for dental sales professionals january 2018 nitrous oxide · for dental offices looking to offer...
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For Dental Sales Professionals January 2018
A partnered publication with Dental Sales Pro • www.dentalsalespro.com
More dentists are finding that nitrous oxide leads to enhanced patient satisfaction, efficiency and revenues.
Nitrous Oxide
NSK America Corp. 1800 Global Parkway, Hoffman Estates, IL 60192, USA TEL: +1 888 675 1675 FAX: +1 800 838 9328
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FOR DENTAL SALES PROFESSIONALS
Piped vs. Portables4 Piped nitrous oxide systems often offer the best solution – provided they are properly installed.
EditorLaura [email protected]
Managing EditorGraham [email protected]
FounderBrian [email protected]
PublisherBill [email protected]
Senior Director of Business Development Diana [email protected]
Director of Business Development Jamie [email protected]
Art DirectorBrent [email protected]
CirculationWai Bun [email protected]
Associate EditorAlan [email protected]
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Editorial Staff
JANUARY 2018
Healthy RepsHealth news and notes
Windshield TimeAutomotive-related news
QuickbytesTechnology news
Pain ManagementImproved technology anddelivery systems have madeit easier for dentists to keeppatients comfortable and calm
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Nitrous Oxide and Oxygen SedationMore dentists are finding that nitrous oxide leads to enhanced patient satisfaction, efficiency and revenues.
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Piped vs. PortablesPiped nitrous oxide systems often offer the
best solution – provided they are properly installed.
BY LAURA THILL
Although there is an upfront cost for piping a nitrous oxide/oxygen sedation system (i.e., the cost of a medical gas plumber, copper piping, a manifold system, zone valve emergency shut off systems, if required, and a verification/inspection fee), there are long-term cost savings and benefits of which some clini-cians might not be aware, notes Michael Civitello, sales man-ager, Porter Instrument. “It makes sense for dentists to sit down and evaluate the long-term benefits before making a decision that they may later regret,” he points out.
In some cases, portable e-cylinder carts continue to offer a viable solution, he continues. He recommends portable systems when:
• The dental office is already built, and there are no options for running piping through a drop ceiling or basement.
• The current dental owner will only be at that location for a couple of more years, after which he/she plans to build a new office or stay on as an associate.
• The office has no plans to incorporate nitrous oxide/oxy-gen sedation into its regular routine, and only expects to use it a few times each year.
For dental offices looking to offer nitrous oxide/oxygen sedation more routinely, however, there are a number of benefits to adding piped or plumbed nitrous oxide systems, says Civitello, including:
• The cost of gas from larger H/G type cylinders com-pared with E size can easily equate to a $10 savings per patient on the gas itself. “Multiply that times the number of uses per week, and calculate that out over five, 10 or 20 years. It’s a large expense.”
• Portable e-cylinder systems may seem like a good idea, but compared to a centrally plumbed system, many den-tists (as well as assistants) often find reasons to not use them. Portable systems are never ready for use; often
are located in another room; require a constant change of cylinders; and take up valuable floor space. In addition, the cylinders generally arrive from the gas suppliers dirty and rusty, and they will be in plain sight of their patients.
• With a central system, every operatory is ready for ni-trous use. Having operatories set up for all types of uses helps avoid situations where one case may run long and the office must move a scheduled patient to another operatory, where nitrous may not be available. “Dentists don’t want to be in a position where they are unable to provide nitrous to patients who want or need it.”
• If nitrous oxide/oxygen sedation is easier to use, it will be used more often. “The whole reason to have a nitrous sys-tem is to provide comfort and relaxation for patients, while at the same time make it easier for the dentist to provide the treatment. Dentists who have easy access to nitrous oxide/oxygen sedation are likely to offer it to their patients more often, in situations where it could be beneficial.”
• Offices that can offer nitrous oxide – and, in turn, offer their patients a more comfortable, relaxed experience – can make a positive impression and facilitate more return visits. “Patients draw conclusions quickly based on what an office looks like and how it is set up. For instance, is it clean? Does it have modern equipment? That said, does the dentist really want to wheel in a portable cart that has rusty and dirty cylinders and various hoses hanging from it? Or would he/she rather have a built-in professional looking system that is designed for the space?”
• Nitrous oxide can be very profitable for a practice. When centrally plumbed, the per-patient cost is very low, particularly when one considers the concurrent fees the office may charge (on average, $75). And, when patients are satisfied with their care, they are more likely to complete – or follow up with – their treatment, return for future care and refer their family and friends to the practice.
More and more dental offices rely on nitrous oxide/oxygen sedation to re-duce patients’ anxiety and help them relax during complex dental procedures. For offices that use nitrous oxide/oxygen sedation even a few times each week, piped – or plumbed – systems could offer the most efficient and economical solution.
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NITROUS OXIDE
• Many states are adopting expanded duties certifications for hygienists, permitting those who are qualified to administer nitrous oxide, provided the dentist is on site. “Think of the additional profit the hygienist can produce by offering nitrous oxide to every patient. This isn’t easy to do with a portable E-cylinder cart.”
• As more general dentists bring in specialists to their offices, who rely on nitrous oxide/oxygen sedation, an accessible piped-in system is more important than ever.
It’s never too early for dentists to start planning their exit strategy, and piped nitrous oxide should be part of it, Civitello adds. “If dentists plan to sell their practice at some point, they should keep in mind that it may not attract specialists, such as pediatric dentists or oral surgeons, who are used to relying on easy access to piped nitrous oxide.”
Rely on the experts Manufacturer equipment specialists can ensure that piped ni-trous oxide systems are installed correctly and safely, and den-tists and their sales reps should involve their nitrous equipment manufacturer representative early in the process, notes Civitello. “There are many flowmeter options from which dentists can choose, as well as several installation options,” he points out. Once the needs of the practice and the design of its operatories are clear, the manufacturer rep/equipment specialist can recom-mend the best possible solutions, as well as advise on what is required from a code perspective. “Many Porter representatives have an ASSE 6005 Medical Gas System Generalist certification, which is essentially the same course that a Certified Medical Gas Plumber takes (without the hands-on/brazing portion).”
Equipment specialists can work with a dental office to address a number of important points, including:
• Flush mount flowmeters. It’s important to consider the style and type of cabinetry in which the flowmeter will be installed, as not all flowmeters fit in all cabinets. The manu-facturers rep can advise which flowmeter will work best in each cabinet style, and how best to position the flowmeter.
• Outlet stations. If using outlet stations, it is critical to plan where the outlets will be located. Installing outlets on the wrong side of the room can be a disaster.
• Piping. It is essential to pipe all operatories, even if they are not being set up with a flowmeter. Non-functional operatories can be piped, with a termination-point shut-off valve installed. If at some point the practice wishes to expand, the piping is in the wall; it will be easy to access the piping and connect a flowmeter. (If an operatory is not
piped, and the office decides to expand, it must bring in a medical gas plumber to cut pipes, rip open walls, etc.)
• Detached tank room. When the tank room is detached from the main office, both an automatic changeover manifold and zone valve will be required. An example of this would be a tank room in the basement or in a storage room located outside the main building (with no internal door from the main office to access).
Dentists should consider installing an automatic changeover manifold, rather than a manual changeover manifold, notes Civitello. “The manual changeover manifold may appear to save them some money,” he says. But, with this option, when the cylinder is empty, someone must go to the tank room to close one cylinder and open another, wasting time. It can be disruptive to a patient’s procedure
and inevitably lose the prac-tice money. “With an auto-changeover manifold, when one cylinder runs low, it au-tomatically switches to a full cylinder,” he says. “There is no disruption in the patient procedure, nor does anyone have to go to the tank room.”
An experienced manu-facturer rep can also ensure that the piped nitrous oxide system is installed by a prop-erly certified plumber, and inspected by an independent
third party, Civitello continues. “It’s important that only a certified medi-cal gas plumber works on the piping system,” he says. “These plumb-ers have an ASSE 6010 certification. They are required to carry an identification card at all times and are the only ones allowed to handle the piping and installation.” In fact, they can’t have an apprentice as-sist them unless that individual is ASSE 6010 certified, he points out. “Dentists and/or general contractors absolutely should not hire Joe the plumber who is trained to fix toilets. This is where major mistakes can happen, and it can cost patients their life.”
The piping system must be inspected by an independent verifier, notes Civitello. “This cannot be the person who did the installation, and he or she must have an ASSE 6030 medical gas system verifier certification. Dentists and/or general contractors cannot skip the verification to save $1,000. This is required.” Installation is not complete until both the medical gas plumber and medical gas verifier have conducted all required safety and functional tests, including the crossed lines test, he adds. “In the end, these documents must be turned over to the dentist.”
Offices that can offer nitrous oxide – and, in turn, offer their patients a more comfortable, relaxed experience – can make a positive impression and facilitate more return visits.
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Nitrous Oxide and Oxygen SedationMore dentists are finding that nitrous oxide leads to enhanced patient satisfaction, efficiency and revenues.
BY LAURA THILL
Relaxed patients are less likely to cancel their appointment and procedures often run more efficiently, she continues. That means each office can schedule an additional patient appoint-ment each day, realize cost savings and add revenues.
The science behind the technologyEnhancements in technology have made it increasingly safer and more efficient for dentists to administer nitrous oxide. Nitrous oxide/oxygen flowmeters have traditionally relied on needle valves and glass tubes to control the flow of gas, ac-cording to Keefer. Today’s systems feature flat screen dis-plays; digital, touch pad controls that offer greater accuracy over longer time frames; and enhancements in infection con-trol. As such, it’s important for clinicians to stay up-to-date and educated about the process.
When patients enter into treatment feeling com-fortable, relaxed and confident, they are more likely to cooper-ate and follow through with their plan – and, there’s a good chance they’ll refer family and friends to the practice. From the solo office to elite DSOs, “the use of nitrous oxide in den-tistry – commonly used to reduce anxiety, or to increase anal-gesia, relaxation, and cooperation levels of patients – can also be useful for prolonged or more complex dental procedures, as well as for patients with hyper-responsive gag reflexes or low pain tolerance,” according to Leann Keefer, RDH, MSM, director, corporate education & professional relations, Cross-tex. The use of nitrous oxide/oxygen sedation is a “practice builder, enabling patients with dental fears or certain medical or mental conditions to get the treatment they need,” she says. “Patients tend to be more relaxed and comfortable, because nitrous oxide can reduce their anxiety and assist them with pain management.”
January 2018 First Impressions www.firstimpressionsmag.com8
NITROUS OXIDE
Nitrous oxide continues to be administered by inhalation, ab-sorbed by diffusion through the lungs and eliminated via respi-ration, she notes. Proper equipment for monitoring, and storage unit integrity, are necessary in order to avoid unintended gas leakage or excessive exposure. In addition, clinicians should be educated on the various components of a nitrous oxide/oxygen sedation system:
• Nitrous oxide is stored in closed gas cylinders. Oxygen and nitrous oxide are part of the required equipment.
• Regulators ensure safe delivery of gas to the patient by reducing/controlling the pressure from the cylinders.
• Manifolds in a central delivery system connect several large cylinders of gas together, ensuring the constant availability of gas to each treatment room through cop-per lines within the walls of the building.
• In a portable system, a yoke stand is the metal frame-work on which the equipment rests and is easily moved on wheels to different areas of the dental office.
• Flowmeters are highly calibrated devices designed to indicate the amount of gas being delivered to the patient. Flowmeters further reduce the pressure level to local atmospheric pressure, and restrict the proportion as well as the flow rate of nitrous oxide with a fail-safe mechanism to keep a minimum oxygen concentration of 30 percent.
• The reservoir bag contains the gas mixture being deliv-ered to the patient.
• Gas is delivered through conduction tubing, which runs from the delivery unit and attaches to the breathing apparatus.
• The capnography device monitors patient breathing by measuring the actual CO2 in the patient’s exhalation.
• A specially designed nasal mask/hood fits snugly around – and fully covers – the patient’s nose, al-lowing the mixture of nitrous oxide with oxygen to flow, while providing complete access to the patient’s mouth. Single-use, disposable masks are preferred to reduce the spread of infection. Disposable masks today are available in various designs and sizes, as well as patient-friendly scents like vanilla, strawberry, mint, grape, and bubblegum. Newer low-profile masks provide unencumbered access, with a small lightweight scavenging system, which is easier to work around than the traditional masks and co-regulated hoses, and contributes to more efficient care and reduced chair time. While traditional masks are opaque, some newer nasal hoods are translucent, allowing clinicians to visu-ally monitor their patient’s breathing.
Resolution 37In October 2016, the passing of Resolution 37 at the American Dental Association’s (ADA) annual meeting called for revisions to safety regulations for providing anesthesia and sedation, accord-ing to Keefer. The rules and regulations for nitrous oxide sedation largely remain the same in light of Resolution 37, she explains. “Healthcare providers are required to complete 14 hours of CE for N2O/O2 alone and 16 hours for N2O/O2 combined with a single-dose sedative up to the MRD. MRD is maximum FDA-recommended dose of a drug for unmonitored home use.
“Sedation levels deeper than what are typically found with nitrous oxide (minimal sedation) now require considerably more
training than in the past,” she continues. “Perform-ing oral, intravenous or any other method of moderate sedation now requires a 60-hour course and at least 20 patients. Previously, only a 24-hour, 10-patient course was needed. Dentists who were already practicing se-dation dentistry before the guidelines [were issued] are now required to be re-trained and will not be grandfathered in as in the past. Critics of the resolu-tion cite the financial im-pact of the new regulation, as the increased training will drive costs up, prevent-ing dentists from pursuing advanced sedation training.
“Resolution 37 is only a guideline and the ADA has no en-forcement authority,” Keffer explains. However, most state dental boards will adapt the ADA guidelines in drafting their own regu-lations. “Dentists offering sedation can vastly expand the scope of their practice,” she says. “Yet, probably fewer general dentists will elect to go through the trouble and expense to get their mod-erate sedation certification. Following the dramatic increase in training required for deeper states of sedation, many will limit their practice to nitrous oxide, with or without a single-dose oral sedative up to the MRD.”
Regular service, enhanced safety and longer life expectancyIt is important for dental offices to have their nitrous oxide and se-dation equipment serviced and calibrated at a minimum every two
Newer low-profile masks provide unencumbered access, with a small lightweight scavenging system, which is easier to work around than the traditional masks and co-regulated hoses, and contributes to more efficient care and reduced chair time.
www.firstimpressionsmag.com First Impressions January 2018 9
years, notes Keefer. Doing so can help avoid the potential for leakage and en-sure the equipment is safe to use, as well as ensure it runs efficiently for 15-20 years. “Manufacturers recommend vari-ous levels of maintenance and service for their units, including routine, preventive, scheduled and recalibration,” she says. In addition to recalibration, service proto-cols should include pressure testing and internal component integrity/replace-ment, as well as any other necessary fac-tory testing procedures. Clinicians should refer to the specific manufacturer’s IFU (Instructions For Use) and follow the rec-ommendations to ensure safe use and delivery of NO2/O2 for patients and staff. The service and inspection of anesthetic gas equipment should be performed by qualified service personnel.”
An investment for the practiceImplementing nitrous oxide/oxygen se-dation in a dental practice – no matter how small or large – can quickly become a source of revenue, as well as help the practice address the needs of patients anxious about their pain management. (The current ADA/CDT-4 code for billing dental procedures using nitrous oxide/oxygen sedation is 09230.)
There are two options for delivering nitrous oxide, notes Keefer: portable units and central systems. “Portable – or self-contained units – can cost between $3,500 for a two-cylinder system to $8,000 for a four-cylinder, enclosed system,” she says, noting that portable systems are recom-mended for offices that only occasionally use nitrous oxide/oxygen sedation.
The cost of centrally installed systems – which are recommended for practices that routinely implement nitrous oxide/oxygen sedation – ranges from $2,500 to $4,000 per operatory, with a total av-erage cost of $28,000 for a mid-sized office, notes Keefer. “Although the initial set-up costs are high, the central system
is more cost-effective in the long run,” she points out. “The smaller E cylinders of a portable system are approximately five times more expensive than the larger G or H cylinders, due to the high cost of packaging the gases. In addition, the centralized system is more convenient, as it minimizes the need to change cylin-ders frequently. Not only are the cylinders larger than those of a portable system, several cylinders can be connected via a manifold system. When one cylinder is depleted, the system automatically switches to the next available cylinder.”
Indeed, when a dental practice con-siders that the use of nitrous oxide/oxy-gen sedation systems helps patients re-lax in the chair – thereby reducing patient chair time and increasing office efficiency – and leads to greater revenue, most clinicians will agree it’s a worthwhile in-vestment. At the end of the day, satisfied patients mean more return visits, more patient referrals and a greater bond with the community.
Sales reps can initiate a discussion about nitrous oxide with their dental cus-tomers by asking a few probing questions:
• “Doctor, do you currently offer N2O/O2 sedation?”• “If not, can you tell me why?”• “If so, how often is it used per week?” • “Do you charge a fee?”
• “Do you consider your patients’ comfort levels valuable?”• “Are you less stressed when your patients are relaxed and cooperative?”• “Are you aware that by implementing nitrous oxide at your practice, you
can potentially generate about a $30,000 profit annually, simply by using it just 3-4 times each day?”
• “Have you considered the number of potential new patients who might call your practice to inquire whether you offer nitrous oxide/oxygen sedation, and how many might not schedule an appointment if you do not offer it?”
• “Have you seen the Digital Ultra Flushmount Flowmeter by Crosstex/Accutron?”
• “Have you seen the new Crosstex/Accutron Axess LOW PROFILE Nasal Mask?”
A conversation starter
Indeed, when a dental practice considers
that the use of nitrous oxide/oxygen sedation systems helps patients
relax in the chair – thereby reducing patient chair time
and increasing office efficiency – and leads
to greater revenue, most clinicians will
agree it’s a worthwhile investment.
January 2018 First Impressions www.firstimpressionsmag.com10
HEALTHY REPS
Health news and notesThird dose of mumps vaccine?With the U.S. facing a growing number of mumps outbreaks, an expert panel that advises the Centers for Disease Con-trol and Prevention recommended that people who are at risk during outbreaks (such as those on college campuses) should receive an additional, third dose of vaccine, reports STAT. The Advisory Com-mittee on Immunization Practices unani-mously voted to approve a third dose of mumps-containing vaccine as a tool for outbreak control, despite acknowledg-ing evidence to support the practice is limited. After years of low numbers of mumps cases – fewer than 1,000 cases nationally a year – the disease has made
Blood thinners are often prescribed to help prevent blood clots that can lead to pulmonary embolism, heart attack and stroke. Though effective at prevent-ing these clots, warfarin can cause life-threatening bleeds. Warfarin has led to more emergency room visits for older people over the last decade than any other medication. This is because it can be difficult for doctors to determine the right dose. A team of scientists led by Dr. Brian F. Gage at Washington University in St. Louis investigated whether genetic testing can help predict the best warfarin dose to give a patient. They compared outcomes for patients whose initial doses were based on clinical information alone (e.g., age, weight, etc.) to those whose initial doses were based on their genetic makeup (genotype) along with clinical factors. The researchers collected blood samples from the patients and screened for ge-netic differences in the genes VKORC1, CYP2C9, and CYP4F2, which are related to blood clotting and warfarin metabolism or sensitivity. Adverse events were tracked for 90 days, including major bleeding, deep vein thrombosis, and pulmonary em-bolism. There were fewer adverse events in the genotype-guided dosing group: 87 events, or 10.8 percent of the genetic group, versus 116 events, or 14.7 percent of the clinically guided group. No patient died during the study.
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a resurgence in the past decade. There were nearly 7,000 cases nationally in 2006 and more than 6,000 in 2016. As of early October, there were 4,667 cases in 47 states and the District of Columbia in 2017.
Memories are made of thisUsing an innovative “NeuroGrid” technology, scientists showed that sleep boosts communication between two brain regions whose connection is critical for the formation of memo-ries. The work, published in Science, was partially funded by the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, a project of the Na-tional Institutes of Health. A brain structure called the hip-pocampus is widely thought to turn new information into permanent memories while we sleep. The study – in-volving rats – confirmed the presence of ripples in the hippocampus during sleep and found them in an area on the brain’s surface involved in processing complex sen-sory information. As a result, the researchers theorize that such communication is im-portant for the creation and storage of memories, and they hope to use the NeuroGrid in people undergoing brain surgery to see if the same ripples occur.
How do the biggest losers keep losing?Researchers have been working to understand which aspects of diet and physical activity are most important for weight con-trol. A team led by Dr. Kevin D. Hall of the National Institutes of Health studied participants in a season of “The Biggest Loser,” a televised weight loss competition. Of 16 competitors enrolled, 14 participated in a follow-up study six years later. Seven par-ticipants had maintained an average weight loss of about 25 percent of their starting weight. The other seven returned to a weight that was within 1 percent of their starting weight. The calorie intake of both groups was similarly reduced from be-fore the competition began. The main difference was in levels of physical activity. The weight loss maintainers increased their
physical activity by an average of 160 percent from before the competition began, while those who regained their weight had only a 34 percent increase. The scientists calculated that an in-crease of about 80 minutes per day of moderate physical activ-ity or 35 minutes per day of vigorous activity was necessary to maintain lost weight. These amounts are much greater than current recommendations for daily physical activity.
Heartburn: The lesser of two evils? The recent rise in the use of stomach-acid-suppressing medica-tions might be contributing to an increased incidence of chronic liver disease, according to a team of researchers led by Dr. Ber-nd Schnabl at the University of California San Diego School of Medicine. The researchers found that mice lacking stomach acid had higher levels of intestinal bacteria as well as imbalances among the microbes. In particular, the mice had increased levels of Enterococcus in their guts. Further experiments suggested that these bacteria can reach the liver, where they can cause liver inflammation and damage. The team looked at whether people taking proton pump inhibitors – heartburn medication – have similar microbiota changes. They collected fecal samples from healthy people before and after PPI treatment. After two weeks, those taking the PPI treatment also had a higher number of Enterococcus.
Steady as she goesOne in four Americans aged 65+ falls each year, resulting in more than 2.8 million injuries treated in emergency departments annually, and more than 27,000 deaths, per the U.S. Centers for Disease Control and Prevention. The National Council on Ag-ing leads the National Falls Prevention Resource Center, which supports awareness and educational efforts about falls, and pro-motes evidence-based falls-prevention programs (such as exer-cises). For more information, go to www.ncoa.org/fallsprevention
Vacation deprivationAmericans are struggling to use their vacation time, per Expe-dia.com’s Vacation Deprivation® report. Millennials are the most vacation-deprived age group (62 percent) and receive the least vacation time. They are also the most likely to shorten their trips due to impending workload (53 percent). But it’s not just millen-nials who are struggling to achieve work/life balance. Around half of workers in the U.S. report feeling somewhat or very va-cation-deprived, and were projected to lose approximately 462 million vacation days in 2017. The primary reasons cited for not taking time off are budget (43 percent), the desire to save up vacation days for a longer holiday (30 percent), and not being able to get away from work (22 percent).
One in four Americans aged
65+ falls each year, resulting in more
than 2.8 million injuries treated
in emergency departments annually, and
more than 27,000 deaths, per the U.S. Centers for Disease Control and Prevention.
January 2018 First Impressions www.firstimpressionsmag.com12
WINDSHIELD TIME
Chances are you spend a lot of time in your car. Here’s some automotive-related news that might help you appreciate your home-away-from-home a little more.
Car dealer of the futureFrom Automotive News: The year is 2030, and the 10,000-square-foot showrooms of the past are relics. So are many of the staffers who once worked in them. Those who remain need new skills to mirror the new realities of automotive retailing. Now, a few mod-els of autonomous vehicles sit in the center of a tidy, tasteful and tiny showroom, available for purchase or subscription ride-hail-ing services. The vehicles are framed by just four desks where the transportation consultants – formerly called salespeople – work. Whether a customer buys an autonomous vehicle, or signs up for a subscription ride-hailing service, most transactions hap-pen digitally, including virtual in-home test drives. On rare occa-sions, some customers visit the micro dealerships to touch the cars and work with a transportation consultant on a personalized subscription plan. The product presenters or transportation con-sultants understand the car, present its features online, arrange financing or payments, and deliver it if needed – tasks that go beyond today’s “Genius” staffers at BMW dealerships.
I want one of theseYou probably won’t need one of these to get around in your town, but it is cool thinking about it. The Tesla Semi is a full-size elec-tric truck that can go from 0 to 60 mph towing 80,000 lbs., its max tow load, in 20 seconds, according to Tech Crunch. It can go 500 miles at highway speed, and it requires no shifting of gears (as is normal for most electric vehicles), with regenerative braking, which provides “basically infinite” brake life per Tesla. One 30-minute charge will get you 400 miles. The driver is cen-tered in the cab, with touchscreens on either side of him or her,
offering navigation information, blind spot monitoring and trip data logging applications. Take advantage of the million-dollar warranty. And take pride in parking this beautiful vehicle in your driveway … or the nearest rest stop.
Self-driving shuttle busesDespite this fall’s fender bender involving a small driverless shuttle in Las Vegas, autonomous shuttles could become viable tools of mass transit, according to Wired magazine. They could be used on college campuses, in retirement communities, or to supplement public transportation in the suburbs. “Most transit authorities are looking for opportunities to answer the first-mile, last-mile question,” bridging the distance between transit hubs and people’s final destinations, Maurice Bell, Keolis North Amer-ica’s head of mobility, was quoted as saying.
By the way, here’s how the fender bender in November oc-curred: The shuttle encountered a semi-truck backing out of an alleyway and stopped. It couldn’t back up, because there was a vehicle directly behind it. So it just sat there as the truck slowly backed into it. (The shuttle could have honked, a Keolis repre-sentative said, but didn’t because the truck’s trailer moved in a way that the autonomous system did not anticipate.)
Flying cars on demandUber announced it wants to launch at least a few flying “cars” in Las Angeles in 2020, with a real commercial service to follow a few years later, reports Wired. Uber is reportedly working with aerospace partners at Embraer, Bell Helicopter, Pipistrel, Au-rora Flight Sciences, and Mooney Aviation, to develop a drone.
Automotive-related news
www.firstimpressionsmag.com First Impressions January 2018 13
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Don’t expect the program to look like Uber’s ground service, at least not for a while. It’s likely the first flights will have to follow agreed-upon routes, such as above freeway corridors.
On-demand test drivesA mobile used-car dealership in Nova Scotia is offering the op-portunity for car buyers to inspect, test drive and purchase their next used-car from the comfort of their driveways. The service, Clutch, is only available to residents in the Halifax metro area. How it works: Clutch captures high definition photographs of its used cars at their headquarters. Once listed on their website, anyone with a computer or smartphone can browse, book an at-home inspection or test-drive and even get financing on Clutch’s proprietary buying platform. www.clutchcanada.com
How much longer?Customers at automotive body repair shops can get a real-time update of the repair process via Carbeat™, a software appli-cation introduced by AkzoNobel’s Vehicle Refinishes business. The application is deployed on a large touch-screen monitor, and provides a comprehensive overview of the work in production. The company says Carbeat “enhances the quality and granular-ity of captured cycle time data, which enables deeper insight into ways to improve efficiency and eliminate waste.”
Cool dashcamCar and Driver magazine introduced a new dashcam – the MinioPro – featuring 1080P video capture, auto recording, a microSD drive with up to 64GB card capacity and a GPS antenna. While dashcams are often used to document time spent on the track, they also are increasingly essential as electronic evidence resolving disputes stemming from road incidents, according to the magazine. The MinioPro features a built-in motion sensor, which detects abrupt changes in vehicle speed and automatically captures a still image and locks in the five seconds prior to and subsequent to an incident. It is available at Best Buy with a suggested retail price of $200.
Formula EThe first thing you notice about electric car racing is that it’s relatively quiet, according to the author of an article by the Con-sumer Technology Association. There is a high-pitched whining sound, but not nearly the eardrum-shattering blasts one gets at NASCAR races or from Indy cars. Formula E racing takes place in the world’s largest cities, right in the heart of the city. Hong Kong, Mexico City, Paris, Montreal, Marrakech and New York were on the calendar this year; Santiago, Rome and Sao Paolo are lining up for future races.
January 2018 First Impressions www.firstimpressionsmag.com14
Editor’s Note: Technology is becoming an integral part of the day-to-day business of sales reps. In this department, First Impressions will profile the latest developments in software and gadgets that reps can use for work and play.QUICKBYTES
Are you ready, boots?UnitedHealthcare and Qualcomm Inc. have integrated wearable devices from Samsung Electronics America Inc. (Fit2 Pro and Gear Sport) and Garmin International Inc. (vivosmart® 3) into United-Healthcare Motion™, a national wellness program that provides eligible plan participants access to activity trackers and enables them to earn more than $1,000 per year by meeting certain daily walking goals. UnitedHealth says that Motion participants have collectively walked 130 billion steps, earning more than $19 mil-lion in incentives since the program began. The program enables employees to earn up to $4 per day in financial incentives based on achieving F.I.T. goals: 1) Frequency: complete 500 steps within seven minutes six times per day, at least an hour apart; 2) Intensity: complete 3,000 steps within 30 minutes; and 3) Tenacity: complete 10,000 total steps each day.
For those long, long ridesNaztech (www.naztech.com) introduced the Xtra Drive Mini, a thumb-sized, high-speed Micro SD card reader capable of up to 256GB of extra storage for iOS devices including the iPhone 8, iPhone 8 Plus and the iPhone X, as well as the iPad and iPod. It has a capacity of up to 170,000 photos, 74,000 songs, or 72 hours of video. Shows can be watched directly from the drive without using any of the Apple de-vice’s own memory.
Your personal physicianThe Apple watch doesn’t have a sphygmomanometer or poly-somnographic equipment found in a sleep lab – but thanks to machine learning, it might be able to help with their work, reports Wired. Research presented at the American Heart
Technology News
www.firstimpressionsmag.com First Impressions January 2018 15
Association meeting in Anaheim claims that, when paired with the right machine-learning algorithms, the Apple Watch’s heart-rate sensor and step counter can make a fair prediction of whether a person has high blood pressure or sleep apnea. The new study adds to evidence that the right algorithms might transform the Apple Watch from personal trainer to personal physician.
Weekend dealsApple is offering a feature to the App Store called “This Week-end Only,” which lists deals that can be found inside apps, as opposed to discounts on downloads of apps themselves, ac-cording to TechCrunch. Every Thursday, users will find on the Apps tab an app labeled “This Weekend Only,” with promotions valid through Sunday.
Startups to watchSome startups that could make your life easier and your business run smoother, per the Chicago Tribune : 1) Foodietrip (matches people looking for food tours with hosts for tastings); 2) Gadget Flow (shopping site for cutting edge products, including those from Kickstarter, Etsy, Amazon and IndieGoGo); 3) COSIGN (lets you click on objects, such as clothing, on a friend’s social media page and tells you where you can buy it); 4) globalVcard (could become the premier provider in digital payment); 5) Pindrop (neutralizes phone calls that are trying to steal someone’s iden-tity); 6) Nowait (partners with Yelp to let you virtually stand in line at a restaurant); and 7) Bellhops (active in 50 cities, hooks you up with college kids who are willing to move your stuff).
Do it yourselfBITalino is a set of hardware and software ingredients that allow just about anyone to build their own body monitoring
devices, reports Madgad-get. The folks behind BITalino have made it easier to collect data from different body sensors, to process it, and to share it. The software, which previously required stand-alone computers to run, is now available in a cloud-based version. It makes it easy to go from assem-bling a kit to using the gathered data, as there’s no software to install or a computer to manage. Moreover, BITalino is be-ginning to provide plugins for the software that are designed to process spe-cific kinds of data in a proper way. One of the first releases is a heart rate variability package
that implements guidelines from the Task Force of the Euro-pean Society of Cardiology and the North American Society of Pacing Electrophysiology. All the gathered and processed data can be stored on Dropbox, Google Drive and other on-line cloud storage systems. There’s also an Android app that can be used to gather data, and work is underway to allow memory cards to be used to acquire the data.
The new study adds to evidence that the right algorithms might transform the Apple Watch from personal trainer to personal physician.
January 2018 First Impressions www.firstimpressionsmag.com16
PAIN MANAGEMENT
Improved technology and delivery systems have made it easier for dentists to keep patients comfortable and calm
Pain Management
Pain: A major concernFor most patients, receiving an injection is the most “fear-in-ducing” aspect of a dental visit, says Stanley Malamed, D.D.S., Emeritus Professor of Dentistry, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA. In fact, it is estimated that some 30 to 40 million persons in the United States avoid seeking dental treatment because of their fear of pain and needles.
Malamed – a consultant for St. Renatus – believes that “pain control is the most important aspect of dentistry, as most dental treatment cannot be performed without ad-equate pain control.”
Not only do most patients fear the pain associated with an injection, many dentists are equally frustrated by their inability to successfully – and consistently – manage their patients’ pain, Malamed points out. Making matters worse, some needle-phobic
BY LAURA THILL
The dreaded needle! For most patients about to receive an anesthetic, it’s their big-gest nightmare and the last thing dentists want is for their patients to be uneasy in the chair. Contrary to what many patients believe, the needle isn’t the greatest source of their pain; the majority of pain comes from the anesthetic itself, according to experts.
www.firstimpressionsmag.com First Impressions January 2018 17
patients have been known to faint (syncopy) – the most common medical emergency in dentistry, he notes. This – together with concern that the use of a syringe and needle can lead to inadver-tent needlesticks and potential transmission of such diseases as Hepatitis C and HIV – have led some doctors to explore a needle-less alternative. “Kovanaze – a nasal spray consisting of 3 percent tetracaine and 0.05 percent oxymetazoline – effectively provides anesthesia to maxillary non-molar teeth via a nasal spray,” he ex-plains. “No needles are involved.
“Most dentists dislike administering palatal injections be-cause, in their mind, they hurt,” Malamed continues. “The same is the case for their patients. Offering a new technology that pro-vides profound anesthesia without the need for injection should be well received by both doctors and patients. Further, there is no anesthesia extra-orally, so the upper lip does not get numb or droop.” This is a “significant advantage in some esthetic dentistry procedures,” he adds, as it won’t impair the patient’s abil-ity to eat, drink or speak.
In addition, the availability of a rela-tively new drug called OraVerse – a local anesthesia reversal agent introduced to the market in 2008 – helps reduce the amount of time a patient is numb.
Needle: Addressing misconceptionsWhile more dentists are incorporating Kovanaze in their practice, needle in-jections remain a common and efficient means for delivering anesthetics. By se-lecting the right needle size, dentists can provide injections safely and more comfortably, notes Matt Woolson, product manager, Septodont. However, sales reps may have to help clear up a few misconceptions for their dental customers.
“Many dentists hate giving injections as much as their pa-tients hate getting them,” says Woolson. But that needn’t be the case. Features such as needle sharpness, length, bore size and quality all impact the injection delivery, he points out. “Most den-tists don’t know what needle brand they use,” he notes. Yet, the manufacturing process and quality of materials can have a big impact on the efficacy of the needle.
Dental needles are typically available in three gauges (25-gauge, 27-gauge and 30-gauge), according to Woolson. The smaller the needle gauge, the larger the needle size. In addition, the 25-gauge and 27-gauge needles are available in two lengths (long and short), while the 30-gauge needle is available in short and extra-short. Dental schools encourage students to use a 25- or 27-gauge needle, and most commonly a 25-gauge long needle and
a 27-gauge short needle is used. However, practicing dentists tend to favor the 30-gauge needle because it is the smallest size avail-able, he notes. Indeed, many dentists have a misperception that a smaller needle size is associated with less pain for the patient. “This is absolutely wrong and, in some cases, dangerous,” he says.
“A 30-gauge needle is only available in short or extra-short,” Woolson continues. “Extra-short needles are designed for use with PDL injections, while short needles are designed for infiltrations. (Long needles are designed for block injections.) Some dentists use 30-gauge short needles for block injections, but that is ill-advised, he says. This particular needle is 25 mm long, he notes. If it is used for, say, an inferior alveolar nerve block injection, and the dentist needs to advance the needle 15–20 mm into the tissue, “that leaves very little room for error if the needle breaks.
“I met one dentist who used a 30-gauge extra-short needle for an inferior alveolar nerve block injection,” Woolson recalls. “An extra-short needle is only 10 mm long. That means this dentist not only advanced the needle to the hub, but had to com-press the patient’s tissue enough to permit the needle to be in-jected even further. Imagine the discomfort for the patient!” And, if the dentist inadvertently breaks a short or extra-short needle during an inferior alveolar nerve block, he or she may need to surgically remove it. To do so would cause scarring on the pa-tient’s neck, not to mention a lawsuit, he points out.
“Years of clinical research shows there is no perceptual dif-ference between a 25-, 27- and 30-gauge needle when inserted into the oral tissues,” says Malamed. “Yet dentists persist in using 30-gauge short and ultra-short needles for all injections, including the inferior alveolar nerve block.” In fact, over half of all needles sold to dentists in the United States are 30-gauge, he points out. “I’d love to see them use 27-gauge long and short needles, but after 43 years of teaching and preaching, I’m running short on hope in this regard.”
Looking sharp
At Septodont, needles and pain management can mix – as long as the needles are high quality and designed with optimal patient comfort in mind. First and foremost, needle sharpness is key, notes Matt Woolson, product manager, Septodont. In addition, the company offers the Septoject Evolution needle – a uniquely designed needle featuring a beveled scalpel – and the Septoject XL, which features an oversized lumen or bore. “The Evolution needle is so sharp, it is only indicated for infiltrations and PDL injections,” he says. “There is too much risk using it on block injections, where it could damage a nerve.”
January 2018 First Impressions www.firstimpressionsmag.com18
PAIN MANAGEMENT
Reaching out to customersReps can initiate a discussion about pain management by asking a few probing questions:
• “Doctor, have you ever had a patient faint during an injection?”
• “Do your patients ever ask you if you have to give them a shot in order to do a procedure? Do they ever confess that they hate getting shots, but once they are numb they’re okay? These patients are prime candidates for needleless nasal spray for their planned treatment involving maxillary non-molar teeth.”
The cost of new technology may be a factor to the dentist, but it shouldn’t be, says
Malamed. “I am perplexed at how a dentist can quibble over the cost of new technolo-gies that enable him or her to provide better quality pain control, more easily, more com-fortably and with increased safety. Yet they do. Yet these very same doctors will spend many thousands of dollars buying lasers, intraoral TV cameras and other truly expen-sive technology that, in many cases, cannot be used without the dentist first achieving effective pain control.
“To paraphrase the old Mastercard ad-vertisements: What is it worth to be able to provide your patients with pain-free dentist-ry using, for example, a needleless technol-ogy, when the two most important items in a patient’s shopping list for a ‘good dentist’ are, ‘I don’t want to be hurt’ and ‘a painless injection?’ It is truly priceless.”
For many patients, the worst part of a dental procedure is the initial injection of the anesthetic. A fear of the needle – together with their concern that the numbness might not last and they’ll experience great pain – presents a challenge for dentists, whose goal is to provide an optimal patient experience.
Indeed, a common misconception among patients is that the stick of the needle is the biggest source of pain when, in fact, the bulk of pain comes from the anesthetic itself. “Lo-cal anesthetic is very acidic, with a pH level as high, if not higher than that of citric acid,” says Ryan Vet, vice president of marketing, Anutra Medical. Consider getting injected with lemon juice, he points out. “No wonder it burns!”
One solution is the Anutra Local Anesthetic Delivery System, notes Vet. “By utilizing buffered anesthetic from the Anutra Local Anesthetic Delivery System, practitioners are able to inject local anesthetic at an acidity level that mirrors that of the patient’s body,” he continues. Some patients have even commented that they were unaware of receiving the shot, he adds. Additionally, whereas only two-thirds of patients typically reach pulpal anesthesia after the first injection of anesthetic, with buffered anesthetic, “the majority of patients get numb the first time,” he says.
“Utilizing buffered anesthetic helps the anesthetic take effect – on hard-to-numb patients as well as during nerve blocks – often in two minutes or less,” says Vet, providing dentists with as much as 15-20 minutes for each restor-ative procedure they perform. For dentists who perform as many as 20 or more cases each week, they may gain an extra hour or two in a typical day, he points out, offsetting the higher expense for dentists purchasing a premium anesthetic such as Anutra.
Buffered anesthetic is far more reliable than traditional anesthetic, says Vet. This means fewer bail-out shots. Anutra is also more predictable, making it possible to schedule shorter appointment times and schedule more efficiently. Buffered anesthetic is more profound than tradi-tional local anesthetic, allowing dentists to use less volume than they traditionally would have. Additionally, with the multi-dose Anutra Syringe, dentists are able to deliver the precise amount of anesthetic required, eliminating waste. This means the dentist is no longer confined to a 1.8 mL carpule. Most importantly, Anutra helps ensure peace of mind for patients, making their experience in the chair a positive one.
Buffered anesthetic
“ Offering a new technology that provides profound anesthesia without the need for injection should be well received by both doctors and patients.”
– Stanley Malamed, D.D.S.
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