Introducing Cutting-Edge Services to Your Patients

Figure 1. Supragingival preparation for a partial coverage all-ceramic onlay replacing the fractured cusp.

Figure 2. Restoration after cementation with a resin cement.

Figure 3. Preoperative view showing 2 old veneers with staining and poor morphology.

Figure 4. Immediate postoperative view of gingivectomy and temporary veneers.

Tom M. Limoli, Jr
limoli.com
When has the mere existence of a procedure code ever been a guarantee of reimbursement by either the patient or their benefit plan? It never has and it never will.
There is absolutely no question that a happy as well as comfortable patient is in fact a satisfied patient. Anesthesia reversal agents are nothing new in that they have been around in one way, shape or form for the last 20+ years. Also not new is the fact that they are not specifically identified by a definitive procedure code. Future revisions of CDT may or may not address this deficiency, but the facts of the matter remain the same—the code’s existence has nothing to do with its reimbursement via the benefit plan.
The observations of Amy Morgan concerning patient comfort and satisfaction are right on the money. However—in that benefit plans rarely, if ever, reimburse separately for the delivery of local anesthesia in conjunction with the completion of an operative or surgical procedure, why would they even consider paying for a simple anesthesia reversal agent? If I did not pay you to put it there what makes you think I would pay to nullify its effects? Hmmm, could be on to something here.
In today’s reality of politically motivated as well as entitlement driven healthcare financing, I recommend that the reimbursement of local anesthesia reversal agents be addressed in the dental office the same as bonding agents, cement bases, and cavity liners were addressed. Do it when you need to do it and don’t do it if you don’t. And as concerns its fee—it’s part of the global fee for the completed operative or surgical procedure.
See you on the road.

Lou Shuman, DMD
To cancel, or not to cancel? That is the question.
Sarah, a patient with a noontime appointment for a crown preparation, has been called upon by her boss to give an important impromptu presentation at 3 pm sharp. In all likelihood, Sarah’s tongue and lips will still be numb at 3 PM. What should she do?
Assuming that Sarah (1) cares about giving her best performance, and (2) isn’t in pain, we all know it’s a foregone conclusion: Nine times out of 10, Sarah will reschedule. A lose-lose for doctor and patient…that is, perhaps, until now.
Enter OraVerse, a new drug recently introduced by a company called Novalar at the Chicago Dental Society Midwinter Meeting in 2009. FDA-approved since May of 2008, OraVerse has been shown in recent studies to reverse the effects of soft-tissue anesthesia up to 80 to 85 minutes faster than what is normally expected when not administering the drug.

HOW IT WORKS
OraVerse (phentolamine mesylate) is an agent that helps to reverse the effect of the vasoconstrictor, which prevents blood from removing anesthetic from the mouth too quickly. OraVerse is thought to act by dilating the blood vessels, thereby speeding up blood flow to help carry the anesthetic away. From the patient’s perspective, the drug speeds up the return of normal sensation to the lips and mouth area following dental work.

OBSERVED BENEFITS

• Effective results—In adult and adolescent clinical trials, OraVerse reduced the median time to recovery of normal sensation in the lower lip by 85 minutes (55%), and in the upper lip by 83 minutes (62%) compared to control.
• Easy to administer—OraVerse is administered with a stand­ard syringe using the same location(s), same technique(s) (infiltration or block injection), and in the same proportion (1:1) as that used in the administration of the local anesthetic.
• Safe—The most common adverse reaction with OraVerse is injection-site pain. According to Novalar, the clinical trials did not demonstrate an increased risk of complications. In multicenter, controlled, randomized double-blinded clinical trials there were no serious adverse events and no discontinuation due to adverse events. The majority of adverse events were mild and resolved within 48 hours.
• Patients like it—Studies show that there is strong interest in the drug.
• Children 6 years and older (more than 33 lbs) will be less likely to bite their tongue or lip due to the soft tissue anesthesia.

POTENTIAL CHALLENGES AND OTHER OBSERVATIONS

• Not currently covered by dental insurance.
• OraVerse comes in prepackaged inserts for syringes, and costs about $12.50 per injection.
• Possible limited applicability since the mandibular block may be administered less frequently now for some routine dental procedures.
• There is growing use of shorter acting dental anesthetics.
• In some circumstances, increased duration of anesthesia may be warranted in the interest of optimizing patient comfort (ie, root canal therapy or oral surgery).
• Not recommended for children less than 6 years of age, or for children who weigh less than 33 pounds (15 kg).
• Phentolamine mesylate belongs to a class of drugs that can cause rapid heartbeats and irregular heart rhythms.

Such events have apparently been very uncommon with OraVerse. Clinicians should be alert to the signs and symptoms of these events, particularly in patients with a history of cardiovascular disease.
All in all, OraVerse brings very promising news for both dentists and patients. Hopefully soon, patients like Sarah will have more options when making decisions related to their dental appointments.

Amy Morgan
Every new piece of technology and each advance in clinical processes affects how you manage your practice—your team, your patients, your systems, and your statistics. In our premier article (Schroder, et al, Dentistry Today, September 2009), we talked about answering 8 questions (visit dentistrytoday.com to review these questions or the first Practice Pyramid Series article) before embracing new models and new methods. A proactive leader always analyzes the potential challenges and successes of an upgrade so that there is a plan to maximize success during implementation.
In this article, we are looking at Novalar’s OraVerse—a new pharmaceutical discovery that reduces residual soft-tissue numbing time, significantly. Following the 8 questions provides key insights on how to make this wonderful step in enhanced patient care a viable part of your practice culture.
If your vision is to create a comfortable patient experience for adults and children (older than age 6 years) customized to address their unique needs and concerns, then OraVerse is a welcome addition when it comes to procedures requiring anesthetic.
The cost is approximately $12.50 per injection. To maintain a viable, fresh stock of this new item in inventory and to make this addition profitable depends on the patient’s willingness to pay an appropriate additional fee. As of right now, there is no current dental terminology (CDT) procedural code for the additional injection. However, Novalar is currently working with ADA and the insurance companies to remedy this.

The doctor and team must be prepared to “inform before they perform” to make sure:

• Shortened numbing time is a motivator for the patient.
• Patient is willing to experience an additional injection.
• Patient is willing to pay an additional fee for the injection.
• Patient is willing to go beyond an “insurance mindset.”

Your assistants will need to manage the inventory, and the entire team will need to be comfortable with the benefits so that they can inspire patients to embrace this new innovation. They must also be comfortable with the additional fee.
If the dentist and team are utilizing expanded duty assistants to create the temporary restoration, the scheduling system may need to be tweaked. In a traditional overlapped schedule, the last 20 to 30 minutes of a crown preparation is usually an assistant-only procedure, creating and placing the temporary crown. If the dentist chooses not to administer OraVerse at the end of the preparation, time will need to be allocated for the dentist to come back in the room to deliver the second injection. If the team elects to offer OraVerse in the hygiene chair, after scaling and root planing (and if state law does not allow the hygienist to administer injections), provisions will need to be made to bring the dentist back in a second time.
There is no doubt that this new pharmaceutical innovation is a tremendous boost to customer service and care. Not every patient will be interested—but many will. Marketing on the Web site, newsletters, and notes to your patient base will inspire patients of record. In new patient marketing, letting prospects know that the practice uses the latest techniques to enhance their patient experience—will make you enhance how patients feel about you and will help to distinguish your practice from others. So, have a staff meeting and tweak your inventory, fees, and scheduling to accommodate this new technique. Let your patients know you are doing everything possible to exceed their expectations and this will be a successful practice upgrade.