One Patient’s Story
July 25, 2012
This is the story about a woman I met recently named “Carol”. Carol’s story is the reason I do what I do every day and brings me back the next day. The interesting thing is that it has absolutely nothing to do with performing the actual physical work of dentistry.
Carol is in her 70’s and for most of her life has gone to the dentist infrequently. She presented to my office a couple of months ago for a second opinion. At our first appointment Carol brought her most recent x-rays, a treatment plan from another dentist, and a page-long list of questions. She was well-prepared for the complimentary consultation I was giving her and seemed to know exactly what she wanted.
About 8 years ago, Carol visited a dental office that touts itself as “holistic”. Carol had about $10,000 of dentistry done at that office and unfortunately had not seen a dentist since. Her reason for visiting that particular office was because she was/is very concerned about her health and believed that a “holistic” office could provide her with what she was looking for. Now, only 8 years later, her teeth were falling apart.
Carol had eight crowns done on her upper back teeth at that time. The crowns, still in her mouth, were failing due to recurrent decay. More importantly to Carol, her front teeth were in severe breakdown. Carol had her mind made up; she wanted full dentures.
Carol sought out a local dentist, presented her desires, got a written treatment plan with fees, and then came to me for a second opinion. She brought that treatment plan with her and it appeared very reasonable – take out all remaining teeth and place full dentures. The first thing I noticed was that Carol had 6 lower front teeth that have been decay-free and have had excellent bone supporting them for 70 years. However, her mind was made-up, she wanted everything taken out. She did not want to have to deal with maintenance of teeth any more.
Over the next two consultation appointments I had with Carol, we discussed many different treatment options. We thoroughly reviewed the advantages of keeping these lower front teeth each time we met. Carol brought a list of questions to each of these meetings, which we discussed in depth. It was decided – Carol was moving forward with full dentures.
We have had two more appointments since then. Because of the location of the dental laboratory that I use, those appointments were spread-out over a few weeks. At this point, we had done some procedural steps to get her ready for full dentures, but the teeth are still there. They would not get taken out until the dentures were ready to be delivered.
At each appointment I discussed a different aspect of why it would be such an advantage to her to keep those lower front teeth. Her mind was not changed. Yesterday, Carol walked into my office to tell me that she has decided that she wants to keep her lower teeth.
Okay, so what’s the point? The point has nothing to do with what Carol’s final treatment is. Carol has every right to decide on what she feels is right for her.
The dentistry Carol received 8 years ago was good technical dentistry on the teeth that were treated. However, the “holistic” dentist did not treat her as a whole person and left the rest of her mouth destined for failure.
The local dentist she got the treatment plan from provided a very reasonable treatment proposal. They had one visit, decided on treatment and her next step was to go to the oral surgeon and have all her teeth out.
Far too many times I see patients and dentists rush into treating teeth. Taking the time to engage in conversation and treat the person as a person and not a tooth is less common than it should be in my opinion. My point of this story is not that I got Carol to do what I felt was best for her, but that I gave her my time, answered all her questions, and allowed her to decide what was best for her. She needed the time.
There are few things we have to rush into in life.
Media Spin on Dental X-Rays
July 22, 2012
For the past couple of months, every dentist in the United States has had to deal (in some form or another) with the story on the front page of the Cleveland Plain Dealer newspaper entitled, “Dental X-rays Linked to Brain Tumors in Yale Study”. The story made national headlines, and why wouldn’t it with a title like that?
The reporter did publish excerpts from a meeting with ADA (American Dental Association) spokesperson Matthew J. Messina, DDS to get the dental communities’ perspective; however that was published on page A-4. As Dr. Messina explained, “Like a courtroom trial, the prosecution went first. Page 1 included the first six paragraphs of the article. The ADA’s defense was well presented, but after the ‘jump’ to page A-4. It required that a person be committed enough to understanding the story, to be willing to actually open the paper and read the article to the end. And that is one of the problems that ‘we’ will always face as a profession.”
For the rest of us who don’t live in Cleveland, or read the Cleveland Plain Dealer on-line, we got our story from the national news media. All I heard was that dental x-rays cause brain tumors. As a consumer and someone concerned about my health it raised an eyebrow. As a dentist I knew there was more to the story.
Here are the facts as presented by Dr. Messina:
How common are the brain tumors? (Six per 100,000) How did the researchers find a link between dental x-rays and brain tumors? (They asked people with brain tumors to remember how many x-rays they had over their lifetime) Is there a problem with this type of study? (Yes, it’’ called “recall bias”) Are dental x-rays different today than they were even 10 years ago? (Yes, the amount of radiation in current dental radiography is dramatically less than in years past) What should patients do with this information? (Talk to their dentist about any concerns so that their dentist can give them accurate information and reassure them)
While there is strong evidence that ionizing radiation may cause cancer, the question remains whether low doses lead to an increase in risk. Regarding dental x-rays, the effective dose is far below the yearly exposure received from natural background radiation. In the case of brain tumors, the cerebral (brain) region is not even in the primary radiation field of most dental x-rays. This was not even considered in the study.
Where do we go from here? If you are in the approximately 50% of the population that does not see a dentist on a regular basis, this information does not mean that much. If you are in the other 50% that understand that oral health means so much more than having your teeth cleaned or a tooth filled, I would recommend the ALARA rule (as low as reasonably achievable). Dental radiographs are a safe, essential and effective tool in identifying dental decay, gum disease, pathology, as well as monitoring proper growth and development.
As a society it is my hope that we are willing to move past the skimming of all the information that is available to us and ask questions when things relate to us. We (dentists) as a profession will continue to work towards educating our patients and providing the safest, most effective care.
The Top Ten
July 13, 2012
This season is often the time there is an influx of new patients being seen in dental practices. Many of the new patients I have seen this spring are people who have not been to a dentist in five or more years. Here is a list of the top ten reasons these patients say they have stayed away from the dental office:
10. Fear of pain
9. Missing work time
8. Moved and haven’t “found” a new dentist
7. Have been out of work
6. My dentist retired
5. Can’t find an office I am comfortable in
4. I don’t like the dentist
3. Economy
2. Lack of concern
And…….the #1 reason people have stayed away from the dentist – Didn’t have insurance.
One of the new patients I saw yesterday (a 40-year-old) said to me, “I haven’t been to a dentist for over five years because I didn’t have insurance. I haven’t had any problems but now I have insurance”.
After examination, this patient was very glad to hear he did not have any cavities. He was not so glad to hear that he had moderate periodontal (gum) disease. When questioned on his familial history he said, “My mother has dentures and I know my father is missing some teeth but I think he’s okay”.
Despite the fact that most people do not know the details about their familial dental history, most seem to know if their parents had/have their own teeth, go to a dentist on a regular basis, and a general knowledge of any problems they have encountered. I always ask this question because it is a good general guideline as to potential dental issues facing the person sitting in front of me.
Luckily for the new patient described above, he will be able to regain most of his dental health with appropriate non-surgical periodontal therapy. However, he was made aware that he has bone loss that will not come back, and because of his genetic pre-disposition for periodontal disease (which affects some75% of the population), life-long maintenance, including hygiene visits every 3 months will be essential to maintain his fragile periodontal status.
And……if his goal is to be healthy and keep his teeth for his life-time, this means every 3 months for the rest of his life…..regardless of whether he has insurance or not. We talked about the annual cost for this maintenance with or without insurance and he was surprised to hear how affordable it is to maintain health.
As I have predicted, due to people staying away from the dentist, dental emergencies are on the rise. I have seen more emergencies (broken teeth, pain, etc.) this spring than I can remember in the recent past. Emergency room dental visits have risen at a staggering rate…..and just so you know, the hospital cannot do anything for you other than prescribe pain medication which often helps only minimally.
I urge you not to put off dental visits. If you have any of the “excuses” listed above, I would suggest re-prioritizing and putting your health at the top of the list. Many dental offices offer complimentary….FREE…initial visits. Talk to the dentist and dental staff about your concerns. There are ways to manage any of these concerns. If the dental office you go to does not listen or does not have a solution, move on to another office. Get a plan that is manageable for YOU!
Is there a Dental Link to Alzheimer’s?
July 9, 2012
Alzheimer’s disease (AD) is one of those diseases you would not wish on anyone. I have it in my family. My grandfather died from it about 30 years ago.
Since its discovery more than 100 years ago, there have been many scientific breakthroughs in AD research. In the 1960s, scientists discovered a link between cognitive decline and the number of plaques and tangles in the brain. The medical community then formally recognized Alzheimer’s as a disease and not a normal part of aging. In the 1970s, scientists made great strides in understanding the human body as a whole, and AD emerged as a significant area of research interest. This increased attention led in the 1990s to important discoveries and a better understanding of complex nerve cells in the brains of AD patients. More research was done on AD susceptibility genes, and several drugs were approved to treat the cognitive symptoms of the disease.
More recently, researchers have found long-term evidence that periodontal (gum) disease may increase the risk of cognitive dysfunction in healthy individuals, as well as those who are already cognitively impaired. The evidence shows that gingival inflammation may contribute to brain inflammation, neurodegeneration, and Alzheimer’s. My own observations in practice show that as the disease progresses, home care becomes more challenging for patients, which leads to more inflammation, and may contribute to progression of the disease.
Previous research has shown that patients with AD had a significantly higher level of antibodies and inflammatory molecules associated with periodontal disease in their plasma compared to healthy people. One of the tests used to evaluate cognitive function is called the Digit Symbol Test, which is part of the standard measurement of adult IQ.
Researchers found that periodontal inflammation in tested subjects at age 70 years old was strongly associated with lower test scores. Participants with periodontal inflammation were 9 times more likely to test in the lower range in this particular test compared to participants with no periodontal inflammation. Amazingly, this strong association held true even in those subjects who had other risk factors linked to lower testing scores, including obesity, cigarette smoking, and tooth loss unrelated to gum inflammation.
Obviously, the research will continue. Another obvious fact is that I continue to read more and more connections between poor oral health and systemic issues. And, the last obvious fact is that I am trying to educate patients on a daily basis about the significance of good oral health. The mouth is the link to the rest of the body.
I had three patients this week who flat-out refused to accept the fact that they have a problem because they have no pain. They think I am trying to pull the wool over their eyes. I say it over and over; lack of pain is not a good indicator of a problem. Your teeth can be practically falling out and I would be willing to bet you have no pain. Dentists wish that gum disease did hurt. It would be easier to get patients to improve their health.
