J. Peter St. Clair, DMD Blog

In a recent study published by the American Dental Association (ADA), visits to the emergency room (ER) for dental related issues have doubled nationwide over the last decade. Last year, over 2.1 million people visited the ER for a dental “emergency”, most of which could have been prevented with regular dental visits.

In another recent collaborative study between the Rutgers School of Dental Medicine and the Rutgers Center for State Health Policy, they confirmed that most of these ER visits were for dental pain and infections that were not related to trauma. This is an increasing burden on the taxpayer and the healthcare system. ER visits can be 10 times more costly than if the treatment was performed in a dental office.

Dr. Cecile Feldman, dean of the Rutgers School of Dental Medicine, recently said the following in an ADA publication:

“The most disturbing aspect of the rise in ER dental visits is that treatment is often ineffective. In emergency rooms, there is a lack of diagnostic equipment and tools – such as dental X-ray machines – and ER physicians aren’t trained to identify and treat oral health problems. Often, they prescribe painkillers and antibiotics for infections while the underlying problem remains.”

The increase in dental ER visits supports the fact that many Americans have inadequate knowledge about the consequences of not getting regular dental check-ups. Many view dental care as a luxury and if their teeth don’t hurt and appear visually acceptable, they do not feel the need to visit a dentist.

Dental decay is the underlying cause of most ER dental visits. Dental decay does not hurt until it has affected the nerve of the tooth. Dr. Feldman states, “Tooth decay, which is almost entirely preventable, is the most common chronic illness among school-age children. Left untreated, it can result in infection, unbearable pain, loss of teeth and acute systemic infection, which in some cases can lead to death. Yet nearly one in four American children has untreated tooth decay.”

So, what are some of the underlying reasons for the increase in ER visits?  Dr. Feldman says, “For many, a visit to the dentist is unaffordable and inaccessible. More than 85 million Americans have no form of dental insurance. For those who have Medicaid, finding a dentist who accepts it can be challenging. Many dentists don’t because the reimbursement payments are a fraction of the cost of care and there is a very high administrative burden.”

I have seen many suggestions for helping address this problem. Some push for more community water fluoridation, others for dental coverage for all. While children do have coverage under some medical insurance plans, it does not extend to adults. I’m not so sure that is the answer anyway, mainly due to the cost.

Dental insurance, in general, is a broken system. Unless there is some major overhaul in the way dental care or dental insurance is delivered in this country, the ER stats will continue to rise. For now, personal responsibility and budgeting for basic preventive dental care is your best defense against future dental problems.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating snoring, sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have, please email them to him at jpstclair@stclairdmd.com

Dental caries (cavities, decay) is still very prevalent in today’s society. There are many factors that contribute to dental decay. In addition, there are some people who are more susceptible to decay than others. In a recent article in the Journal of the American Dental Association (JADA), sugar-sweetened beverages, one of the main culprits for dental decay, was discussed.

Dental decay is a multifactorial disease characterized as an infectious process during which carbohydrates are fermented by specific oral bacteria at the tooth surface. This results in acid production and enamel breakdown. It should be noted that the beverages described in this column are not the only things that lead to dental decay. Anything rich in carbohydrates or with high acidity can lead to decay. In addition, the right bacteria, genetics, insufficient home care, and salivary flow are all contributing factors.

With regard to beverages specifically, as described in the JADA article, the main carbohydrate additives to note are sugar, lactose, high-fructose corn syrup, sucrose, fructose, glucose, maltodextrin, and honey. The beverages to watch for containing these are milk – yes milk, flavored milk, 100 percent fruit juice and vegetable juice, soda, juice drinks, sports drinks, flavored water, flavored tea and coffee, energy drinks, smoothies, and nutritional supplements.

People usually consume multiple beverages daily. As I have described in past columns, one of the worst things you can do is to drink these kinds of beverages slowly throughout the day. Constant introduction of carbohydrates over a prolonged period feed bacteria and never allow the saliva to neutralize the oral environment. If you have decreased salivary production, this makes the situation much worse.

Here is a list of recommendations as stated in the JADA article:

1. Consume these types of beverages at meals only
2. Limit these types of beverages to once per day and to 12 ounces
3. Consume these beverages within a 15-minute time frame
4. Using a straw is preferable
5. Replace these sugary beverages with artificially sweetened or unsweetened beverages. ** I would add to that preferably non-carbonated
6. Brush teeth with fluoridated toothpaste 20 minutes after intake
7. Chew sugar free gum immediately after intake
8. Rinse mouth with water immediately after intake

Dental decay is preventable. Following the guidelines above, and practicing good oral hygiene can prevent the most common reasons for decay. It is important to note that most people have plenty of room for improvement with their oral hygiene. Brush your teeth right before your next dental appointment and then ask your hygienist or dentist to assess how well you are doing at plaque removal. You may be surprised at what you’re missing.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating snoring, sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have, please email them to him at jpstclair@stclairdmd.com

Last week I introduced a couple who had been seeing the same dentist for 30 years and were finally forced to make a change due to the dentist’s retirement. They visited a “new” dentist and were turned off because the dentist recommended significant treatment. Then they consulted with another dentist, who spent more time with them to discuss their specific situations and goals. However, they still missed their “old” dentist.

The couple loved their “old” dentist because she was someone they could relate to. The dentist kept things simple, and they liked simple. If they had a broken tooth, the dentist patched it up and they were on their way. They never talked about the future. They may have lost some teeth over the years, but the dentist never discussed “needing” a lot of dental work.

The first “new” dentist was a nice person. In fact, they knew the dentist outside the office before they became patients. The problem was poor communication and inability to relate to the patient’s specific needs.  This dentist looked in both their mouths and said they each “needed’ 8 crowns. It didn’t make sense to them. It seemed too complicated, expensive and unnecessary.

The second “new” dentist took a different approach and spent time with the couple discussing their current situation and future objectives. They both wanted to keep their teeth but still had trouble coming to grips with the fact that they “needed” significant dental work to accomplish their objective. Why couldn’t they continue on the same simple path they had with their original dentist?

Dentists are sometimes more interested in what they are saying than patients are. It is important to remember that the teeth are attached to a person; and that person has their own story that goes along with their teeth.

People put different values on different things. Whether we sell cars, trips, hairstyles or teeth, the objective of the “seller” is to make the prospective “buyer” aware of what they have and all the possibilities that are available to them. It is always the consumer’s decision. While there is a health component to dentistry, you can compare any other aspect of selling the other commodity examples to teeth. Things that come to mind: comfort, looks, self-esteem, and functioning in life.

To “buy” anything, people have to be ready. What makes someone ready? They are ready when they feel the need to act. In the absence of readiness, over-education by the “seller” often feels like sales pressure to the buyer. I’m sure you have experienced this if you have ever been to a car dealership.

I love analogies. I especially love car analogies as they relate to dentistry. Cars are easy because most of us rely on them every day, just like our teeth. Some of us like simple cars, while others like fancier cars. Some take better care of their cars and they last longer.  Others abuse their cars and they need more repairs. One thing is certain; maintenance is the key to long-term success of the car.

Raising awareness is a difficult task for anyone promoting their product or service. Acting on something is only accomplished when value is realized. Some end up seeing the value in their life and others do not.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating snoring, sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have, please email them to him at jpstclair@stclairdmd.com

People often ask me how I have time to write columns, and how I’ve come up with topics for as long as The Town Common has been around. If you have read my columns over the years, you’ll remember I have discussed that time was one of the barriers keeping people from getting the dental care they need. Time is an excuse and I use it as an excuse all the time. However, we always make time for things that are important to us.

The topics I come up with have been an evolution. I try to keep it interesting. Of course, many of the things that I find interesting in dentistry would bore others. While some of my columns may bore you to tears, hopefully there are others that you can relate to, or stimulate thoughts or questions.

Let’s talk today about a common scenario seen in all dental offices. New patients, husband and wife in their 60’s, are “forced” to make a dental provider change. I say “forced” because regardless of our situation, we always have a choice in our providers.

This couple had been seeing the same dentist for 30 years. Despite the fact that they moved 20 miles from the dentist 10 years ago, they continued to make the drive to the office. They were dedicated and they loved their dentist. Then one day the dentist retired and they decided it was time to choose someone closer to where they lived.

Both went to their new office for hygiene appointments and then discussed their experience. They both felt the office staff was less friendly than their previous office. Of course, they knew that “old” office and loved everyone there. They were still willing to give it a chance, until they met the dentist. The dentist seemed like a nice person but took a quick look and said the same thing to both husband and wife – You NEED 8 crowns.

How could this be, they thought? They had been going to the same office for 30 years, neither ever had a crown, and when something broke, their favorite dentist would “patch” them up. They were completely turned off. They were “forced” again to make a change.

This time they wanted to meet the dentist first and see what the dentist had to say before they committed. They set up a 30-minute appointment. At that appointment, the “new” dentist examined their x-rays and took photographs of their teeth. They had an in-depth conversation about the condition of their dental health. They were asked what their short-term and long-term objectives were. The word “crown” was never mentioned…..until one of them asked the dentist.

The dentist discussed advantages and disadvantages of different kinds of treatment. Since the patient’s long-term objective was to have teeth forever, they discussed options for treatment, prioritization and sequencing, as well as financial options. Although they were not ready to dive into treatment, they left the office with a much better understanding of where they stood and appreciated the time that was taken to explain their specific situations.

Every person, every patient, every dentist, is different. This couple experienced three different practice styles. They could relate to Dentist #1 – their “old” dentist. Dentist #2 lacked communication skills, therefore the relationship failed. Dentist #3 took the time to learn about their specific needs and goals. They didn’t feel sales pressure but are still overwhelmed by their apparent “needs.”

To be continued……

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating snoring, sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have, please email them to him at jpstclair@stclairdmd.com

It is common sense that infected teeth, whether they hurt or not, or are broken down beyond repair, should be removed. We also all know by now that there are mouth-body connections and that the mouth is the “gateway” to the rest of the body. There is no disputing that a healthy mouth is better for you on many levels. However, in a recently released study, the guidelines for treatment of some types of dental problems prior to specific surgery need closer consideration.

According to a study in an issue of The Annals of Thoracic Surgery, removing an infected tooth prior to cardiac surgery may increase the risk of major adverse outcomes, including risk of death prior to surgery. This is a very specific study for a very specific group of patients. It does suggest considering postponing dental problems prior to any surgery.

Dental extraction of abscessed or infected teeth is often performed to decrease the risk of infection during surgery and endocarditis (an inflammation of the inner layer of the heart) following surgery. In this particular study, physician researchers evaluated the occurrence of major adverse outcomes in 205 patients who underwent at least one dental extraction prior to planned cardiac surgery. The median time from dental extraction to cardiac surgery was 7 days (average 35 days).

One of the researchers explained, “Guidelines from the American College of Cardiology and American Heart Association label dental extraction as a minor procedure, with the risk of death or non-fatal heart attack estimated to be less than 1%. Our results, however, documented a higher rate of major adverse outcomes, suggesting physicians should evaluate individualized risk of anesthesia and surgery in this patient population.”

In this study, patients who underwent dental extraction prior to cardiac surgery experienced an 8% incidence of major adverse outcomes, including new heart attack, stroke, kidney failure and death. Overall, 3% of patients died after dental extraction and before the planned cardiac surgery could be performed. Another of the researchers went on to say, “With the information from our study we cannot make a definitive recommendation for or against dental extraction prior to cardiac surgery. We recommend an individualized analysis of the expected benefit of dental extraction prior to surgery weighed against the risk of morbidity and mortality as observed in our study.”

This study, as in many “new” studies, awakens us to consider a departure from current lines of thinking about specific situations. This paradigm shift of thinking has also been noted in the use of prophylactic antibiotics prior to dental procedures in those with cardiac conditions.

Prophylactic antibiotics have routinely been prescribed for patients undergoing dental work who also had existing heart problems because it had been accepted that there is a link between dental bacteremia and endocarditis. Individuals with pre-existing heart problems tend to have a higher incidence of endocarditis. The American Heart Association and others have withdrawn support for this practice of prophylactic antibiotics because the danger from overuse of antibiotics outweighs any other potential risks. Regular tooth brushing, flossing, and even chewing gum are now recognized to dislodge as much, if not more, bacteremia than most dental procedures.

Prevention of dental problems is the best line of defense. Regular professional maintenance, especially as we age, is important to our overall health. Talk with your dentist and physician about your specific situations.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating snoring, sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have, please email them to him at jpstclair@stclairdmd.com