Open Letter

May 15, 2013
Dr.Twerskoi, DDS, DDS PhD Economist (EBS) Ger.
925 S Niagara St., #480
Denver, 80224

to

Colorado State Board of Dental Examiners
1560 Broadway, Suite 1350
Denver, CO 80202

Re: Vladislav Twerskoi, DDS

Dear Members of the Board:
I have prepared this open letter to the Board and request it be included as part of my file at the
Board office.

Recently, on March 22, 2013, the dental Board issued a Letter of Admonition in Case No.
20125069 admonishing me for alleged violations of the Dental Practice Law of Colorado,
specifically C.R.S. 1235129(1)(k) prohibiting acts or omissions which fail to meet generally
accepted standards of dental practice.

The basis for this admonishment was care provided to a patient in 2007, and involved issues of treatment planning and implant placement that, by its own admission, the Board recognizes were previously addressed in the Stipulation and Final Agency Order on January 20, 2010.

Since the previous Stipulation, (which was installed under coercive threats by the Board concerning my license) I have fully complied with all terms and conditions. Both practice monitors, a general dentist and a oral surgeon, observed over 40 surgical and prosthetic procedures without finding any shortcomings, and I have successfully completed the Board ordered postgraduate professional education. The Stipulation terms were released on August 17, 2011.

Even though the Board stated in the Letter of Admonition it believes that the conditions required to be completed as part of that initial Stipulation also covers these issues, the existing Letter of Admonition was added to my public disciplinary file.

I question how this action by the Board advances what should be the purpose of the Department of Regulatory Agencies to be fair and balanced to both licensees and patients in pursuing its mission to promote public health and safety.

No legal Due Process available.

I fully understand that I could have objected to the Letter of Admonition and then defended my care in an evidentiary hearing. However, under the current process available, this case would have been prosecuted by state employed lawyers at the Office of the Attorney General, heard by a state employed Administrative Law Judge (ALJ), and ultimately the initial decision of the ALJ would still be subject to acceptance or rejection by the Board itself, regardless of the outcome.

This procedure is described in the enclosed document titled Information Regarding the Board’s Action provided by the Board with the recent Letter of Admonition. This procedure does not allow for due process, is unfairly weighted in favor of the Boardwhich gets to make the final decision on the discipline it desires regardless of the findings and recommendation of the ALJand is designed to discourage thoughtful, legitimate challenges to the Board’s authority to dictate what treatments and techniques are to be recognized as commonly accepted by licensed dentists in Colorado.

The success of dental treatment plans which include the placement of implants is dependent upon many variables, including the quantity, quality and location of alveolar bone, the number of implants acquired, the patient’s oral hygiene and health habits (brushing, flossing, smoking, etc.), periodontal health, and the patient’s compliance with important instructions by his or her dentist.

Many of these elements, despite their very real ability to negatively impact outcomes, are beyond the direct control of the dentist.

In addition, pursuant to ethical and professional guidelines of the American Dental Association and other professional associations, dentists are obligated to consider and to honor the choices made by patients with respect to their care and treatment, including decisions based upon cost and expense.

Unfortunately, it has been my experience that, on occasion, a patient for whom I provide perfectly appropriate care and treatment based upon a limited treatment plan approved by the patient, receives an opinion from a subsequent treating dentist (in particular, those in direct competition with me who charge far more for more extensive treatment) criticizing aspects of treatment planning and/or routine patient complications without having any familiarity with the clinical circumstances at the time of my consultation with and care of the patient.

There are many roads leading to Rome.

Dentistry is not a one size fits all profession. As a dentist who trained and practiced in Europe for many years, as well as completing a fully accredited dental school in the United States, I have serious concerns that the Board does not give due consideration to treatment practices and clinical approaches that have been recognized, approved, and applied successfully throughout the field of dentistry in U.S. and worldwide.

For example, the primary basis for the Board’s concern and the issuance of the Stipulation in 2010 was my use in 2006 of ball end implants and abutments to place individual crown restorations. This is despite the fact the practice was first taught to me in a U.S. continuing education course accredited by American Association of General Dentistry in 2005/6, and in fact is now recognized and advocated in the United States as a way to achieve retention of restorations and crowns on implants/abutments.

While I was severely admonished for using ball end implants in the years of 20052007 in the coerced Stipulation from 2010, my use of the same implants in the recent case reviewed by the Board in 2013 was not criticized or commented upon at all, presumably because it is now well recognized that their use is reasonable and appropriate. It appears now that the admonishment in 2010 was premature, yet no effective mechanism exists for the retraction of the previous discipline or for the undoing of the harm to my reputation as a professional.

Is the American Academy of General Dentistry teaching wrong doing?

Specifically, in 2005/6 I attended a course accredited by AAGD and learned, in the U.S., of the
use of so called Mini Implants, which have a relatively narrow diameter of only 1.8mm. www.dentistrytoday.com


www.dentistrytoday.com

Besides being narrow and therefore able to be used in limited space situations, it is a one piece implant, which makes it significantly stronger than a comparable two piece implant, and it does not have an obligatory sub-gingival gap between the abutment and the implant body which creates a limit to bone attachment level.

Additionally, it has a rounded ball end abutment head which allows for a variety of applications.

This is a very useful feature, since it allows use of the implant for a denture as a retentive element, but at the same time it can be used as an abutment for fixed cementable restaurations like a crown, if needed.

Because of the ball shape at the top of the abutment, the friction of the cemented crown is greatly improved, which also allows the abutment to be shorter than usual and allows for a more variable line of draw.

In short, this was an innovative advancement taught in a continuing education course, and I reasonably chose to offer it to patients and apply it in appropriate circumstances and with appropriate patients in my practice.

It should be recognized that doing so was within the standard of care a term defined as what a reasonable dentist, with similar training, would do under the same or similar circumstances.

By its very nature, the standard of care encompasses the application of both old and new techniques, even if not all practitioners follow the same path, so long as the practices are rational and based upon reliable knowledge and valid clinical experience.

One would have to presume that techniques, which are being taught in AAGD accredited courses are meeting this standards.

Nevertheless, shortly after the application of the acquired technique on several patients, one of whom was my mother, I experienced circumstances where use of the newly recommended mini implant and the recommended insertion technique could result in fractures in some patients. (It was then recommended to place the implants till they would feel “rock hard”, which lead in many surgical hands to spontaneous implant fractures at the placement procedure.

Several years later, with little noise, this protocol was changed to “maximum 40 Ncm torque”, and then a scaled torque wrench became a standard tool in the surgical kit.)

Before the change in protocol was recommended, after consultations with other colleagues in the U.S., and one U.S. manufacturer (who assured me that many other U.S. dentists are using this approach), and based on my own experience from my previous practice in Germany, I began using larger implants of at least 3.0mm in diameter that were stronger and more reliable than the 1.8mm implants being taught to dentists in the U.S.

Of course, even with the change to a slightly larger implant, the advantages of using a one piece implant with a ball-end remained.

Unfortunately, in the context of one of my previous cases reviewed by the Board, the use of the single piece implant with a ball-end was noted and criticized by one specific dentist (a long time implantologist in Denver area, and a competitor, who was apparently not familiar with this upcoming treatment modality).

Knowledge regarding changes and advancements in implant technique and technology has risen tremendously within last ten years, but widely circulated reliable protocols have still been slow to develop, since modern implantology is a very young discipline.

Dental Board above every thing.

In another case reviewed by the Board, the Board intervened to actually direct the treatment of a patient in question and approved the unnecessary surgical removal of more than ten implants and the fixed prosthetic work in both jaws.

Moreover, this happened after the patient had used the dental work for three years, and just one day before a videotaped deposition was scheduled where my attorney could have preserved evidence of my dental work in function as part of my defense.

We make our own rules, accountability – not for us!

In my opinion, this action amounted to a clear cut intentional spoliation of evidence.

Based on this and another incident, my attorney filed two complaints with the Office of Attorney General.

However, no response was ever received (and it is appropriate to note here that the Attorney general serves as legal counsel for the Board in such matters).

One would expect the Attorney General’s role is to guard the proper application of laws, and not to defend the wrongdoing of governmental agencies.

Once on the hook …

The most recent admonition criticizes the margin of a bridge (FPD) placed on an implant in 2006. In these
images for the same patient, one can see what is being cited as a supposedly improper margin on the tooth (implant) #21. The status is after several years in use!

The dental Board is criticizing the margin on tooth #21.

However, one can clearly see how both hard and soft tissue have healed appropriately near the prefabricated crown margin on the implant.

Here, I decided to not reduce the healthy soft tissue, which would create disadvantageous anatomy for both – the implant as well as the adjacent natural tooth. Furthermore, instead of forcing the cementable margin deep sub-gingivally it is periodontally much wiser to stay epi-gingivally.

This approach, which I have taken from my first dental education in Germany, is being strongly recommended now as I have learned in recent CE courses again and again, since cement remnants after crown cementation in deep sulcuses is a major factor in complications.

The same can be said for screw loosening, bacterial infections of abutment implant connections, etc. in connection with two piece implants.

Many of those complications I was aware of in 2005/6 have led me, and many other clinicians to apply protocols which promised to improve the clinical results.

Without going into detail, this are clear examples of how clinical situations can be assessed differently by different clinicians, with good results for the patients.

While I do not insist on my methods being the only rightful way to treat patients, I believe the Board has not demonstrated the same degree of recognition and tolerance for clinical approaches that differ from those of a particular consultant hired by the Board on any given case.

The adversarial approach of the Board to investigate and to intervene in ongoing treatments in the provisioned aggressive way are not typically in the best interest of the patient, and promotes taking sides over issues that should be the subject of professional debate.

Public blame game not helpful for the treatment quality.

Furthermore, the public posting of such professional disputes as discipline and describing them as substandard care on the internet does nothing more than criminalizing the providers, sew the seeds of mistrust among the parties involved and does not contribute to a sound atmosphere in the field, which depends in large measure on mutual trust. It is nothing less than a modern Witch Hunt similar to those in middle ages, but is absolutely misplaced in a modern society.

At times, these conclusions are based upon the opinions of undisclosed experts retained by the Board who are never called upon to take ownership of their opinions and subject them to reasonable scrutiny, unless the dental practitioner in question wishes to challenge the Board and the Attorney General at great expense in a system that allows the Board to have the final word, even after an evidentiary hearing that might reach a different conclusion than the Board and its attorneys.

I have also learned that I am not the only practitioner who has shared a similar experience with the Board. While attending a course mandated by the Board pursuant to the 2010 Stipulation, I met practitioners also frustrated by the Board. While all agreed regulatory agencies are important and have a significant role to play in monitoring licensed professionals in the state, they also agreed the procedures established for review and enforcement must provide due process, or the credibility of the declared goal of the agencies to protect the public will be at risk.

Students have to be aware, that after having spent years and tremendous amount of funds for their education, they may end up in the forceps between debt, patients, unreasonable law suits, and governmental super vising bodies, which are not being hold accountable.

In the real world, providers must have confidence in the integrity of the regulatory process if they are to invest their valuable time and resources into education about helpful advances in treatment, building successful practices and purchasing new equipment to benefit the consuming public.

Otherwise, innovation, and patient care, will suffer, as professionals are intimidated not to rock the boat. Faced with such circumstances, many professionals will unfortunately chose not to challenge Board decisions at all, which can give the impression the Board is correct in its assessments, but still allow incorrect characterization of the treatment provided.

I have been placing dental implants since 1992 and conservatively estimate I have placed over 6000 since 2005 alone. This is in contrast to the average general dentist who may place only 25 implants per year. Because of the nature of my practice, I have always been a strong patient advocate and stay informed of the latest advances in dental science, both nationally and internationally, so I can offer his patients cost effective options for their consideration.

Unfortunately, this innovation and patient focused approach has not been appreciated by a the undisclosed experts of the Board. The fact that only a handful of patients have filed a complaint over the recent years must be viewed in relation to the many thousands of implants and patients successfully treated. In addition, the treatment of complicated patients often leads to complicated outcomes.

Obviously, it is common for different healthcare providers to have multiple opinions concerning treatment approaches to a particular clinical problem. In addition, the solvation of clinical problems become even more difficult, if financial limitations dominate the treatment choices.

A problem occurs, however, when a hostile dispute resolution system prevents proper communication among practitioners and regulators for the benefit of the patients.

Finally, I want to again note that I previously placed the following narrative in the newly mandated Health Profile on the DORA website to inform my patients about my views with respect to the difficulties created by the present regulatory system. However, this notice was removed from the site:

Dr.Twerskoi DDS DDS, PhD in decay prevention in children, practiced 12y in Germany. UCHSC 2004.

He took Continuing Education (CE) courses with Academy of General Dentistry in 2005 and applied the
technique.

Based on critique of one colleague, three patients complained in 2006/7. Dr.T. cooperated to clarify questions arose.

Knowledge regarding implants tremendously rose within last 10y. (In 2000 there were six implant systems, in 2010 1200). After 3y. there was no agreement rg. the assessment of treatment provided.

Dr.T. was not informed who reviewed the cases in question. His counselor recognized violations of CO Laws by some members at Dental Board and filed twice a complaint with the Attorney General (AG) office. No response was ever received. The CO Law provisions, that in case of a complaint about the Dental Board the AG has to defend the Dental Board.

One concludes, there is no institution to provide for check and balance of governmental actions. The Board provided it’s conclusions in a proposed agreement, and requested among others Dr.T. to attend CE courses. Dr.T. agreed to attend some CE classes, but disagreed with the conclusions of the proposed agreement.

In his view, it did not represent properly the facts. Dr.T. requested a judge’s hearing. Here upon the Board threatened to revoke Dr.T’s license, if he would proceed with judge’s hearing. CO Law provisions: After judge’s hearing the Board can still overrule the judge. Dr.T. was faced to lose the right to work in his profession. He was effectively barred from his right to challenge the decision of an institution in a due process. He was coerced to sign the agreement. Agreement signed under coercion is illegal.

Hereafter Dr.T. fulfilled all conditions as it was determined by the board. Among those Dr.T. attended the PROBE course, which he would otherwise reject to take.

Ethics was taught. Several other medical doctors attended. There Dr.T. learned Doctors who had similar experiences. Furthermore, undercover agents attended the course to elude in a conspiratorially way opinions of attending professionals.

This experience left a profound mistrust in the mind of the attendees as to how citizens are being treated by governmental agencies. All attendees agreed there is a role the agencies have to play. If however, no due processes are in place, and if the agencies have unlimited power to enforce its decisions, the declared goal to protect the public is at risk.

The medical providers can’t rely on law, the continuum of their practices over long term is uncertain. Investments in medical equipment requiring long term commitments are at risk. These questionable authority of Boards is a matter of concern.

One envisions instances where the proper treatment of patients is at risk. For example, the medical providers are aware of the hostile environment and refrain from innovative treatment modalities which may benefit the patient.

Conclusions about providers drawn relying on coerced “agreements” are ill based. Subsequent treatment of patients can be affected, if decisions are not being made based on clinical facts, but on assessments by the board. Even more questionable are board decisions, if their undisclosed experts happen to be competitors of the provider in critique, or are actually treating the patients and benefiting direct financially from the retreatment. Faced with the circumstances many professionals chose not to confront any board decisions at all, which leads to though unchallenged, but still incorrect characterization of the treatment provided. The recent law requires retrospectively to publish settlements in malpractice disputes.

Considerations for settlements were made in the past expecting that they would remain confidential. New legislation should not be effective retrospectively. In 2014 the dental practice law will be reviewed. Dr.Twerskoi is placing implants since 1992 and has since placed several thousand implants. Average GD is placing 25 implants per year.

Please feel free to contact me to review any of the matters addressed in this letter, as I would be
happy to assist the Board to improve the current regulatory landscape for licensed professionals
such as myself.

Respectfully,

Dr.Vladislav Twerskoi, D.D.S., D.D.S., Ph.D., Economist (EBS), Ger.
Enclosure

This is the complaint process for dentists in Colorado:

This is the complaint process if some one is not satisfied with his attorney.

No further comment is needed.

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Read more at http://www.nber.org/bah/fall04/w10709.html