Care for the Poor Is Stricken Dentist's Legacy

By David G. Jones

A critical juncture in dental health was fast approaching a decade ago in an otherwise serene northern California valley known best for its fine wines and restful spas.

As the crisis reached its boiling point, a Napa general dentist with a giving heart stepped in to bring the community together to turn down the heat and assuage the hurt.

Despite the desperate nature of the problem he has helped solve, today Lawrence E. Hess, DDS, is facing an even greater threat: last December he was diagnosed with pancreatic cancer.

Now, a grateful community is once again coming together because of Hess, 51, this time to show their thanks to him for his transcendent efforts to establish dental care for the area's poor, which was basically nonextistent when he took the project to heart.

Hess was honored August 18 when the Napa County Board of Supervisors presented him with a resolution praising his work in providing dental care to the county's indigent population, which began in 1988 when Hess and Napa oral surgeon Greg Winnen, DDS, co-founded an austere, volunteer-staffed children's dental clinic in Napa's Queen of the Valley Hospital.

"In the late '80s there was truly just nobody in Napa County accepting DentiCal patients, other than on an emergency basis," Hess says. "The hospital was treating a lot of children's dental emergencies. I think there was also a lack of understanding on dentists' part in the county as far as how great the problem was."

Catholic Sister Ann McGuinn, who was working at the time at Queen of the Valley Hospital, recognized the problem and now recalls the clinic's humble beginning.

"We found a little space in the hospital, got some equipment donated, and started a small clinic staffed by volunteer dentists from the Napa-Solano Dental Society every Friday," says McGuinn, now vice president for sponsorship at St. Joseph's Hospital in Eureka. "We got the clinic started through the efforts of Larry and his dedication. He's a very gentle and compassionate man, who is very good with the children, and was instrumental in getting other dentists interested in helping."

It wasn't long before it became apparent to Hess that there was a tremendous need, and it wasn't being serviced even through the voluntary effort. So after moving to another location for about a year, Hess and Winnen teamed up again early in 1991 to start a permanent clinic.

"We were able to get a grant from the state, and through a lot more effort things got rolling," Hess says.

The Sister Ann Community Dental Clinic, named for McGuinn, has five operatories, a full-time staff, and two full-time dentists. Last year, the clinic served more than 6,000 low-income residents. Sixty percent of the patients were under age 20, and DentiCal pays most costs with help from the Napa Valley Wine Auction.

General dentist Edward Bartlett, DDS, has worked at the clinic since it opened. He readily found an analogy to describe Hess' persistence in finding solutions to problems of any size.

"Hess is very focused, like a bulldog," Bartlett says. "If he hears of a problem, he just grabs onto it until it gets solved."

The clinic was more of a triage center when it opened, and its staff was confronted with children who had suffered through an almost complete lack of dental care. Sorting though those potential oral disasters and working on the most serious and debilitating problems was the initial challenge.

"We worked for several years to get most of it under control in this population," Bartlett says.
But the work was effective, and now the clinic's focus has turned to maintenance and preventive dentistry.

Since being stricken with cancer, Hess has stepped back from dentistry, having sold his practice in February to spend more time with his family. But his legacy remains an animating factor in the clinic he worked so hard to start.

"We're fortunate to have some good dentists and staff who treat patients fairly and with dignity," Hess says. "It's that simple. I believe that by giving I receive more. Many people find outlets, and this is certainly one that you can do and know you're doing something good for others."

When Hess became ill, many dentists and friends offered their help.

"We all took his emergencies on various days, and other dentists in Napa checked exams, maintained the hygiene schedule and kept his practice working," says Samuel E. Gittings, DDS, a Napa general dentist. "It was amazing and very heartwarming to see how people responded."

McGuinn said that so many good things came about because of Hess' compassion and concern for others.

"Unfortunately, that doesn't happen often enough," she says. "He is so unassuming, and simply did it, without any fanfare or thought about himself, just for the children's sake. The two full-time dentists at the clinic are really wonderful, but I wish I had another Dr. Hess."

Hess tries to make an objective assessment of his illness.

"It's an interesting transition, one of the things that we all go through, one of the surprises in life," says Hess, a 1971 graduate of the UCLA School of Dentistry. "But I can't overemphasize how much the support from the community helps."

TB Continues Its Lethal Ways

Tuberculosis kills more young people and adults than any other infectious disease in the world.

According to a report by the World Health Organization that appeared in the March 1998 issue of FDI World, it is a bigger killer than malaria and AIDS combined and kills 100,000 children each year.

Like the common cold, TB spreads through the air, and to become infected, a person needs only to inhale TB bacilli that become airborne when an infected person sneezes, coughs, spits or talks.

This year, more people will die of TB than in any other year, according to the FDI World story. New outbreaks are occurring in Eastern Europe, where TB deaths are increasing after almost 40 years of steady decline. Southeast Asia has the largest number of cases with nearly 3 million per year.

HIV and TB form a lethal combination, each speeding the other's progress. One-third of the increase in the incidence of TB in the last five years can be attributed to HIV. Of the nearly 31 million people worldwide who were HIV-positive in 1997, about one-third were believed to be infected with TB.

Until 50 years ago, there were no medicines to cure TB. Strains that are resistant to a single drug or even a combination of drugs have now emerged. Multidrug-resistant (MDR) TB is caused by inconsistent or partial treatment, the wrong drugs or the wrong combination of drugs, or an unreliable drug supply.

Poorly supervised and incomplete treatment of TB can be worse than no treatment at all. If someone with MDR-TB infects another, the newly infected person will have the same drug-resistant strain. Drug-resistant TB is more difficult and more expensive to treat, and more likely to be fatal.

In the US, one-third of TB cases are among foreign-born people. Untreated TB spreads quickly in crowded refugee camps and shelters. Homeless people in industrialized countries are also at risk. In 1995, almost 30 percent of San Francisco's homeless population was reported to be infected with TB.

The World Health Organization recommends a treatment strategy for detection and cure of TB called DOTS (Directly Observed Treatment, Short-course). DOTS combines five elements: political commitment, microscopy services, drug supplies, monitoring systems and direct observation of treatment.

DOTS produces cure rates of up to 95 percent, even in the poorest countries, and prevents new infections and the development of MDR-TB. A six-month supply of drugs for DOTS costs $11 per patient in many parts of the world.

In the few years since DOTS was introduced on a global scale, more than 1.7 million infectious patients have received effective DOTS treatment. In spite of this rapid progress, only 12 percent of estimated TB patients received DOTS in 1996. At the beginning of 1997, 95 out of 212 countries had adopted the DOTS strategy. Of those, 63 have implemented DOTS countrywide.

If the WHO goals of detecting 70 percent and curing 85 percent of new infectious TB cases are met by 2010, one-quarter of TB cases and one-quarter of TB deaths could be prevented in the next two decades.

DOTS

Directly Observed -- It is the responsibility of the health worker, not the patient, to ensure that powerful anti-TB medicines are used properly. That is why patients must be observed swallowing their medicines, especially during the first months while they still are seriously ill and at risk of developing drug resistance.

Treatment -- The objective of treatment is to cure the patient. To accomplish that, health workers must do more than pass out medicines. In the case of contagious patients, sputum must be examined under a microscope after two months and at the end of treatment to help ensure that each patient will not relapse again with TB.

Short-Course -- The correct combination of anti-TB medicines must be used for the right length of time.

Source: WHO fact sheet number 104, February 1998.

Generosity With a Practical Twist

By Marios P. Gregoriou

Generosity and philanthropic motives are important factors behind most charitable giving.
However, they often are not the only factors.

Many investors also may be motivated by the significant tax, investment and estate planning advantages associated with the making of charitable gifts through a charitable remainder trust (CRT).

If you are an investor in your 50s or older, or are nearing or are in retirement, and if you own highly appreciated securities, you may wish to consider a CRT to take advantage of the tax benefits provided by such a trust. Through a CRT, you may receive:

* Relief from capital gains taxes on the sale of contributed assets.

* An income stream for the rest of your (and your spouse's) life.

* A current-year income tax deduction.

* The potential to reduce estate taxes.

* The ability to diversify your investment portfolio.

* The personal satisfaction that comes from supporting a favorite charity.

How a CRT Works

A CRT is created to provide lifetime or term income payments to you, and/or family members, while the remainder eventually is payable to a qualified charitable organization.

Your payments, subject to income tax, may be an annual fixed dollar amount (an annuity trust) that is equal to a percentage of the trust's initial value. Or, they may be variable annual payments (a unitrust) equal to a percentage of the value of the trust fund. In that case, the fund is revalued each year.

Because a CRT is tax-exempt, appreciated assets transferred by you to the trust may be sold by the trustee free of capital gains taxes. Assets in the trust may then be reinvested in a high-quality diversified portfolio which can potentially generate increased income.

Another benefit a CRT can provide is a charitable income tax deduction in the year you fund your trust. Keep in mind that your deduction will be less than the total value of the trust assets if you or other beneficiaries are to receive payments from the trust.

An additional tax advantage provided by a CRT is that assets transferred to the trust will not be counted as part of your estate. That helps to reduce the value of your estate, which could reduce potential future estate taxes. Federal and state estate taxes range between 37 percent and 55 percent on taxable estates valued at $625,000 or more (for 1998).

Wealth Replacement

Many individuals who are interested in establishing a charitable remainder trust ask about leaving assets to their heirs.

While assets in the charitable remainder trust must go to the charity upon the death of the surviving beneficiary, the increased cash flow and tax savings that result from the trust may be used to purchase life insurance in an irrevocable life insurance trust. With a properly structured life insurance trust, (1) premiums are paid with dollars that would have gone to taxes, (2) proceeds are outside the estate and are not subject to estate or inheritance taxes, and (3) proceeds are received by your beneficiaries income tax-free.

Keep in mind that a CRT is irrevocable. Assets in the trust eventually will go to your designated charity. Consult your tax and legal advisers to be sure a charitable remainder trust fits into your overall estate plan. If it does, you may enjoy significant tax, investment and financial benefits as well as leave a lasting legacy to your favorite charity.

Mr. Gregoriou is associate vice president and financial adviser for Morgan Stanley Dean Witter in Sacramento. He can be reached at (800) 755-8041. This article does not constitute tax or legal advice. Consult a tax adviser and attorney before making tax- or legal-related investment decisions.

Why is That Investor Smiling?

Dental companies touting the next great idea only to see their stocks tumble as the claims don't pan out as expected have taken some hits lately. However, there are dental stocks with real track records that match the steady path of the profession.

According to the federal Health Care Financing Administration, $45.8 billion was spent in 1996 on dental office supplies and services, an annual growth of 7.7 percent since 1990. Projections indicate that demographic trends such as an aging population and increasing demand for cosmetic work and preventive care will drive up industry revenue 5.6 percent a year through 2001.

Some companies are poised to grow even faster than that, with accelerating consolidation fueling double-digit revenue and earnings growth. A handful of dental product and equipment makers are buying smaller competitors; the resulting economics of scale provide some compelling margin expansion. Distributors of those products are joining forces to gain bargaining power with manufacturers.

The stocks to watch are those companies which show sound management fundamentals and strong growth projections. It's the long-range, steady growth of many dental companies that make investors take a look, and when they see the earnings, they smile.

Sit Up Straight

"How many of us deliver care year in and year out while seated with rounded backs and heads down and forward?" asks Steven Fong, DDS, in the May edition of the Southern Alameda County Dental Society Explorer.

Fong says dentists should consider that, while they preach prevention of disease and the penalties for neglect, they often are guilty of not applying those principles to their own need for good posture.

Good posture protects the supporting structures of the body against injury or progressive deformity. The health of thoracic and abdominal organs is optimized under conditions of good posture. Good posture creates alignment and balance whether in rest or in motion, says Fong. It allows movements to be made in proper patterns which denote power and athleticism.

And, says Fong, good posture is sexy.

Improper sitting position involves slumped shoulders, rounded back, head forward and lumbar spine exhibiting a backward curve. In this position, scapular joint alignment is offset, resulting in the inability to make effective arm movements. Too much load is placed on the facets of the cervical vertebrae, leading to neck soreness. Breathing is impeded, causing poor oxygenation. Prolonged slumping can lead to musculoskeletal conditions such as disk protrusions, muscle imbalance, spasms, pinched nerves, and weakening caused by muscle shortening -- definitely not sexy.

In the days of stand-up practitioners, dentists could be identified by their sideways deflected backs. Even in today's sit-down dental practice, says Fong, posture is often compromised. Poor posture can result from the difficulties inherent in the visualization of the oral cavity. The use of abundant lighting, optical magnification, rubber dams, indirect mirror techniques and particularly video imaging can help overcome those vision problems, allowing maintenance of good posture.

Proper posture in standing and walking is an extension of proper sitting posture. No matter what a person's age, good posture can become a habit that enhances one's future quality of life, says Fong.

Web Sites 101

Not too long ago, if someone was talking about "the web," the first thing that came to mind was an ugly black spider. Then came the scramble to "get on the 'net" and investigate all the hoopla. Many people built their own web sites, sure that the marketing advantages would catapult their earnings into the stratosphere.

Some of those people have become disappointed because their web site doesn't seem to do anything and their initial investment is not bearing fruit.

So, how does one build a web site that can attract visitors and, even better, get them to return? How is value built into the site? What is it that people want in a web site?

A good web site for a dental practice will provide general information about the dentist and staff. With the ability to be updated quickly and inexpensively, a web site can introduce a prospective patient to the "feel" of the office and even offer virtual tours of the provider's facilities and other information that cannot be included in traditional printed materials. Web sites can be static or interactive, simple or complex, stand-alone or part of a web community.

It's a good idea to develop a strategic plan for a web site. The plan should encompass these three areas:

* What do you hope to accomplish with an Internet presence?

* What is the target audience, or who do you want visiting the site?

* What do you want people to do once they visit the site?

People will only visit a web site if it provides value. Identify the level of web site sophistication desired. Create links to other appropriate sites. Build in e-mail capabilities. Include information about the dentists and staff, including credentials, office philosophy, location, hours, and how a patient can contact the office. Above all, present a consistent message.

There are many resources, software and connection companies available to assist in the web site building process. Once the site is in place, remember to add web site and e-mail addresses to business cards and invoices.

Periodontitis Presents Pregnancy Risks

Recent research has suggested a relationship between periodontal disease and a serious complication of pregnancy, says Timothy J. McNamara, DDS, in the May 1998 issue of WDA News. He writes that women with severe periodontitis have more than seven times the risk for preterm, low-birth-weight delivery than women without severe periodontitis, even after adjusting for all other known risk factors.

Preterm, low-birth-weight (PLBW) deliveries account for 10 percent (250,000) of all U.S. births and more than 60 percent of infant mortality, excluding congenital anatomic or chromosomal defects. PLBW is responsible for 5 million neonatal intensive care unit days per year, with an annual cost of $5 billion per year.

There are many recognized risk factors for PLBW: maternal age under 17 or over 34; African-American race; low socioeconomic status; inadequate prenatal care; alcohol, tobacco, or illicit drug use; hypertension; genitourinary tract infection; diabetes; and multiple pregnancies. About 25 percent of PLBW cases occur in the absence of any known risk factors. Studies have revealed that mothers with periodontal disease have a greater than seven-fold risk of PLBW after adjusting for all known risk factors.

McNamara says it long has been known that women are more susceptible to periodic periodontal inflammation, especially gingivitis, as a result of normal fluctuations of hormonal cycles and that pregnant women experience marked progression of periodontal disease during pregnancy. Pregnant women can expect no periodontal inflammation or other symptoms if they enter pregnancy free of periodontal disease, practice good oral hygiene and maintain regular professional care.

"We just now are recognizing a greater health risk for pregnant women with periodontitis," he concludes.

The ABCs of Vitamin D

Researchers believe that Americans -- especially those who are older -- are not always getting the vitamin D they need, exposing themselves to osteoporosis or thinning of the bones.

Vitamin D is made by the skin when it is exposed to sunlight and also is found in foods such as sardines, salmon and fortified milk. The nutrient makes calcium and phosphorus more available for bone mineralization. However, while calcium has received plenty of media attention recently, vitamin D has become a poor stepsister, even though many researchers believe it is just as important as calcium. In fact, the body cannot absorb sufficient amounts of calcium without vitamin D.

People who have low blood levels of vitamin D are at an increased risk for fractures associated with osteoporosis and osteomalacia, softening of the bones. Vitamin D also is needed to maintain strong, disease-resistant teeth as well as keep jawbones that hold the teeth strong and healthy.

Older adults are more likely to be deficient in vitamin D because the body's mechanism for producing the nutrient from sunlight declines with age. In addition, older people often don't get outdoors. Because vitamin D is stored in fat, younger and middle-age adults, who often get outdoors more frequently, usually can rely on reserves built up during summer months to get through the winter.

Last year, the National Academy of Sciences increased the Dietary Reference Intake for vitamin D from 200 International Units (IU) to 400 IU for people aged 51-70 and 600 IU for those 70 and older. However, a recent study suggests that those levels still could be too low because vitamin D deficiency appears to be more prevalent than previously thought.

Milk fortified with vitamin D does not always contain consistent amounts of the vitamin. A study conducted by Boston University researchers, published in the New England Journal of Medicine in the early 1990s, indicated that half of the milk samples they tested contained 50 percent or less of the government-required 400 IU of vitamin D per quart. Also, people may mistakenly believe that other dairy products such as yogurt, ice cream and cheese are fortified with vitamin D when none of them are.

Good Call

The next time the phone rings in your office, you may want to pay attention to how your staff answers it.

Patients' first impressions help them form their perception of the quality of your practice and the care they receive.

When was the last time you heard a patient say "The margin on the lingual of that crown is perfect"? According to the Academy of General Dentistry, the way in which the telephone is answered and the subsequent conversation tell the caller a great deal about your practice.

That is especially true for first-time callers. They have not had the opportunity to visit the office to evaluate your practice. If the voice on the telephone and the language used is not that of caring, warmth and concern, your potential new patient, who may be anxious already, may be turned off to you and your practice.

Following are a few telephone tips which will be help callers recognize an office that is organized and practices good communication:

* Select a standard phrase that everyone uses when answering the phone.

* Always be courteous and pleasant. Good manners are essential to good business. There is a huge difference between the phone being answered, "Dental office, hold please," and "Good morning, Dr. Scott's office, this is Kathy speaking, how may I help you?"

* Delegate one person to answer the telephone and one person to serve as backup. Rotate the assignment as necessary for different days of the week.

* Use a telephone message slip to record the date, caller and reason for the call. Use a message slip instead of a sticky note or scrap paper because it's more difficult to lose.

* It is very important for incoming calls to be screened. Make a rule to avoid interruption when seeing patients unless there is an emergency, another dentist is calling about a patient in the chair, or it's an expected call.

Overall, good telephone management prevents many unnecessary interruptions to patient care and helps build your communication with patients.

Honors

John S. Sottosanti, DDS, a private periodontal practitioner from La Jolla, Calif., has been awarded a Special Citation in recognition of outstanding contributions to the American Academy of Periodontology.

Mark Lisagor, DDS, of Camarillo, Calif., and Neil Silverman, DDS, of Santa Rosa, Calif., received Certificates of Recognition for Volunteer Service in a Foreign Country from the Council on ADA Sessions and International Programs.

Upcoming Meetings

1998

Nov. 19-21 International Dental Showcase, NEC Birmingham, U.K. 01722 335599

1999
Feb. 3-6 Academy of Laser Dentistry's Sixth Annual Conference and Exhibition, Palm Springs, Calif. (248) 548-7171

Feb. 11-13 East Coast District Dental Society Miami Winter Meeting and Dental Expo, Miami (800) 344-5860 or (305) 667-3647

April 8-11 CDA Scientific Session, Anaheim (916) 443-3382, Ext. 4470

April 13-17 International Dental Show, Cologne, Germany, http://www.koelnmesse.de/ids

April 23-26 UOP/ADA Second National Conference on Over-the-Counter Dental Drugs and Products, San Francisco (415) 929-6486

Sept. 16-18 CDA Scientific Session, San Francisco (916) 443-3382, Ext. 4470

Sept. 17-18 Society for Advanced Dentistry Annual Meeting, New Orleans (317) 290-2613

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.