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Monday, January 21, 2013

Dentistry and depression: Part II -- How to cope

By Rochelle Sharpe, DrBicuspid.com contributing writer

August 21, 2008 -- Few of those who attended the spring meeting of the California Dental Association in Anaheim, CA, suspected anything unusual. But while most were in the convention center listening to lectures on topics such as crown lengthening and digital photography, John H. Newman Jr., D.D.S., was losing his battle with depression. On May 2, the opening day of the conference, he leapt to his death from the balcony of his 14th-floor room at the nearby Disneyland Hotel.

Dr. Newman's suicide came as a reminder of the devastating potential of depression -- and the need for dentists to take care of themselves as well as their patients.

"The most important asset in the dental office is the health of the dentist," said James Willey, director of the American Dental Association's Council on Dental Practice, which now sponsors biannual conferences on health and wellness issues.

It's no secret that dentistry can be a stressful profession. Performing technically complicated procedures on anxious patients in a small, confined space can take its toll. Add financial pressures, government regulations, and the threat of malpractice suits, and it's no wonder that dentists have the reputation of committing suicide at a higher rate than any other profession (see part I of this series).

A difficult job

"It's a difficult job that is very demanding -- and people don't appreciate [dentists]," said Dorothea Lack, Ph.D., a San Francisco psychologist who used to work as a dental hygienist. Dentistry is comparable to medical surgery, she said, yet medical surgeons are revered like gods, while dentists are often feared.

Dentists reporting stress
Work is stressful	80%
Work stress is moderate	69%
Work stress is extreme	11.7%
Sometimes have difficulty falling asleep	21.4%
Sometimes feel depressed	17.8%
Sometimes feel hopeless	10.3%
Dentists in counseling	6.8%

It is unclear how many dentists are suffering. But in the ADA's 2003 Dentist Well-Being Survey of 2,565 dentists, 80% said their work was stressful. (See chart for more survey results.)

While the pressures may not always be openly discussed, many dentists appear eager to vent about them, if given the opportunity. When Robert Rada, D.D.S., M.B.A, co-authored an article for the Journal of the American Dental Association (June 2004, Vol. 135:6; pp. 788-794) on stress, depression, and burnout, he got more feedback than he has on anything else he ever published. The clinical assistant professor at the University of Illinois at Chicago found himself commiserating with dentists and even trying to give a dentist's wife ideas on how to help her husband cope.

Some dentists get too absorbed by the profession, Dr. Rada said. "Practices that were once simple have gone out of control."

But typically, it's not just work that that drives dentists over the edge, psychologists say. Instead, it's a combination of professional and personal stresses.

To deal with his own stress, Dr. Rada, who maintains a general practice in La Grange, IL, decided to shorten his workweek -- first from six to five days a week, and eventually down to four days. "I cut my hours, kept making as much money, and enjoyed my practice more," he said. Not only did he learn to be more efficient, but he had fewer patients cancel appointments. They knew that his shortened workweek meant that appointments were harder to reschedule.

When dentists are in their offices, they can find plenty of ways to reduce stress, too, experts say. "People don't realize how easy it is to reduce stress simply by breathing," said Uche Odiatu, D.M.D., a Canadian dentist who is also certified as a nutrition specialist and fitness trainer.

When most people are stressed, they hold their breath or take shallow breaths, while depressed people often hunch over or look at the ground, Dr. Odiatu said. Unfortunately, dentists are forced to hunch over for most of the workday, a posture that is not optimal for their mental well-being, he noted.

But it can help to simply take deep breaths and pause to lift your head up, pretending to look out over the horizon, he said. "The brain gets fooled into feeling good."

Dr. Odiatu also advocates exercise, getting enough sleep, and staying hydrated, noting that physiological changes in the body begin when the body is just 1% dehydrated.

When to get help

Depression and suicide resources

ADA
The ADA offers a Web page on health and wellness with links to other resources.

National Suicide Hotlines USA
Offers a list of state hotlines. (National hotlines include 1-800-SUICIDE and 1-800-273-TALK.)

American Association of Suicidology
The organization is dedicated to the understanding and prevention of suicide by promoting research, public awareness, education, and training for professionals and volunteers.

Suicide Prevention Action Network USA
A nonprofit organization dedicated to the creation of an effective national suicide prevention strategy.

American Foundation for Suicide Prevention
An organization also dedicated to understanding suicide.

On his Web site, Mark Hillman, Ph.D., a New York psychotherapist, wrote that dentists can use progressive relaxation techniques whenever they feel stressed -- even in the office. By tensing then releasing the muscles, the technique allows muscles to deeply relax, he wrote, inducing a physiological state that is incompatible with anxiety.

Hillman also recommends thought-stopping: concentrating briefly on unwanted thoughts and then emptying your mind of them. By controlling negative thoughts, stress levels can be reduced, he said.

There are productive ways to deal with anger, too, said psychologist Marian Stuart, Ph.D., a professor at Robert Wood Johnson Medical School and author of The Fifteen Minute Hour: Practical Therapeutic Intervention in Primary Care, a book on incorporating psychology into healthcare practices.

Instead of dwelling on what is wrong, dentists should think about what it is they want and what they can do about it, she said. If nothing can be done, then they need to try to accept the situation or try to reframe the problem.

Certainly, dentists need to know the warning signs of depression and seek professional help if they are suffering from them. These signs include feelings of worthlessness, decreased ability to concentrate, diminished interest in pleasurable activities, and recurrent thoughts of death or suicide. "When people think about killing themselves, they want to do anything possible to stop the pain," Stuart said.

Her message to overwhelmed dentists: There are better ways out of the anguish.

Sirona stock drops on news of possible sell-off

By DrBicuspid Staff

August 21, 2008 -- Shares of Sirona Dental Systems fell $2.64, or 9%, to $25.85 on August 20 after a private equity firm that holds more than two-thirds of the company's stock said it may sell part or all of its stake in Sirona.

According to a shelf registration filing with the Securities and Exchange Commission, Sirona Holdings Luxco S.C.A. could sell its entire holding, nearly 37 million shares (67.5% of all available Sirona shares). The holding company, which comprises Madison Dearborn Partners, Beecken Petty O'Keefe, and members of Sirona's management, bought a controlling interest in the company in June 2005.

Upgrade available for older Waterlase lasers

By DrBicuspid Staff

August 21, 2008 -- Biolase Technology is offering a software upgrade designed to extend the capabilities and useful life of first-generation Waterlase hard- and soft-tissue dental lasers, the company announced in a press release.

The upgrade is intended to provide smoother cutting and increased patient comfort by giving the first-generation lasers variable pulse repetition rates (frequency) similar to the company's latest generation Waterlase MD and Waterlase C100 systems.

The software upgrade comes one month after the introduction of the Waterlase C100, which is due to begin shipping at the end of the current quarter.

The upgrade includes the Waterlase LB 3.0 Operating System, which provides five different repetition rates (from 10-30 Hz) in addition to the original 20 Hz, and a new CPU board.

The upgrade is being launched with the company's exclusive North American distribution partner Henry Schein Dental, and installations will start in Waterlase dentists' offices in September.

Sunday, January 20, 2013

Plaintiff wants FDA amalgam settlement overturned

June 24, 2008 -- Just when it looked as though the FDA had calmed critics of mercury fillings, the hornet's nest has been stirred up again. Two weeks after the FDA negotiated a settlement in a lawsuit filed by anti-amalgam activists, one of them has moved to reopen the case.

In the settlement, the agency changed the way it describes amalgam on its Web site -- to imply that some patients may be at risk from the substance -- and agreed to reclassify it by July 2009.

Now one of the plaintiffs, Karen Palmer, a former dental assistant, claims she was not notified of the settlement agreement and would not have accepted it if she had been, according to her new attorney, Jim Love, who also serves as counsel for the International Academy of Oral Medicine and Toxicology. She is asking to be removed from the settlement and for the court to consider earlier petitions that call for a complete ban of amalgam.

"There was a mediation scheduled by the court that was attended not by the plaintiffs but plaintiff's counsel, and there was no authority to settle the case on any particular terms," Love said in an interview with DrBicuspid.com.

Charles Brown, the attorney representing the 11 plaintiffs in the original lawsuit against the FDA, says he is shocked by Palmer's sudden opposition to the settlement. He claims she originally agreed to it "until some lawyers started talking to her."

"We didn't anticipate getting a settlement that day, but I was in a settlement room [with the FDA] and we ended up getting the thing we have never had before: an agreement to reclassify," Brown told DrBicuspid.com. "The goal of the case was to get a date to classify and we achieved that, and even more. The FDA has actually gone from praising mercury to advising of its risks. The plaintiffs had a contract to accept reasonable settlement offers, and they were very excited about this settlement agreement. She [Palmer] was very excited about it. I have e-mails from her saying how much she praised the settlement."

But Love maintains that Brown and the FDA had no right to negotiate the settlement agreement without the plaintiffs knowing the details beforehand.

"The settlement was reached by the attorneys for FDA and by Mr. Brown, but you can't limit a plaintiff's or party's right to control the settlement through a fee agreement," he said. "Whether the settlement agreement was reasonable or not isn't the point. The point is that he [Brown] didn't go to Ms. Palmer to get her authority. She was never contacted concerning the terms of the agreement."

In her motion, Palmer says that if she had received notice of the settlement before it was reached, she would not have agreed to its terms. In particular, she "would have agreed to no more than three months for the completion of the classification process," the motion states.

Love says he has already had assurances from FDA counsel that it will go along with the motion to overturn the settlement. FDA spokespeople could not be reached. But Brown is confident that the settlement agreement will move forward as is.

"We will file a motion and we will win that motion," he said. "That settlement will not be overturned because there is no basis for it."

Patient swallows screwdriver, aspirates wrench

By Rabia Mughal, Contributing Editor

June 24, 2008 -- Florida dentists and their patients were puzzling this week over the case of a dentist who dropped both a screwdriver and a wrench -- in two separate appointments -- down the same patient's throat. The patient later died.

Standard precautions would have saved the 90-year-old patient's life, according to his daughter, who is suing the dentist, according to an Orlando Sentinel story.

The patient, Charles Gaal Jr., first went to Wesley Meyers, D.M.D., of Winter Park, FL, in September 2006 complaining that he was having some trouble with a set of lower dentures, according to a complaint filed with the Florida Department of Health. Dr. Meyers proposed a treatment plan to replace them with an implant-supported set of dentures.

Treatment began in October 2006. During a visit, Dr. Meyers dropped an implant screwdriver into the patient's throat. Gaal swallowed the object, which later had to be retrieved from his large intestine via a colonoscopy.

Despite the incident, Gaal wanted to continue treatment with Dr. Meyers, said Gaal's daughter Anne Marie Greer in theOrlando Sentinel story.

But during another visit in May 2007, Dr. Meyers dropped a miniwrench into the patient's throat. This time he unsuccessfully tried the Heimlich maneuver to dislodge the tool. An x-ray done later revealed that the patient had aspirated the miniwrench into his left lung, according to state documents.

Two emergency bronchoscopies were performed to remove the tool, but both were unsuccessful. More procedures followed and, even though the miniwrench was eventually removed, Gaal never regained his strength and died on June 19, 2007, from complications that included acute respiratory failure, pneumonia, and aspiration, according to his death certificate.

The complaint with the Florida Department of Health states that Dr. Meyers did not take necessary precautions while performing the implant procedures, failed to report the incidents to the state as required by law, and did not call 911 or engage in emergency protocol in both instances.

Dr. Meyers license was briefly suspended in January 2008. Last week the state fined him $17,000 and restricted from performing implant procedures until he completes further training. He will also reimburse all medical costs to Gaal's family, and has voluntarily agreed to practice only on patients who are 65 or younger.

Kim Gowey, D.D.S., past president of the American Academy of Implant Dentistry, said that such incidents are rare and that he has never heard of one that has been fatal.

However, he recommends some basic safety procedures to prevent such a tragedy.

Small implant instruments such as screwdrivers have little holes near the top, and dentists can put a piece of floss through them so they can be retrieved in case they fall down a patient's throat, Dr. Gowey explained.

For objects that cannot be tied to floss, placing a 4 x 4 piece of gauze on the tongue between the throat and the area being worked on is a good safety mechanism, he said.

Another precautionary measure is to have your patients sit upright, reducing the risk of anything falling down their throat.

"Having a patient lying flat on the back with an open throat is not a good idea," Dr. Gowey cautioned.

Finally, it is important to order an x-ray if you are certain something has fallen down the patient's throat.

"The minimum standard of dental performance while performing surgical implant treatment requires that a dentist utilize prophylactic measures to prevent a patient from swallowing or aspirating any foreign objects during the surgical placement and/or removal of implants," states the Florida Department of Health complaint. "Dr. Meyers failed to employ any of these measures on at least two separate occasions and failed to meet the minimal standard of dental performance in his treatment of patient CG [Charles Gaal]."

Dr. Meyers could not be reached for comment.

FDA to reclassify amalgam by July 2009

By DrBicuspid Staff

June 23, 2008 -- The FDA has announced that it will reclassify dental amalgam by July 2009. This deadline has been set as part of a settlement between the FDA and the consumer group Moms Against Mercury, according to an ADA news article.

"The ADA supports the FDA's decision to reclassify amalgam and reinforces this support in a news release stressing that the recent settlement agreement and FDA's Web site do not mean that FDA has changed its position on dental amalgam," noted the ADA article. "Rather, FDA's final position will be determined through the ongoing regulatory process and call for public comments on that issue."

The changing face of dentistry: Part I

June 23, 2008 -- Ah, the allure of entrepreneurship: Be your own boss. Set your own hours. Make a decent living and help people in need.

Surprisingly, despite dentistry being one of the most attractive small-business ventures around, in recent years there has been a shortage of dentists in the U.S. -- due in large part to a "generation gap" between retiring and incoming dentists, with not enough of the latter to replace the former. But now this trend is shifting, and with it the face of dentistry.

According to the American Dental Education Association (ADEA), the peak year for new dentists was 1983, when 5,756 dental students graduated. In 2005, total graduates only numbered 4,478, a 23% decrease.

"Those nearing retirement age were part of a big surge of graduating students in the mid-1970s to late 1980s, so actually too many dentists were being produced for the need," said Laura Neumann, ADA's senior vice president of education and professional affairs. "Now things have equalized and once again there's an increase in dental school applicants."

In fact, the ADA expects the number of dentists to increase by 8% between now and 2025, with many more women and minorities stepping into the lead role. In 2005, 12,287 students applied to dental school.

There still aren't enough seats for all the dental school applicants. In addition to a decline in the number of dental schools (56 in 2005, down from 60 in the 1980s), the capacity of those schools is restricted, said John Williams, D.D.S., dean at the University of North Carolina at Chapel Hill School of Dentistry.

"It's not like undergraduate schools where they only need to provide instructors and space," he said. "Huge infrastructure is needed for a new dental school, like labs and clinic spaces. So the small increases we're seeing in dental school enrollment is primarily due to new schools opening up."

But help may be on the way. Three new schools have opened in the past decade, and a new one in Virginia is under way.

The reasons why more people are opting to enter dental school these days vary, but the key seems to be the promise of independence and entrepreneurship. In 2006, when the ADEA polled people about to enter dental school and asked them why they chose that profession, more than 80% listed the top reasons as "ability to control my work time," "self-employment," "income potential," and "service to others."

The values of this generation coincide with dentistry, according to Anne Wells, ADEA's associate executive director for Education Pathways. "They value lifestyle. Income is important but not only the thing; they want control over their practice. It's much more significant to them to develop a meaningful philosophy in life."

Those are the reasons Rhett Raum, a 28-year-old senior at the University of Alabama School of Dentistry in Birmingham and vice president of the American Student Dental Association, went into dentistry. "I have a degree in business management and I used to run a B&B, so I have an entrepreneurial background. What drew me to dentistry was the ability to be a small-business owner, be my own boss, and have financial flexibility."

Raum is an anomaly of sorts, however, because he is purchasing a practice in a small Tennessee town with a population of 4,000. Most dental school graduates are opting to go to urban and suburban areas where there are already plenty of dentists, leaving sizable portions of the U.S. without access to oral care.

"It's less of a shortage and more of a maldistribution," Neumann said. That means dentists in inner cities, rural areas, and small towns who are planning to retire will have a harder time finding their replacements.

Some young people are being lured away from medical school when they hear about equally lucrative and less hectic careers in dentistry. In 2004, general practitioners earned an annual average of $186,000, while specialists averaged $315,000, according to the ADA.

"My physician friends send their kids to dental school because they don't like what's going on with the laws in their industry, whereas the dental industry has not been nearly as encumbered," said Paul Gruber, a 64-year-old dentist in Sheboygan, WI.

Who’s signing up

What will the next generation of dentists look like? In terms of demographics, one population that is taking off is women, who now account for 44% of all dental school graduates and 19% of all dentists, according to the ADEA.

While these numbers are expected to continue to increase, however, another trend is worth noting: a growing number of female dentists will work part time to balance career and family. According to the ADA, 14% of dentists now work part time; this number is expected to reach 19% by 2025, with most being female dentists.

Jack Dillenberg, D.D.S., dean of the University Arizona School of Dentistry & Oral Health, worries about that figure. "Women make up half our class and they are great dentists, but they don't work as long and therefore won't be as productive overall."

But others argue that the flexible hours of dentistry will allow women to be at least as productive as men. That's the opinion of Laura Rammer, a 29-year-old general dentistry student who graduated from Marquette University Dental School in Milwaukee last summer. She mentored with Dr. Gruber in Sheboygan, and is considering taking over his practice when he retires.

"It's now an option for the woman to be a full-time worker and the husband a stay-at-home parent," she said. "I'm going to keep going to the office. Besides, I work four days, from 7 a.m. to 5 p.m. That's accommodating for families."

The flexibility of dental work is also attracting many women to become hygienists. The number of dental hygiene programs has steadily increased during the past decade, numbering 270 with 7,200 graduates in 2004. That's nearly twice the amount of dental school graduates -- and the education is half the cost of dental school.

Dental hygiene is the fifth fastest growing profession in the U.S., said Jean Connor, president of the American Dental Hygienists' Association (ADHA). "They are mostly women, often because hygienists stay licensed for their life cycle, so it's good for women who want to have kids and a flexible or part-time career. It's a good-pay salary. And you can be a healthcare professional, but unlike nursing you don't have to work nights or weekends."

Hygienists are expected to be on the front lines of expanding oral care to underserved populations. The ADHA is developing a curriculum to create a master's degree for advanced dental hygiene practitioner. Graduates would be able to do many services a dentist does -- such as cavity prep, extractions, and prescriptions -- and without a dentist's supervision. The goal is to have them serve in lieu of dentists in underserved areas.

"They can be a long arm reaching out to people in need," Connor said. "They'll be important because they can provide dental services and get people on the learning curve of oral health."

Serving the underserved

While the number of female dentists is on the rise, minority enrollment is lagging. More Asians are enrolling, which accounts for the vast majority of minority applicants. However, blacks and Hispanics currently comprise less than 10% of U.S. dentists, far below their numbers in the U.S. population.

This is where targeted minority recruitment of dental students and mentoring can play a key role. The ADEA found that dentists of an ethnic minority background, especially Asians and Hispanics, often chose the career because they wanted to serve their ethnic group or a low-income population in general.

"It's a priority for dental schools as well as for organized dentistry to raise those numbers," Neumann said. "It's a concern about our ability to meet the needs of the public because people want to go to a health provider that comes from their own background and speaks the same language."

In its numerous programs to boost minority representation, the ADEA is working with the Association of American Medical Colleges on the Summer Medical and Dental Education Program that identifies college freshmen and sophomores interested in dentistry and give them a summer-school education.

"This can enhance their chances to do well in both undergrad and dental school," Wells said. Nearly 1,000 students currently participate, along with 12 medical and dental schools.

In part II of this series on the future of dentistry, author Vanessa Richardson tells how dental education is changing, from revised dental school curriculums to targeted recruitment and mentoring.