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September 14th, 2011

Is dentistry ready for 'the cloud'?

By Dan Tynan

August 8, 2011 -- Cloud computing may not be taking dentistry by storm just yet, but it is steadily making its way into the world of practice management software and systems. And there are many reasons dental practices should consider investing in it.

"It was a no-brainer that we weren't going to purchase software," said Karah Maloley, who serves as business director for Vail Valley Dental Care. "We didn't even price it. If we were going digital, we thought we might as well go all the way."

So instead of investing thousands of dollars on a dedicated software package, they spend less than $200 a month for Denticon, a Web-based practice management service offered by Planet DDS. Unlike traditional software, Denticon isn't installed on a hard drive inside Dr. Maloley's front office PC. It lives in "the cloud," on Web servers in data centers located across the Internet.

When the Maloleys need to access patient records or schedules, they can log in from virtually any device connected to the Net, whether it's a computer, a smartphone, or a tablet PC. Having their data in the cloud allows the Maloleys to use Planet DDS's Virtual Business Service (VBS), which provides a team of assistants a thousand miles away to handle calls and schedule appointments. In fact, it allowed Karah to work from home after the birth of their first child.

Better access, lower costs

Cloud computing is not merely transforming dentistry, it's also changing how the entire world does business. If you've ever downloaded an email from Hotmail, made a Skype phone call, bought something from Amazon, or checked your bank balance online, you've used cloud computing.

Simply put, the cloud consists of tens of thousands of computers in data centers around the world. Because most of the data processing and storage takes place inside these data centers, you can use smaller and less powerful devices to do the same things that used to require a beefy office PC. All you need is a fast Internet connection.

“The key benefit is that it reduces your IT costs.”— Marty Jablow, DMD

For example, when Dr. Maloley gets an emergency call from a patient, he can look up the patient's records using an app on his iPhone, no matter where he happens to be.

"I want to be accessible to my patients whether they have a dental emergency or just a concern," he said. "This iPhone app lets me have all the patient information immediately when I'm not in the office or at home. I don't have to wait until Monday to find a resolution to their problem."

Cloud computing also offers a dramatic reduction in computing costs. Because cloud-based services can be shared by hundreds or thousands of users at a time, service providers can charge much less per user and still make huge profits. This gives small companies access to the kind of computing power once reserved for big multinationals.

That's why when Adrian Huang, DDS, moved his practice from Arizona to Utah, he went with Curve Dental, another cloud-based practice management service. The cost savings for a small start-up were simply too hard to turn down, Dr. Huang said.

"We wanted to be able to access the system from our computers anywhere, anytime," he said. "Using Curve meant we could start booking patients while our office was still being built and set up all our insurance fee schedules before we even moved in. It's a huge advantage for a start-up to not be forced to open and burn through capital while waiting for construction to be completed."

While Curve's cloud-based dental management service costs slightly less per month than standalone software Dr. Huang has used in the past, he said it saves money in other ways because his office needs less powerful computers.

"We're not really buying the software, we're just buying access to it," he said. "And because all of our data is already online, we don't need to worry about backing it up as much. As a start-up, it felt like we spent less."

In fact, Dr. Huang runs his Ninth East Dental practice almost entirely in the cloud. He uses Gmail for email communications, Google Docs office suite for writing letters and crunching numbers, and QuickBooks Online for accounting. The only thing he really needs an office PC for is storing before-and-after photos for his cosmetic patients, he said -- and even that may soon change.

"We still have patients' photos on our hard drives," he said. "But we're testing a new service from Curve that lets us upload those as well."

Software vendors follow suit

Even patient information systems are moving to the cloud. Patterson Dental Supply recently introduced Caesy Cloud, an Internet-based version of its well-know patient education system. Instead of installing and maintaining a dedicated server in each office, dental pros can subscribe to the service and let patients to watch streaming videos about treatments and procedures on an office PC, laptop, smart phone or even a tablet such as the Apple iPad.

Marty Jablow, DMD, a general practitioner at Green Street Dental in Woodbridge, NJ, and author of the DrBicuspid.comcolumn Ask Marty, has been beta testing the Caesy Cloud system for a couple of months. Using the cloud is a more efficient and less costly way of educating patients, he pointed out.

"Dentists don't have to pay for a server," he said. "There's no setup other than logging in. You don't have to update the service periodically because Patterson will do that automatically. But the key benefit is that it reduces your IT costs."

Of course, moving to the cloud entails some risk. If your Internet connection goes down or your service provider has an outage, you could be unable to process patients. And you must rely on a third party to keep your patient data private and secure.

But Karah Maloley says having the practice's data in the cloud actually makes them feel safer.

"I feel the risks are lessened because our data is stored in the cloud instead of on a computer that can crash," she said. "And if our Internet connection goes down, our extended staff at VBS, who work in a variety of locations, will still be able to access our office information and schedules. There are always concerns about hacking and privacy, but with Planet DDS I feel like I've outsourced these concerns to professionals."

August 18th, 2011

Here is a good analysis of recent the Joint Commission recommendations on sterilization and high-level disinfection from the Association for Healthcare Accreditation Professionals Blog.

Joint Commission recommends a look at sterilization and high-level disinfection

In a recent announcement, The Joint Commission has urged hospitals and other accredited organizations to review their sterilization and high-level disinfection (HLD) processes in detail. The accrediting body said that a review of existing policies and procedures will help ensure organizations are up to date, and this process will also help identify areas where leadership can take a more active role.

The Joint Commission has taken several steps in recent years in the area of sterilization and HLD to help curb the ongoing problem of healthcare-associated infections (HAI). The accrediting body implemented such items as IC.02.02.01, Element of Performance 2 and NPSG.07.05.01, both of which are intended to address surgical site infection rates.


July 25th, 2011

This year, a Seattle nurse named Kim Hiatt committed suicide. Ms. Hiatt's death came nearly seven months after she had given an unintended overdose to an infant heart patient, a medical error that was said to have contributed to the child's death days later. Ms. Hiatt had been a nurse for 27 years and had often cared for the 8-month-old girl during the child's stay in the pediatric intensive care unit of her hospital. She had probably drawn up the right dose of the drug hundreds of times in her career. But once, she made a life-changing error. A baby died, and she was suspended, then fired from a profession she loved. And now she's dead.

This story makes me feel sick -- sick for that dead baby and her parents, and sick for Kim, who must have felt so alone with her pain.

It's a pain that I, and every nurse and doctor, can relate to on some level. We've all made mistakes, most of them small and inconsequential to the patient's health, but sometimes the mistakes are serious. Most of the time, our errors don't amount to much because the hospitals where we work have put in place systems of checks and balances to be sure serious mistakes don't slip through. But even when your mistake is caught and a potential crisis averted, you are left with the knowledge that you almost harmed a patient you were trying to protect. My worst mistake ended up not mattering at all, but it still pains me to think about what could have happened as the result of my error. I had been working a full shift but agreed to stay later than my scheduled 12 hours so the floor wouldn't be short-staffed. Hospital error rates go up when nurses work more than 12 hours, but I'd done it before, when needed, and all had been fine. One of my patients had a new diagnosis of cancer and was going to the operating room to get a permanent intravenous line placed in her chest. During morning rounds, the medical team had decided to delay the patient's chemotherapy by a day, but late that same afternoon the doctor in charge told me that the chemo would, in fact, start that night. I was caring for three other patients and hadn't planned on anything new coming up. But now the patient would soon be coming back from the operating room and I had chemo orders to check, double-check and send to the pharmacy. Then I had to administer the treatment. After I completed all my checks on the doctor's orders, I saw my patient, who had returned from the operating room. She was very hungry, but I couldn't get a meal from the hospital kitchen, so I took out bread and peanut butter from our pantry and made her a sandwich. While trying out her new IV line, I discovered it had a strange leak. It was a problem that neither I nor the charge nurse had ever seen, and sounded unusual enough to the surgeon that he came back to the hospital from home - in a sweatshirt and his Merrells - to make sure all was well with the line. Everything turned out to be fine, and I gave the patient her scheduled chemotherapy. I went home exhausted, but flushed with the satisfying feeling that I could do it all - I was Super Nurse. Until the phone call came the next day. There was a dose of chemo still in the drawer. The patient was supposed to get two drugs, and I had given only one. Holding onto the phone, I actually bent over with the pain of surprise. With chemotherapy, the timing of the drugs can affect the effectiveness of the treatment. I worried that the patient's treatment had been compromised and that she might die from her disease because of my mistake. I felt that I had broken a sacred bond. As nurses, keeping our patients safe is always our most important priority. If my error endangered my patient in any way, I had completely failed in the most fundamental obligation of the job. But I was lucky that my mistake ended up not having any clinical consequences. The second drug did, in fact, need to be given within a certain time frame relative to the first drug, but there were hours left on the clock for the second drug to be given. The patient would be fine. The next day at work, I saw the doctor who had written the chemo orders. I'm certain my face was drawn with shame, and I apologized. The doctor was instantly reassuring, saying the data showed no difference in treatment effect if the second drug was started at the same time as or slightly later than the first drug.

And then this doctor said something that made a huge difference to me, and it's a sentiment I think about often. "A situation like this can build trust, Theresa,'' he told me, "because the patient knows we're being honest." He also said that the situation had been fully explained to the patient. Amazingly, the patient knew of my mistake, but once she learned that it didn't matter in terms of the course of treatment, her only concern was for me. The patient told the doctors that I had done a good job caring for her that evening, and she didn't want me to be fired.

I was touched by her reaction, and it made me think about all the nurses, doctors and pharmacists who are all trying to do such a good job. But there are times when we don't, and then we have to live forever after with the knowledge and the consequences of our own failures. And sometimes other people, like the poor parents of that baby in Seattle, have to live with the consequences of our failures too. My penance was twofold. I printed out article after article on that particular chemo regimen and read them in a bizarre form of intellectual self-flagellation. I also swore that I would never again stay late on top of a 12-hour shift, and I never have. Because now I know that I'm not Super Nurse - I'm human just like everyone else.

By THERESA BROWN, R.N.  and author of "Critical Care: A New Nurse Faces Death, Life and Everything in Between."


July 20th, 2011
One of my favorite things to bake is homemade rolls. There is nothing like the feel of dough in my hands, or the aroma that fills my house when I have a batch baking in the oven.

Recently, I sent my husband to the store for some flour so that I could grant him his single wish of a tray filled with "Slap Your Mama" rolls. When he returned, I realized he had not heard a word I said. He came home with the cheapest flour on the shelf, not the "better for bread" flour I had requested. The choice he made would directly affect what I was trying to accomplish. This flour did not contain the amount of protein that science has proven is needed to create the gluten air-filled sacks that make bread light and airy.

Choosing and using a surface disinfectant in dentistry is much like shopping for and using flour.

In 2003, the Guidelines for Infection Control in Dental Health-Care Settings gave us all science-based information that told us we should clean and disinfect clinical contact surfaces that are not barrier-protected by using an EPA registered hospital grade disinfectant with low- (such as HIV and HBV label claims) to intermediate-level (such as tuberculocidal claim) activity after each patient. Use an intermediate-level disinfectant if visibly contaminated with blood.

  • Clinical contact surfaces: Surfaces that are touched by contaminated hands, instruments, devices, gloves, etc. They include light handles, switches, radiograph equipment, dental chairside computers, reusable containers of dental materials, drawer handles, faucet handles, countertops, pens, telephones, and doorknobs.1
  • Cleaning: Removing visible contamination from a device or surface.
  • Disinfection: Destruction of pathogenic and other kinds of microorganisms by physical or chemical means.2

The preceding directives give us great information. Other points to remember include:

? We have to clean and then disinfect. This is a two-step process. We must first clean off the debris and then disinfect the surface. Those are two separate steps. For example, in following label directions for using disposable towels that are premoistened, you would use one to clean the contact surface and then throw it away. You would get a fresh towel and use it to disinfect the contact surface. Following directions on the package ensure compliance with the science-based experiment that was conducted in developing use of this product.

? EPA-registered, hospital grade disinfectant is not just something you pick up off the shelf at a local store. It must have an EPA registration number and state that it is a hospital grade disinfectant.

? Barrier protection is a very effective method of preventing cross-contamination. If the area is difficult to clean, barrier protection should be utilized. If barrier protected surfaces are contaminated during treatment or when removing barrier protection, they should be cleaned and disinfected.

? You must use an intermediate-level disinfectant if the area is visibly contaminated with blood.

In choosing and using a surface disinfectant, you need to keep several things in mind:

? Is it safe for the surface I am going to use it on? An office recently shared with me that they had switched to a product and suddenly the threads on their chairs were falling apart. They read the label and soon discovered this hospital grade disinfectant was not intended for use on cloth and had destroyed the thread quickly. Manufacturers of dental devices and equipment should provide information regarding materials compatibility with liquid chemical germicides, whether equipment can be safely immersed for cleaning, and how it should be decontaminated if servicing is required.1

? What personal protective equipment do I need to wear in order to use this product? Both the direction label and the material safety data sheet (MSDS) will tell what you need to wear while using this product. Because of the risks involved with working with chemicals and contaminated surfaces, gowns, masks, eye protection, and chemical- and puncture-resistant utility gloves are a must. Many products can break down latex based gloves exposing clinicians to chemicals that are toxic. Chemical and puncture resistant utility gloves should be utilized during this task.

? How safe is it for me to work with? It is important to note if any staff members are allergic to ingredients or if any of the ingredients have side effects in the method with which it will be used.

? How long can I be exposed to this product? The MSDS will give you the time-weighted average (TWA) for the product and any cautions for length of time of use. It is important that all office members who are using a product are trained in the TWA and MSDS. All tasks need to be delegated so no one is over-exposed.

? What is the shelf life of this product? If the product has a short shelf life, it is important that you are tracking it and replacing it when necessary. Short shelf lives may mean wasted products. Many products require special handling for disposal.

? Do I have to mix this myself? Sometimes just having the time to mix and formulate a product can be very confusing and time consuming. Keeping products simple and easy to use can eliminate the chances for mistakes being made.

? Am I using this for intermediate or low level? Low level targets HIV and HBV label claims, and intermediate level targets tuberculocidal claims. Remember, if there is visible blood, you must use intermediate level.

? How easy is it for me to work with? Some products both clean and disinfect, saving you the time of switching back and forth from one product to another. Some are premixed and ready to use. Check to see if the product is is complex or simple to use, if instructions are included, and if the intended use can be accomplished in your setting.

? Is the wait time realistic? Not very many of us have 15 minutes between patients. Yet there are disinfectants that require that amount of time. Time yourself and see how much time you have between patients and match the product to that time.

The Organization for Safety, Asepsis and Prevention (OSAP) is a nonprofit organization. OSAP is a unique group of dental educators, consultants, researchers, clinicians, industry representatives, and others with a collective mission to be the world's leading advocate for the safe and infection-free delivery of oral care. OSAP supports this commitment to dental workers and the public through quality education and information dissemination.

Your membership in this organization will assure you access to the most current and valuable information you will need in your daily clinical practice to keep you and your patients safe. Membership is an inexpensive investment that includes all compliance issues being addressed in one place!

Check out their website at www.osap.org. I love the "Ask OSAP" section; it has all of the questions you are facing in clinical practice with the science-based answers! The association also maintains a list of EPA-registered, hospital grade disinfectants atwww.osap.org/page/SurfDisinfec2010.

Choosing and using a surface disinfectant in dentistry is much like shopping for and using flour. My husband finally got his "Slap Your Mama" rolls after a second trip to the store to get the product that was developed for this purpose. As you make choices with surface disinfectants, I hope that you will use your clinical reasoning skills and science-based information to keep patients and yourself safe.


  1. Guidelines for Infection Control in Dental Health-Care Settings 2003
  2. From Policy to Practice, OSAP's Guide to the Guidelines, 2003

From RDH   http://www.rdhmag.com/index/display/article-display/8373153520/articles/rdh/volume-31/issue-6/columns/choosing-and-using-surface-disinfectants.html

by Noel Kelsch, RDHAPn.kelsch@sbcglobal.net
July 12th, 2011

Q. What might cause teeth to chatter other than the cold?

A. There are several kinds of involuntary jaw movements, said Dr. Steven Syrop, section chief of temporomandibular disorders at NewYork-Presbyterian Hospital/Columbia University Medical Center, and it is important to distinguish chattering from grinding and from still another problem, called oromandibular dystonia. “Teeth chattering is usually related to shivering, which is the body’s response to cold,” Dr. Syrop said, but it can also result from an infection causing chills.

Teeth grinding, or bruxism, is thought to be a habit aggravated by stress, he said. The exact cause is not known, but recent evidence has de-emphasized the role of occlusion, or the way the upper and lower teeth come together. “Different from this is when the jaw muscles contract and relax spontaneously, producing constant jaw movement,” Dr. Syrop said. “This is called oromandibular dystonia.” This kind of motion can be the result of several different medical conditions, including reaction to certain medications.

According to the Dystonia Medical Research Foundation, oromandibular dystonia is one of more than a dozen kinds of dystonia, in which the neurological mechanism that makes muscles relax when they are not in use does not function properly. The contractions can interfere with chewing and swallowing.

By C. CLAIBORNE RAY New York Times