Dental help

[sirspamalot]

Lol. No Choosing Wisely with hypofrac eh?

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[Saddleshoes]

I am an Attending Dentist in a General Practice Residency Program (GPR). I just read this whole post. I have several comments...

1. When you sent a patient to a dentist the insurance game changes drastically.
   1. If it is a Medicare case odds are the over 65 person has no dental coverage
   2. If it is a Medicaid case the game is very different state by state --- BUT about a dozen states provide ZERO coverage for Medicaid adults.
      1. About 1/2 of states have a reimbursement rate so low for adults that 90% of private practices will not accept a Medicaid patient.
      2. If they go to the "Community Clinic" those places are paid by the visit. As a result community clinics will make the patient come back 5 times to remove 5 teeth. (Dumb! I know but the MBA's in Washington DC came up with that one.)
2. Young dentists these days simply are not trained to do extractions. (Another Dumb but true fact.)
   1. As a result many will send the patient to an Oral Surgeon, slowing up the whole process.
   2. Also young dentist's these days are not trained to handle medically complected cases and the stuff you send them scares them silly.
3. The business side of dentistry is rapidly changing. The corporate world is taking over. The old solo dentist office is a dinosaur. Under the corporate model you have to make money on every patient. The per-radiation, extraction only, patient is a money loser so they try to up-sell them on deep cleanings and comprehensive dental care.

If you can locate a dentist in your area that has completed hospital GPR program you might want to develop a working relationship with that guy/gal. They understand the situation and are trained to handle it.

 

[sirspamalot]

The per-radiation, extraction only, patient is a money loser so they try to up-sell them on deep cleanings and comprehensive dental care.

Lol by the time they get done with the dentists, they don't have any teeth (or certainly less than 5). The state of dental care in my patient population is.. frightening. Truly, I tell you. I can see the roots of some of my patients teeth. How are they able to tolerate eating anything? God forbid they bite into an apple..dental holocaust no cap.

 

[taserlaser]

Eighteen fractions is an interesting regimen for Dupuytrens. Can anybody guess what dose this might imply?

My shot in the dark guess is 2 Gy x 18 = 36 Gy. We do the more common 30 Gy / 10 split course here (2 bouts of 3 Gy x 5), and coincidentally EQD2(3) of 3 Gy x 10 is 36.

 

[evilbooyaa]

My experience is awesome with Radiation Oncology. A lot of my family has Dupuytren's including a brother. I noticed a little tightening in my palm. This would really screw up my career. I had to do some research as RT for Dupuytren's doesn't appear to be common in the states (at least currently). As an example, two hand surgeon friends never heard of it being done. I think there are actual clinics in Europe.

I was able to reach out to a fantastic Radiation Oncologist who was sort of excited to try this. I'm not sure if he ever did it before. Anyway 18 treatments and 3-4 years later I am great. We will never know if it would progress, but I was willing to deal with the long-term ramification if any. I am very grateful. I will admit getting on the table when you are "healthy" sure gets your attention.........lol.

My hand hasn't been an issue for me I haven't really thought about this in 3-4 years. Maybe some of you treat Dupuytren's? What an amazing gift and I am sure it would be a nice adjunct to what you normally do.

It is an option and I'd be happy to do it if requested but not a common scenario. Unfortunately we don't have a means to the Dupuytren's patients directly ourselves and as you can tell from your hand surgeon buddies, even the people who actually get referred Dupuytren's are actively clueless regarding the proven role RT plays in managing it. Anytime radiation is mentioned for not a cancer everyone kinda puckers their butt a little bit, while they're just blastin' away at all sorts of benign things over in Germany....

 

[Middle Age DDS]

My shot in the dark guess is 2 Gy x 18 = 36 Gy. We do the more common 30 Gy / 10 split course here (2 bouts of 3 Gy x 5), and coincidentally EQD2(3) of 3 Gy x 10 is 36.

I am going on memory, but this seems accurate. 10 Split was the treatment. They let me be the first patient of the day so I could get to work. It was actually set for 20 but at 18 my hand was absolutely on fire and it was patently obvious that the fingers curling a little and tightness were long gone. So we called it. I'm in a relatively small community. I have seen him a few times in the past years. Sent him emails with pictures of before and after a few years out. He is very, very gracious. Loved that I kept in contact, and he replied he shared the pictures with colleagues and staff.

It very well may of been a money loser for him. I tried to do all the nice things that makes the job worthwhile. Gifts for the staff. Nice gift certificates to the doc's favorite restaurant etc. He was pretty interested in the process. I had insurance but quite frankly I have no idea what it paid, if any. He was very experienced RO, and sounds like he has even pioneered/adopted a few treatment modalities. Anyway, I got the idea I may have been his only Duyputren's patient ever. To his credit he certainly took the time to plan my treatment for an optimal outcome.

I am very grateful to him and what Radiation Oncologists do. In a way your specialty and dentistry seem to both be killing themselves. A ton of dental schools have opened once the word got out it can be a nice gig. Sound familiar?

 

[Middle Age DDS]

It is an option and I'd be happy to do it if requested but not a common scenario. Unfortunately we don't have a means to the Dupuytren's patients directly ourselves and as you can tell from your hand surgeon buddies, even the people who actually get referred Dupuytren's are actively clueless regarding the proven role RT plays in managing it. Anytime radiation is mentioned for not a cancer everyone kinda puckers their butt a little bit, while they're just blastin' away at all sorts of benign things over in Germany....

Before I had this RT I saw two hand surgeons. Both of whom I can text or email. Again, a smallish community. They really didn't seem to know what to do if Dupytren's was just starting. They certainly did not know about RT but were interested in it. My brother told me about it and I had to do the dreaded Dr Google research. There is some kind of Dupytren's Society that had a pretty active message board if I recall.
RT is really common in Europe so it seems for early treatment. I am glad I timed it right. I was just fortunate that my brother had it and knew all about treatments. I really haven't thought about this in like 4 years. That is a hell of an outcome. We all have enough physical issues when you get up there. What hurts this week? My hand just isn't an issue.

 

[dieABRdie]

I haven’t sent for extractions for HNSCC RT in many many many years. Maybe before the previous decade. With good salivary gland sparing (5mm or smaller PTVs help, don’t go wild with CTV margins, etc), sequential and midtx replanning, encouraged dental followup at all times post treatment, I just have not had a single ORN case in practice. So my theory is you really have to “try” to give them the ORN and have a patient with super infaust protoplasm. I like to mentally pat myself on the back at these times and think sequential IMRT vs SIB (and not going up above 2 Gy per fraction to any cells, and BID boosting gross dz at 1.5 per fraction … less late effects… past 50 Gy to quasi replicate concomitant boost fractionation) must have helped.

My patients mostly don't have teeth.

 

[metallica81788]

My patients mostly don't have teeth.

That's the dream

 

[sirspamalot]

"Dentists hate this one simple trick..."

More teeth, more problems.. lol.

Me? Scrape those bad boys every day.

On another note (warning rant ahead): /Rant ON

The closer to a metro area you get, the increase in greed the dentist exhibits. Horrible. Their favorite move:

"yeah we take your insurance" and then you find out guess what, your dental insurance doesn't cover jack. Oh, and btw, the dentist has charged 300% of the insurance rate. You recoil in horror.. and ask. Dentist: "They (insco) don't pay enough! They're the worst payor."

Meanwhile, you got the damn insurance because YOU SAID IT WAS OK TO GET THIS ONE AND THAT YOU'LL TAKE IT. This "knowledge gap" is deliberate.

HOW ABOUT YOU TELL US YOU'RE GOING TO CRANK THE BILL. Because they're hoping you'll eat it and pay.

You call the dental insurance company and they sigh and say "Yeah, dentists pull that all the time." Turns out all dental insurers will pay... anyone. Period. More or less depending on network but bottom line: EVERYONE "TAKES" DENTAL INSURANCE EVEN IF THEY SAY THEY DON'T. Because you can, of course, get that dental insurance $ payout yourself to offset your cost if at a cash only practice. What a joke.

End of story? Good luck with your collections, after you angrily rejected a 50% split the difference... your greed has resulted in a big fat 0 additional payment.

/Rant OFF