productivity and belly laugh brings on a feeling of calm San Francisco, her first talk, titled “Got harmony. and relaxation. She also gives 20 humor Humor? Get Calcium for Your Funny “It’s amazing how many people are ter- triggers, or specific things you can do to Bone!” will be held on Saturday, Sept. rified to see the dentist,” she said. “When elicit a smile. 28, from 9:30 a.m. to noon. It focuses on a dentist has a good sense of humor, These techniques include keeping a how humor can enhance brainstorming, it trickles down. The staff is happy and Smile File, making a Good Mood Com- increase job satisfaction, create higher it creates a fun atmosphere, which the mitment, and going on a Secret Mission. productivity, and improve relationships. patients can sense.” The Smile File can be filled with patients’ Her second talk is from 2 to 4:30 p.m. Holton-Cashen told of a dentist’s thank-you cards and notes, and even let- the same day and is called “Why Can’t office that had a poster on an operatory ters you’ve written to yourself. Everybody Just Get Along?” During this wall of the Three Stooges with Curly and “I encourage people to send them- course, attendees will learn the secrets to Larry pulling Moe’s tooth. Another den- selves a postcard every time they go on defuse anyone in any situation, maintain tist would sit down and greet his patient vacation telling about what they’ve done emotional control, and find the perfect wearing big goofy glasses and say, “Let’s and closing with ‘Wish you were here.’ words for any discussion. have a look in here. Oops, these are my I call it a mini mental vacation. You can Holton-Cashen runs her own busi- reading glasses.” even feel the sand between your toes.” ness, A Dynamic Speaker, and gives talks Humor comes naturally to Holton- Her Good Mood Commitment chal- all over the United States, as well as Cashen, since she grew up in a self- lenges people to commit to saying they Canada, South Africa, and Australia. She proclaimed “family of lunatics.” As part are in a good mood for the first two hours is a member of the National Speakers As- of a large Italian family where humor was of every day. She said that you have to sociation and holds a bachelor’s degree in mandatory, she was shocked when she make a conscious effort not to be brought communication and a master’s degree in moved out into the world and found how down by co-worker’s complaints, and to adult education. serious most people are. tell everyone who asks that you are in a “It scared me,” she confesses. good mood. More american Children Have Health She said she feels that, especially in “Your brain is like a computer, and Coverage the workplace, people have lost their it is programmed by the things you say,” A new Health and Human Services sense of humor. she explained. “Even if you are feeling report shows that American children are Although Holton-Cashen is a natural lousy, just fake it. Those two hours will set significantly more likely to have health september 2002 655 impressions cda journal, vol 30, nº9 insurance today than in 1997, when the on skeletal abnormalities. This case is more challenging and important for State Children’s Health Insurance Pro- notable since the detected periodontal health care professionals to be sensitive gram was enacted. breakdown was severe and could be only to cultural and religious traditions while In 2001, 10.8 percent of American chil- partly explained by known risk factors, still providing optimal care, Julie A. Brow dren did not have health coverage, down such as cigarette smoking and inadequate wrote in the May/June 2002 issue of the from 13.9 percent in 1997, according to the oral hygiene,” said Maurizio Tonetti, Dental Assistant. new report from the HHS’s Centers for DMD, PhD, professor and chair of the Dentists and their staffs must work Disease Control and Prevention. During Department of Periodontology at the Uni- together to ensure that patients feel un- that period, the number of children with- versity College London. “It also supports derstood and respected, Brow said. One of out health insurance fell from 9.9 million our hypothesis that a variety of connec- the most common complaints of patients to 7.8 million. This 21 percent reduction tive tissue disorders may increase suscep- is that no one listens to them anymore. occurred as HHS worked to establish tibility to periodontal tissue breakdown.” By listening to patients, dentists can learn programs in every state to expand health An oral examination determined the valuable information that can alleviate coverage to uninsured children. 41-year-old patient had swollen and reced- cultural conflicts that may arise over the “This report shows that governors ing gums, severe periodontal ligament course of treatment. have turned SCHIP into a genuine suc- attachment loss on all teeth, and bleeding Sometimes listening is not enough, cess story, with healthier children all gums at 76 percent of the areas exam- Brow said, and other tools must be used. across America. Still, we know we must ined. The patient had no family history of In some instances, patients will cite reli- do more,” HHS Secretary Tommy G. periodontitis. gious reasons for not having a procedure Thompson said. “We have given governors “It is important to note that this case done, but those reasons may turn out to more flexibility to use SCHIP to expand report does not show a causal relation- be erroneous and show a lack of under- coverage in their states. We’ve also asked ship between Marfan’s syndrome and standing of their own religious doctrine. Congress to give states more time to use periodontal diseases,” said Kenneth Brow said it is important to be respectful unspent SCHIP funds so we can build on Bueltmann, DDS, president of the Ameri- and nonjudgmental when confronted our successes in getting children health can Academy of Periodontology. “More with this possibility and for the dentist coverage.” research needs to be conducted to deter- to ask if he or she might speak with the SCHIP is a state and federal partner- mine if there is an association between patient’s religious leader on the patient’s ship designed to help children without the diseases.” behalf. health insurance, many of whom come However, Tonetti recommends that Another key component to providing from working families with incomes too Marfan patients follow a preventive oral good patient care to a culturally diverse high to qualify for Medicaid but too low to program based on professional tooth population is being proactive and learn- afford private health insurance. According cleaning and daily brushing and flossing, ing as much as possible about the cultural to state figures, about 4.6 million children and that they receive regular screenings heritage, beliefs, and customs of patients. received health coverage through SCHIP by a periodontist. Brow said misunderstanding other at some point in fiscal year 2001. SCHIP Marfan syndrome is a heritable customs can create a breach of the trust plans operate in all 50 states, five territo- disorder of the connective tissue that needed between a patient and dentist for ries and the District of Columbia. affects many organ systems, including effective care. the skeleton, lungs, eyes, heart, and blood researchers identify First Case of Peri- vessels. The condition affects both men Fixing Fillings the natural way odontitis in Marfan’s syndrome Patient and women of any race or ethnic group. Researchers at the University of Texas Researchers from the Eastman Dental Scientists estimate that as many as 1 Health Science Center at San Antonio Institute at the University College in million people in the United States may have identified specialized protein cyto- London identified the first case of severe have a heritable disorder of connective kines that stimulate odontoblasts. periodontitis in a person with Marfan’s tissue, according to the National Institute Mary MacDougall, PhD, associate dean Syndrome, a rare heredity disorder that of Arthritis and Musculoskeletal and Skin for research and professor of pediatric causes connective tissues to be weaker Diseases. dentistry and H. Ralph Rawls, PhD, pro- than normal. The case report is published fessor of biomaterials in the Department in the July issue of the Journal of Peri- sensitivity to Culture important Part of of Restorative Dentistry, have developed odontology. Providing Care a liquid “carrier” system to deliver the “Reports of oral findings in Marfan’s With new immigrant groups flocking cytokines to the site of a cavity, reports syndrome patients have focused mainly to the United States each year, it becomes an article in the June 2002 The Mission, 656 september 2002 impressions cda journal, vol 30, nº9 publication of UTHSC. They noted that the usual filling mate- rials, amalgam or tooth-colored compos- Associate Buy-ins a Viable Option for New Dentists ites, are not perfect solutions; and the Although associate buy-ins are more complex than outright practice purchases and liquid carrier system helps preserve the sometimes result in the associate not buying into the practice, the associate buy-in cytokines and stimulates dentin forma- remains a viable option for many new dentists, wrote Larry R. Domer, MBA, in the spring tion. 2002 issue of New Dentist. Rawls said tertiary dentin is the tooth’s own natural defense mechanism, Domer defined an associate buy-in as a transition strategy that includes a formal and over time a tooth will naturally pro- associateship phase followed by the associate purchasing a portion of the practice. An duce tertiary dentin, which forms a bar- associate buy-in implies that the associate and practice owner will become co-owners of rier against bacteria leaking into the pulp. the practice. “Stimulating this natural repair Domer said that an associate buy-in differs from a simple associateship because of the mechanism is the first step toward being intent of the parties: that the associate dentist eventually becomes a co-owner of the practice. able to replace part of the tooth with its An important advantage of an associate buy-in is that it provides a trial period for own natural material,” Rawls said. both the associate and the owner. According to Domer, this trial period provides the owner “This is the body’s own natural with first-hand information concerning the associates’s clinical capabilities, philosophy of process,” MacDougall said, “We are just practice, management skills, and compatibility with patients and community. enhancing it.” Another advantage of a buy-in for an owner dentist is that it allows the owner to begin jigsaw Puzzles a guide to life phasing out of practice, reducing the number of days practiced per week, while retaining Everything I needed to know about control of the practice. Domer said a buy-in also helps to preserve the value of the practice life, I learned from a jigsaw puzzle, wrote during the phase-out process. editor Jeffrey B. Dalin, DDS, in St. Louis Another advantage of the buy-in is that the arrangement can provide security and Dentistry, June/July 2002. comfort for the owner dentist and family as well as the associate. Domer said there is usually nnDon’t force a fit. If something is meant a buy-sell agreement between the associate and the owner (and later the co-owners) that to be, it will come together naturally. provides for the mandatory sale of the practice, or portion of it, to the associate or new nnWhen things aren’t going so well, take partial owner in the event of permanent disability or death of the original owner. a break. Everything will look different In some cases, Domer wrote, a practice is too large or too unusual for a new dentist to when you return. purchase or for a senior dentist to sell outright to one dentist. An associate buy-in may be nnBe sure to look at the big picture. the only way an owner can sell a large general practice or specialty practice. And, Domer Getting hung up on the little pieces said, it may be the only way a new dentists can finance and learn to run a large practice only leads to frustration. before full ownership. nnPerseverance pays off. Every important puzzle went together bit by bit, piece by piece. nnWhen one spot stops working, move to even little ones. against S. mutans. They said the anti- another. But be sure to come back later. nnAnything worth doing takes time and body works by sticking to the S. mutans nnThe creator of the puzzle gave you the effort. A great puzzle can’t be rushed. molecule that normally sticks to teeth, picture as a guidebook. Modified Yogurt Bacterium Works causing the two species to clump together nnVariety is the spice of life. It’s the Against Tooth Decay and go harmlessly down the throat. different colors and patterns that make Researchers have genetically modified In a trial using laboratory rats, ani- the puzzle interesting. a common bacterium found in yogurt to mals whose mouths were swabbed with nnWorking together with friends and fight the Streptococcus mutans bacterium the modified bacteria showed a sharp family makes any task fun. that can cause tooth decay, the Karolinska reduction in S. mutans in the mouth and nnEstablish the border first. Boundaries Institute in Stockholm reported. developed fewer cavities compared with give a sense of security and order. According to a report in Nature untreated animals. The researchers believe nnDon’t be afraid to try different Biotechnology, researchers modified the the antibody might also have the second- combinations. Some matches are Lactobacillus zeae bacterium, which is ary effect of killing the streptococcus surprising. responsible for the fermentation process bacteria with the lactic acid the lactobacilli nnTake time to celebrate your successes ... in dairy products, to carry an antibody produce. september 2002 657 impressions cda journal, vol 30, nº9 The Karolinska team is also investigat- ing how to modify the lactobacilli bacteria with antibodies to work against a range of infectious agents including rotavirus and helicobacter, agents that cause severe diarrhea and stomach ulcers. Correction Scott Jacks, DDS, was incorrectly referred to as a general dentist in the July 2002 issue of the Journal. Jacks is a pediatric dentist. Honors John C. Greene, DMD, of San Rafael, has been chosen to receive the Oral Health America Tuttle Award for leadership in spit tobacco education and prevention. Theodore T. Fortier, DDS, was recently appointed as commissioner to a second term on the West Vector Control Board, an Los Angeles County Agency. PHOTO 658 september 2002 mending the past cda journal, vol 30, nº9 Dentist Hero Finally awarded Congressional Medal of Honor Collette Knittel Author the story unfolds on a battlefield his inclination for military service, he in Saipan and concludes in the spent his spare hours scaling the teeth of Collette Knittel is CDA’s White House Rose Garden, the men in his platoon. On weekends, he staff writer. She can be but what lies in the middle is would drive a group from his regiment reached at collette@cda. an incredible string of events down to his Los Angeles practice for free org. that revised American history. The main dental care and have them back in time to characters are dentists: two men who report for duty on Monday morning. never meet, yet their lives are forever After the attack on Pearl Harbor, intertwined. The story tells of war, death, Salomon’s platoon shipped out to valor, perseverance, and honor regained. Christmas Island, south of Hawaii. Here, And the story is true. he spent considerable time developing his During the years just prior to World skills as a soldier. His commanding officers War II, a man named Benjamin Salomon described him as the best all-around found himself newly graduated from solider on the island. Within a year, he was the University of Southern California a sergeant in command of a machine-gun School of Dentistry and eager to serve section in his heavy-weapons company. his country. In 1937, he applied for a Salomon’s combat training was cut commission as an Army dentist, but short when the government switched his application was denied due to a lack plans on him; and by August 1942, he of need for service dentists. Instead, was transferred to the 105th Infantry Salomon opened a private practice in Regiment in Hawaii, where he was Lt. Los Angeles until the political climate Salomon, the regimental dentist. He not changed. only cared for the dental needs of his men In 1940, President Franklin Delano during the mornings, but he also served as Roosevelt signed the Selective Service an infantry instructor in the afternoons. Act, which required men age 21 to 35 to In the 105th, the regimental dentist also register for military training. Salomon won most of the infantry proficiency signed up and was immediately called competitions. Within a year, Salomon was into the Army as a private of the infantry. promoted to the rank of captain. Assigned to the 102nd Infantry Regiment On June 15, 1944, the 105th landed in Fort Ord, Calif., near Monterey, on Saipan, Marianas Islands, where the Salomon reported for duty with his dental Japanese army had been reduced from instruments in hand. While discovering 30,000 troops to 9,000 troops with a september 2002 665 mmeennddiinngg tthhee ppaasstt cda journal, vol 30, nº9 limited weapons supply. Refusing to was heard to say to the others in charge, surrender, approximately 5,000 Japanese “Everybody’s dead out there. I can do troops advanced on the American soldiers these guys more good out there than I can one last time on July 7, the day Salomon in here. I’ll hold them off until you get fought his first and last battle. According them to safety. See you later.” to information from the U.S. Army Center That was the last time anyone saw for Military History, it was one of the Salomon alive. The regimental historian, largest attacks attempted in the Pacific Capt. Edmund J. Love, was present the Theater during World War II. In the first next day when they found Salomon’s body minutes of the attack, approximately 30 bent over a machine gun, his finger still wounded soldiers walked, crawled, or were on the trigger. carried into Salomon’s aid station; and the Love later wrote, “The Japanese dead small tent soon filled with wounded men. lay scattered before him like trees felled by As Salomon struggled to work on his a tropic storm.” He counted 98 Japanese men, he looked over and saw a Japanese bodies in front of Salomon’s position. soldier bayoneting one of the wounded Salomon himself had 76 bullet wounds in soldiers lying near the tent. He turned his body. around and saw two more Japanese Dr. Benjamin Salomon’s photo appeared in the 1937 Because of his heroic effort, Salomon soldiers appearing in the front entrance USC yearbook, El Rodeo. was recommended for the Congressional to the tent. As he grabbed a wounded Medal of Honor. soldier’s rifle and fired on the enemy According to the Congressional Medal soldiers, four more crawled under the Walking outside, Salomon saw that of Honor Society’s Web site, the Medal tent walls. Rushing them, Salomon kicked the machine-gunners protecting the tent of Honor is the highest award for valor the knife out of the hand of one, shot were dead. Realizing the severity of the in action against an enemy force that can another, and bayoneted a third. He butted situation, he returned to the tent and be bestowed upon an individual serving the fourth enemy soldier in the stomach ordered the wounded to try to get back in the Armed Services of the United and a wounded comrade then shot and to the regimental aid station, while he States. In Allen Mikaelian’s book, Medal killed the enemy soldier. attempted to hold off the enemy. He of Honor: Profiles of America’s Military Heroes from the Civil War to the Present, Mike Wallace of TV’s “Sixty Minutes” points out in the Introduction the special circumstances required to be eligible for this prestigious award. “To my surprise, I learned no one can receive a Medal of Honor for having acted under orders, no matter how heroically he carried out those orders, for the medal is reserved strictly for those who act of their own accord and out of complete selflessness. It is those rigorous conditions that set the Medal of Honor apart from all other military citations.” However the proposed citation for Salomon was returned by the commanding general with the following message, “I am deeply sorry that I cannot approve the award for this medal to Capt. Salomon, although he richly deserves it. At the time of his death, this officer was Marines run for cover during battle in Saipan. These are the kinds of conditions under which Capt. Salomon treated in the medical service and wore a Red soldiers and ultimately earned his Medal of Honor. Cross brassard upon the sleeve of his 666 september 2002