Over the course of my 22 years in dentistry I have witnessed some significant changes in the materials that are used to restore teeth. In fact, most of the materials I use today were not in existence when I started to practice. The demand for materials that are tooth-colored have taken over. There are very few patients who ask for gold or silver fillings any more. And, while some of these newer materials are white, there are many factors which need to be considered in determining what material is appropriate for each individual situation.

As I said last week – The best dentistry is NO dentistry. Prevention of decay and other factors that require teeth to be restored is the best defense to not needing restorative dental work. Keeping up with maintenance cleaning appointments and listening to your dental team’s recommendations regarding diet, homecare and other forms of prevention such as nightguard use, is key to avoiding many dental problems.

One of my favorite quotes in dentistry comes from a pioneer dentist who was killed in a plane crash back in the 1970’s named Bob Barkley. He said, “The goal of dentistry is to make the patient worse at the slowest possible rate”. I think about this quote all the time when making recommendations and treating patients. Sometimes it leads me to recommend extensive treatment and other times it leads me to not recommend any treatment at all, even despite apparent need.

Dr. Barkley also coined the phrase “co-diagnosis” which refers to the patient taking an active role in their dental health. It is the role of the dentist to not only educate the patient on their specific situation and different options for care, but to also extract (no pun intended) from the patient their goals for their dental health. It is so important to think beyond the immediate fix sometimes. Taking the time to talk to patients about why things are happening and about their choices for prevention and treatment allows patients to become active participants in their health.

However, there are many barriers to this model including the patient’s lack of interest or concern, time involved, lack of trust, money and even fear. The dentist can also be a limiting factor depending on their philosophy of care. And one of the biggest issues facing both dentists and patients today is the role of patient’s dental benefit companies. This broken system is often responsible for patients choosing less than ideal care, thereby setting themselves up for more problems down the road.

My simple suggestion is to take a more active role in your own dental health. Think forward and ask your dentist or dental hygienist about things that can make your situation worse at the slowest possible rate. You very well may be doing fine or just need a couple tweaks to your home care regimen. Or maybe it’s time to consider preventive treatment or re-consider your dental team’s suggestion for an increase in the number of times you visit your hygienist a year.

Unfortunately, lack of pain is not a good indicator of lack of problems. Put your health first, find a dental team that listens to your concerns and takes the time necessary to establish a plan that makes sense and you are on board with.

I strayed from my original intention of discussing more on CAD/CAM dentistry that I introduced last week. However, as you will see next week, CAD/CAM dentistry often aligns perfectly with making your situation worse at the slowest possible rate.

Here are a few answers to questions asked by readers:

Jim H:  I was recently told by a dentist that I need a root canal, a post, periodontal crown lengthening surgery and a crown. The total cost of treatment is $3500! Do I have any alternatives?

That is a difficult question to answer without seeing the specific case but here are some thoughts. There are quite a few things to consider. The first is the general condition of the teeth. If you have numerous other dental problems that need to be addressed, you must prioritize these and decide if the cost of doing them all is something you can afford. The last thing you want to do is spend $3500 on one tooth and then be out of funds to address the other problems. This could lead to more serious problems in the future.

Let’s assume that this is the only tooth that needs to be addressed. What is your past history of dental problems? If you have had limited problems with a low rate of dental decay in general, this treatment may be the best option. If you have had a problem with dental decay, the best alternative may be to extract the tooth and do a dental implant. The cost of the treatment would be about the same, but there would be no chance of recurrent problems with decay.

Extracting the tooth and not replacing it can lead to teeth shifting, bite problems and a decrease in function. If the cost of treatment is beyond your means, ask the dentist if they have options to stretch the payment out over a period of time. Or, if you decide to have the tooth out and place an implant at a later date, ask your dentist about how to maintain the space so teeth don’t shift and fill the space so at least it looks like a tooth is there.

Tom O: My son has been in braces for over a year and has multiple teeth with decay. What should we do?

My first question would be – Why does he have so much decay? Although there are many factors, diet and home care are most likely the culprits for the problem. If the decay can be easily fixed, the diet can be controlled (i.e. decrease sugar intake), and his home care can improve (including a prescription fluoride toothpaste), that would be the best way to go and the braces treatment can move on. If the decay is extensive and his compliance is poor, the best thing to do may be to remove the braces and wait until improved conditions are met before continuing with the braces.

Linda C: My dentist keeps telling me that I need a bunch of crowns. I don’t have any pain and the crowns seem excessive and costly. Why can’t I just wait until something happens and fix the problem when it arises?

You can wait. However, there is probably a good reason the treatment is being suggested. Often, being proactive in replacement of aging large fillings can prevent bigger and more costly problems to come. Waiting for “something to happen” can often mean more treatment down the road such as root canals or gum surgery. If you have multiple teeth that need this treatment, ask for a treatment plan to sequence the treatment over time. This is better than waiting.

Head and neck surgeons are knowledgeable about the human papillomavirus (HPV) and show generally positive attitudes and beliefs about HPV education and vaccination, according to a new study in JAMA Otolaryngology–Head & Neck Surgery. However, 68.9% reported that their daughters had received or would receive the HPV vaccine, while 55.8% reported that their sons had received or would receive the vaccination.

The relationship of HPV to oropharyngeal cancer is now well-established, with 40% to 80% of cases of oropharyngeal squamous cell carcinoma (OSCC) in the U.S. estimated to be related to HPV, noted the U.S. team of researchers. The incidence of OSCC has been increasing over the past 30 years in many parts of the world, a trend now attributed to the HPV epidemic.

In the U.S., the incidence of HPV-positive OSCC increased by 225% between 1988 and 2004, compared with a 50% decline in the incidence of HPV-negative OSCC. Recent epidemiologic evidence indicates that the prevalence of oral HPV infection is associated with an increased number of lifetime sexual partners.

Head and neck surgeons play a critical role in detecting and treating HPV-related OSCC, and they are arguably the best poised to educate patients, families, and the public regarding the prevention of the disease, the study authors noted.

In the study, a majority of the respondents (94.9%) said they routinely discuss the risk factors for head and neck cancer with their patients. Most (90.9%) also specifically mention HPV as a risk factor. However, only 160 respondents (49.1%) discuss the importance of current efforts to provide HPV vaccine to preadolescents.

When asked why they do not discuss the HPV vaccine with their patients, respondents gave various answers. The most common reason (38.7%) was because their patients are adults. The next commonly cited reasons were that the safety and effectiveness of the vaccine have not yet been proved (16.7%), and they didn’t consider it part of their healthcare role (13.5%).

A majority of respondents in the study agreed that it’s necessary to discuss sexual issues with patients before recommending HPV vaccines (56.2%), and they agreed that efficacy and safety of new vaccines can only be established after they’ve been on the market for five to ten years (59.6%). Notably, 70.1% agreed that discussing the HPV vaccine is appropriate and helps patients.

The U.S. Centers for Disease Control and Prevention currently recommends routine HPV vaccination for girls and boys ages 11 to 12 years, although the series of three shots can be started as young as age 9. Catch-up immunization is recommended to age 26 years for women and age 21 for men.

If you have children in these age groups, and this subject has not been brought up, I think it is worth a discussion with your children’s physician.

As I discussed last week, dentistry is full of old, new, and emerging technology. For example, the different ways to use dental implants over the last 30 years has been a major game changer in the field of dentistry. Likewise, CAD/CAM technology (computer-aided design and manufacturing of dental restorations) has seen steady growth over the same 30 years. Here is a little background on the some of the reasons this technology is here to stay.

Let me start by saying that the best dentistry is NO dentistry. Prevention of decay and other destructive things that happen to teeth is the best line of defense. Having said that, the fact of the matter is, there are many people who need things done to their teeth to preserve them for their lifetime.

Dental amalgam (silver filling) was introduced to dentistry well over 100 years ago. It proved to be one of the major contributors to saving many teeth that were in need of repair. Dental amalgam is a very hard material which can last for many years. However, there are many aspects of dental amalgam that are undesirable. It is ugly, tooth preparation needs to be more aggressive to retain it, the material breaks down over time, and it contains mercury. Dental amalgam is not used in most of Europe and has been dying a slow death in the United States over the last 30 years.

Progressive dentists, who were interested in providing better, longer-lasting dentistry, learned the skill of using gold. Despite the way you feel about gold in your mouth, done well, gold is still one of the best, most biocompatible and longest lasting materials used to protect teeth. Gold has also been dying a slow death mainly due to the fact that patients prefer tooth-colored restorations.

Then composite resin was introduced. It started as a filling material used to fill cavities on front teeth and eventually evolved enough to be used in back teeth. Dental composite, an ultraviolet light-cured resin, is the main direct restorative material used in dentistry today. It has become the amalgam replacement. It is very esthetic, chemically bonds to tooth structure, and allows for much more conservative tooth preparation. However, it is much softer than natural tooth structure and therefore has its limitations.

Dental amalgam and composite are what we in dentistry call direct restorative materials. This means that a cavity preparation is made and the material is directly placed in the tooth. This is different than gold or porcelain which are considered indirect materials. These are manufactured and then cemented or bonded to tooth structure.

When a tooth needs a larger filling, specifically one that needs to cover the cusp of a tooth due to fracture, risk of fracture due to cracks, or has undergone extensive destruction due to decay, direct materials like composite are not indicated due to wear factors. Indirect materials are more appropriate and are much longer lasting.

The advantage of CAD/CAM is the ability to provide stronger, esthetic, indirect materials in addition to being more conservative in tooth preparation. Next week I will continue this subject with the specific uses of this technology.

Many people avoid technology as long as possible and others embrace it early. For many of us, it’s not easy to decide when, how, and even if, to incorporate different technological advances into our lives. My dilemma is often whether the cost and learning curve will be worth it in the end. How do we know whether the investment in time and money is really any better than an “older model”? Technology is great, but there is no arguing with historical success.

Technology does come at a cost. While we would all love to have unlimited resources to purchase everything that catches our eye and try it out, this is not reality for most of us. Instead, we must try to envision whether the investment in a particular technology will make us better and more efficient at what we do.

Last year I installed more sophisticated (and expensive) programmable thermostats in my office. Despite my hesitation, primarily due to the cost, the technology made sense to me. It didn’t take long to prove itself to be more efficient and produce a better result than without it.

Like any other area, dentistry is full of old, new, and emerging technology. The 5 major technologies being used on a regular basis in dentistry are digital x-rays, intraoral cameras, cone-beam computed tomography 3-D imaging, dental lasers, and CAD/CAM (computer-aided design and manufacturing of dental restorations).

Surprisingly, digital x-rays are still not used in all dental offices. When I first brought this into my office 12 years ago, I was a little skeptical. The cost was high and I didn’t fully understand how it was going to make anything better. It didn’t take long to realize it was far better. Digital x-rays are faster, provide far less radiation to the patient, are easy to e-mail, and eliminated the chemicals needed to develop film – a plus for the environment.

Intraoral cameras are an essential tool in the dental office. They are essential for communication, and communication with patients is everything.

Cone-beam computed tomography (CBCT) is a newer 3-D type of x-ray which is often used for dental implant planning as well as an aid in diagnosis of other dental issues. Although the cost has come down, it is still expensive, which is one reason why it is not found in most dental offices.  It has its place, but as with some other technology, it comes with risk of being overused.

There are many kinds of dental lasers. Lasers in dentistry can diagnose decay, aid in gum disease therapy, prepare teeth without a drill, relieve canker sore pain, and some even claim to whiten teeth. They too have their limitations, but the technology keeps growing.

CAD/CAM technology in dentistry allows the dentist to prepare, scan, design, manufacture, and deliver certain kinds of treatment in one visit. It has some limitations and is still expensive, but the concept is the wave of the future.

In addition to my new thermostats, I purchased a CAD/CAM system last year. While the learning curve has been challenging, the more I learn different applications for it, the more I realize it allows me to offer a higher level of care.

My dental assistants and I are excited to be headed out for 2 days of advanced training on our system later this week. I’ll have more to say about CAD/CAM technology next week.

It is amazing to think that a short time ago we didn’t have pocket cell phone computers or the internet to gather information. Today, everyone searches the internet to get information about everything. That includes where to eat, where to travel, who to see for a doctor, diagnosing conditions, and even treatment options. The information out there is overwhelming and constantly growing.

I have had four patients this past week who presented with issues in which they came armed with self-diagnosis and/or solutions. Much of the information people came with was good. An informed patient can make better decisions on treatment that meets their needs. However, there was also some misguided information. Although it does open-up dialogue, it is important to keep in mind that you can’t believe everything you read.

Since it was founded in 2001, Wikipedia has become one of the most popular websites on the Internet. In 2013, it ranked ninth among all other sites in the U.S., with more than 72.5 million unique visitors per month. The nature of the website’s data, where users submit, edit, or delete data for each entry, have created headaches and challenges for teachers and medical professionals.

Now a new study by researchers from several U.S. universities and graduate programs has sought to shed light on just how much of the information contained in health-related entries is inaccurate. “Most Wikipedia articles for the 10 costliest conditions in the United States contain errors compared with standard peer-reviewed sources,” the authors wrote. “Healthcare professionals, trainees, and patients should use caution when using Wikipedia to answer questions about patient care.”

Wikipedia’s coverage of dentistry is thorough, with its own dedicated “portal” page that starts with an overview of this profession at the top. From there, the site offers an ever-changing selection of related articles and finally, a breakdown of the different areas of dentistry, such as fields of practice, restorative dentistry, tooth anatomy, and pathology. One of the most common searches for dentistry is for dental decay. That page alone lists 112 references, many of which are peer-reviewed journals.

Wikipedia’s crowd-sourcing format lends itself to inevitable accuracy issues with its content. However, Wikipedia is not the Wild West and has established processes for weeding out vandalism and unverifiable information; consequently, half of the corrections are posted within three minutes of being verified. And in 42% of cases, corrections are made immediately.

This leads to the deduction that much of the available information is good. However, the researchers warn both patients and healthcare providers, that because their standard is the peer-reviewed published literature, it can be argued that information on Wikipedia contains factual errors.

There is nothing wrong with going to the internet to gather information. Just be aware that the information you learn may or may not be completely correct for your particular situation. The best thing to do is to bring that information with you to discuss with your provider. The experience of your provider is very valuable as well.