Newsbriefs

New Claim Form for ACCESS Program

The Pennsylvania Dental Association (PDA) received a notice to alert all PA Medicaid dental providers of a change in claim processing as of August 1, 2008. If you are a Medicaid provider, you should have received a notice in the mail from the Pennsylvania Department of Public Welfare.

Effective August 1, 2008, the Office of Medical Assistance Programs (OMAP) will only accept the current version of the 2006 ADA Claim Form for submission of paper claims and prior authorization requests. This submission requirement is in effect for all paper claims and prior authorization requests submitted to the state administered fee-for-service ACCESS/ACCESS Plus delivery system for Medical Assistance Programs. Paper claims or prior authorizations received on forms other than the ADA 2006 by OMAP on or after August 1, 2008, are being returned to the provider for transfer to the 2006 ADA Claim Form and resubmission.

If you have questions, you may contact the OMAP Provider Information Center at 1-800-537-8862, option 4.

To access online information concerning completion of the 2006 ADA Claim Form use the following link to reach the “ADA Claim Form – Version 2006 Completion Aid for Dentists”: http://www.dpw.state.pa.us/omap/provinf/promhb/PDF/prombgadadental_dentists2006.pdf

ADA Resources Answer Bisphosphonate Questions

Dentists may have questions about managing patients on bisphosphonates – a class of drugs used primarily for the prevention and treatment of osteoporosis that have been associated with a rare side effect called bisphosphonate-associated osteonecrosis (BON) of the jaw.

For those dentists with questions, the American Dental Association (ADA) developed “Dental Management of Patients Receiving Oral Bisphosphonate Therapy: Expert Panel Recommendations.” The recommendations apply to patients taking oral bisphosphonates, specifically, and not intravenous bisphosphonate medications, where the risk for developing BON is higher. Dr. Peter Jacobsen, vice chair of the ADA Council on Scientific Affairs and a member of the expert panel that developed the recommendations, advises dentists to read the recommendations and urges them to openly communicate with physicians when treating these patients. “Knowledge about bisphosphonates and osteonecrosis is still evolving,” Dr. Jacobsen said. “We still don’t really know the incidence of osteonecrosis of the jaw in dental patients nor how to most effectively manage it. But research and treatment experience is moving quickly and the ADA is closely monitoring all publications on this topic to ensure our panel recommendations are current and accurate.”

He added that cancer patients being treated with intravenous bisphosphonate drugs are “clearly at risk for developing BON” and “should have a dental evaluation, ideally before, but certainly within the first several months of beginning IV therapy.”

The incidence of BON in patients taking the oral form of bisphosphonates is much lower.

In January 2008, an alert from the Food and Drug Administration (FDA) warned of additional side effects from bisphosphonates, including the “possibility of severe and sometimes incapacitating bone, joint, and/or muscle (musculoskeletal) pain.” The alert indicated “bisphosphonate use might be responsible for severe musculoskeletal pain in patients who present with these symptoms” and asked health care professionals “to consider temporary or permanent discontinuation of the drug[s].”

“Bisphosphonates have a history of coming up with unexpected things,” said Robert Recker, M.D., in a January 2008 article of the American Medical News, newspaper of the American Medical Association. Dr. Recker, director of the Creighton University School of Medicine Osteoporosis Treatment Center, added he was frustrated that dentists have told patients to get off the drugs. “The truth is bisphosphonates are among the safest drugs we prescribe in osteoporosis,” he said.

In a letter to the AM News, former ADA Executive Director James Bramson said the ADA recommendations do not suggest patients should stop taking these drugs prior to dental procedures, but instead that “dental treatment should not generally be modified solely on the basis of bisphosphonate therapy. The ADA recommendations stress that the incidence of bisphosphonate-associated osteonecrosis of the jaw is very low, and patients may also benefit from having a dental exam prior to beginning oral bisphosphonate therapy.”

The ADA letter concluded that the association recognizes that discontinuation of these drugs is a serious medical decision and that “the ADA recommends that dentists encourage patients to consult with their treating physician about any health risks associated with use of these drugs.”

The ADA Council on Scientific Affairs released the recommendations in 2006 for practitioners to consult when treating patients taking oral bisphosphonates. The recommendations encourage dentists to talk with a patient’s treating physician about any health risks and recommend that patients have a dental exam prior to beginning oral bisphosphonate therapy. In some cases, patients may want to schedule dental treatments before starting bisphosphonate therapy.

“The use of these drugs is a serious medical decision,” Dr. Jacobsen said. “They provide a very real and measurable benefit by decreasing bone fractures in patients with osteoporosis. All drugs have side effects and any drug has a risk-to-benefit balance that needs to be considered.

“We do know that the older a patient gets,” he continued, “there is a higher risk of a broken hip or fractured spinal vertebra. The risk of osteonecrosis of the jaw is much lower than the risk of such fractures.”

The medications listed in the FDA warning are: Fosamax and Fosamax Plus D (alendronate); Didronel (etidronate); Boniva (ibandronate); Aredia (pamidronate); Actonel and Actonel with Calcium (risedronate); Skelid (tiludronate); and Reclast and Zometa (zoledronic acid.)

To see the ADA recommendations for bisphosphonates online, visit www.ada.org/prof/ resources/topics/osteonecrosis.asp

The August 2006 issue of The Journal of The American Dental Association (JADA) also published the ADA bisphosphonate recommendations and the January 2008 JADA contained the cover story, “Bisphosphonate Use and the Risk of Adverse Jaw Outcomes: A medical claims study of 714,217 people.”

A patient information page may be accessed at www.ada.org/public/topics/osteonecrosis.asp

ADA Adopts Advocacy Plan on Tooth Whitening Services

Recently, the American Dental Association (ADA) Board of Trustees approved an advocacy action plan for engaging the growing public safety concerns of tooth whitening services performed by non-dentists and requested that this information be shared with interested members of the dental community. The wide-ranging plan comprises a variety of legislative and regulatory options to address non-dentists offering tooth whitening kits and/or services in non-dental office settings such as mall kiosks, salons or similar settings. The plan also includes an offer from the ADA Science Division Laboratories to accept and analyze samples of whitening products being distributed to determine composition, including peroxide concentration. Whether whitening services offered by non-dentists is lawful is fact specific and depends on the particular type and method(s) of dental bleaching services employed by the providers and the applicable law in the jurisdiction in which the operations takes place. In an extensive discussion of the action plan, the Trustees agreed that a comprehensive approach is necessary.

British Dentists Extracting More Teeth

Dr. Philip T. Siegel brought to our attention a BBC article that was published on August 21, 2008. The article states that British dentists are now more likely to “pull teeth our or fit false ones than provide fillings or crowns” as a result of a British National Health Service (NHS) contract that became effective in 2006.

In England, treatments that included dentures increased from 38% to 48% between 2003-04 and 2007/08 and extractions from 7% to 8%; but the number of crowns fell from 48% to 35% and fillings from 28% to 26%.

The figures also showed that fewer patients were being treated, despite more dentists joining the NHS after the new contract. Overall, 27 million patients were seen by NHS dentists in England during the past two years – 1.1 million fewer than the previous two years. But there were 655 more dentists doing NHS work in 2007-08 than in the previous year – an increase of 3.2%.

NHS Chief Dental Officer Dr Barry Cockcroft said the figures showed NHS dentistry was “on the road to recovery.” He said, “Our challenge is encouraging people to visit their dentist for regular check ups, even if they feel they don’t need to. There is also a perception amongst the public that there is a growing lack of NHS dentists, and the latest statistics prove that there are actually more and more NHS dentistry services opening around the country.”

But Susie Sanderson, chair of the British Dental Association’s Executive Board, said there were still “significant problems.”

She noted, “Those that are able to access care are confronted with a system that discourages modern, preventive care by placing targets, rather than patients, at its heart. The apparent change in treatment patterns is also of concern and requires further investigation so that the impact of the new contract is fully understood.”

Dr. Weil Weighs in on Amalgams

On his Web Site (www.drweil.com), Andrew Weil, M.D., a leader in the field of integrative medicine, posted the following answer to a question about the “dangers” of mercury fillings to the general public. The posting was made on August 25, 2008:

Mercury amalgam fillings have been around for more than 150 years and have been generating controversy from the start. The material is inexpensive, versatile, durable, and easy to work with. But over the years, repeated concerns have been raised that toxic mercury vapor escaping from fillings poses all kinds of health problems.

In June 2008, the FDA settled a lawsuit with some consumer groups by agreeing to warn the public about the potential health risks posed by mercury from amalgam fillings, even though no new evidence has emerged linking the amalgam fillings to health problems. While there is no question that mercury vapor is toxic, its release from amalgam fillings is very slow, and I'm not aware of any studies here or abroad showing that it presents a health risk. Most release occurs when fillings are put in, making it more hazardous for the dentists who work with amalgam regularly than for the patients whose teeth are being filled. The only documented problems that have been traced to the fillings are rare, local side effects or allergic reactions.

In a notice posted on its Web site, the FDA said that the mercury in dental amalgams "may have neurotoxic effects on the nervous systems of developing children and fetuses" and that pregnant women and anyone else who may have a health condition that "makes them more sensitive to mercury exposure, including individuals with existing high levels of mercury.

The groups that filed the suit argued that the mercury in the fillings can lead to such health problems as multiple sclerosis and Alzheimer's disease. I have seen no evidence to support those claims. One of the FDA panel members was quoted as saying that while there is a "theoretical reason" to suspect harm from the fillings, there is no evidence of actual harm. The use of amalgam fillings has been on the wane in recent years in favor of tooth-colored resin composites (which don't last as long as amalgam fillings but are getting better).

The FDA did not recommend that consumers replace amalgam fillings to cut down on the potential risk they may pose. Given the lack of evidence that the amalgams cause health problems, I wouldn't worry about fillings you already have. When they break down, you can replace them with non-mercury-containing material. But make sure the dentist who removes them takes precautions to protect you from inhaling mercury vapor during the process.