J. Peter St. Clair, DMD Blog

Gravity is precise in nature, governed by laws and formulas; it does not respond to individual circumstances or objectives. It’s easy because it always works. Clinical dentistry, on the other hand, is science for sure, but an inexact science at best. Inexact science requires the skill of an artist to create a consistent and predictable result since it is not a matter of an equation, hence the “Art and Science of Dentistry.” This inexactness is something that dentists struggle with daily.

I am currently treating a patient who presented with a bunch of broken teeth. The patient is frustrated because these teeth have been “fixed” numerous times over the past few years. His previous dentist had tried to bond things here and there to keep the cost down for the patient but they just kept breaking. The patient, an engineer, said that he even tried giving the dentist suggestions to make things “stronger”. Those suggestions only led to more failure. Predictable dentistry often requires doing things that you would rather not do.

I recently heard an ad on the radio with a famous actor talking about colon cancer screening. He describes that having a colonoscopy after age 50 is huge in finding and treating early changes that lead to colon cancer. Most people don’t want to have a colonoscopy, but also don’t want to get colon cancer, so there is a dilemma. These actions have now become inconsistent with the desired outcome, much like the patient I just described. He doesn’t want to have a complete exam and map out a precise treatment plan that will ensure a more predictable result, but he wants to save his teeth.

We have come to a fork in the road. If you don’t want to get colon cancer you get screened and treat any early signs of problems to help avoid the cancer. If you want to risk getting colon cancer, you don’t get screened. If this dental patient doesn’t want to lose his teeth, he should get a complete exam and address the issues in a more logical and predictable manner. If he wants to risk losing teeth, he can keep putting band-aids on the teeth, but they may not hold up as he has already experienced.

Dentists often struggle with patients whose actions are inconsistent with what they want from dental treatment. It is important for dentists to listen to people to know what they want. A patient who says she doesn’t want to do a crown on a tooth has not said she would not do crown. She is saying she doesn’t want to do it, would rather not spend the money to do it, she won’t enjoy doing it, and she will want it to be over as quickly as possible. What does she want the outcome to be?

Too many disappointments have occurred because a dentist compromised treatment and the result was not what the patient expected. The dentist and the patient need to be very clear on compromise. The patient must understand that, if there is failure, it is most likely the result of the decision not to do the more ideal treatment. The dentist needs to thoroughly explain to the patient the risks and benefits of any treatment they are doing so that everyone is on the same page.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

There are very few dental practices that still use analog film and chemicals to produce dental x-rays. With digital technology around for decades, and improving along the way, there really is no excuse not to be digital.

However, patients still often express concern with overexposure from radiation from dental x-rays. While I could bore you with statistics, to put it into perspective, it would take almost 400 dental x-rays in one year to equal the amount of radiation a person picks up from background sources each year.

Here are a few questions answered about dental x-rays:

I had a dental x ray while I was pregnant. I am worried that my unborn child might have been exposed to the radiation. Can you please tell me if there are any risks to my baby from this?

There is no information suggesting any risk to an unborn child from dental x-rays received by the mother. We were taught in dental school to avoid dental x-rays on pregnant patients. However, with newer technology the radiation dose to the fetus is insignificant. Prudent practice would dictate limiting x-rays on pregnant women, but there is absolutely no harm in taking x-rays if needed to diagnose a problem.

Is there residual radiation in a room after a dental radiograph has been taken?

X-rays cease to exist when the machine is switched off, much like the light from a light bulb when it is turned off. No residual radiation remains.

How much has dental x-radiation been studied and how concerned should I be about having dental x-rays done? Is there a limit on how many I can have?

We now have very complete information on patient radiation doses from dental x-rays. They are among the lowest radiation dose exams of any diagnostic radiologic procedure in the healing arts. Current practices deliver patient doses from a full-mouth series of intraoral films (usually 14-18 films) that are less than what a person receives in a month from natural environmental sources (commonly called background exposure).

Doses from bitewing or panoramic films are even less. New technology is reducing the doses still further. There is no limit on how many dental x-rays you can have. The decision to have a dental x-ray is based on the benefit of knowing whether or not there is a cavity, crack, or some other abnormality. The decision to have them is based on what you and your dentist agree on being best for your specific situation.

I recently had some dental x rays and the operator forgot to place the lead apron on me. Is this a problem?

Use of the lead apron to protect the patient undergoing dental radiographic examination was recommended some 50 years ago, when equipment was crude. This was because x-ray beams were not restricted to the area of clinical interest, beams were not filtered, and x-ray film was slower, causing radiation exposures 10 to 100 times higher than received today. With the current technology reducing radiation exposure significantly and the beam limited only to the area of interest, there is little or no measurable difference in whole-body dose whether a lead apron is used or not. The lead apron is no longer regarded as essential although some consider it a prudent practice, especially for pregnant and potentially pregnant patients.

If you have any other questions on dental x-rays, please e-mail them to me.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

The holidays are a time of fun and excitement, but unfortunately the cheer and joy can sometimes get cut short by dental emergencies. Whether you’re traveling, with friends, family, or at parties, this time of the year presents a lot of opportunities for dental disaster. Thankfully, there are some easy tips that you can use to keep your teeth safe for the holidays from a trusted emergency dentist.

Thanksgiving has come and gone and Christmas is right around the corner – Are you stressed out? This time of year always seems more stressful, but stress in general is hard to avoid. We worry about school, work, finances, illness, children, relationships, and more. Some even worry about how much they worry. Not to add to your stress, but you should be aware that all that worrying could have a negative impact on not only your general health but also your oral health.

According to an article in the Journal of Periodontology, there is a strong relationship between stress and periodontal disease (gum disease). In addition to stress, other psychological factors, such as anxiety, depression, and loneliness, are linked to an increased likelihood of periodontal disease.

So how does stressing out about your next car payment, for example, lead to gum disease? Researchers believe that the hormone cortisol may be a factor. Cortisol , also known as the “stress hormone,” is secreted by the adrenal glands and involved in many functions, including proper glucose metabolism, blood pressure regulation, insulin release for blood sugar maintenance, immune function, and inflammatory response. An earlier study published in the same journal the year before found that increased levels of cortisol can lead to more destruction of the gums and bone due to periodontal diseases.

Behavioral factors also may come into play. People who are under extreme amounts of stress or suffering from depression may be more likely to disregard good oral hygiene. They may even take on new behaviors that could negatively impact their oral health, such as the use of nicotine, alcohol, or drugs, all of which can affect the teeth and gums.

Your gums are not the only victims of stress. Another oral side effect is teeth grinding or clenching, which often occurs during sleep. This may lead to headaches, earaches, or toothaches. Facial muscles can become sore and jaw joints tender. Besides causing discomfort, grinding and/or clenching can lead to severe tooth wear, loosening of teeth, and cracked or fractured teeth.

It is important to find healthy things that help relieve stress. A regular exercise routine can do wonders for relieving stress, as well as having a balanced nutritious diet and getting enough sleep. You should be getting 7-8 hours of good sleep every night. If you are not getting that amount, you are depriving yourself of optimal performance.

If you find it difficult to manage your stress, you should see your physician. You should also make your dentist aware of your stress level so that he/she can determine if there are any notable effects going on within your masticatory system and make recommendations to help.

I’ll leave you this week with a quote from A. Cornelius Celsus’s DeMedicina. He was a Roman author and medical historian and wrote this about 2000 years ago.

Live in rooms full of light.

Avoid Heavy food.

Be moderate in the drinking of wine.

Take massage, baths, exercise and gymnastics.

Fight insomnia with gentle rocking or the sound of running water.

Change surroundings and take long journeys.

Strictly avoid frightening ideas.

Indulge in cheerful conversation and amusements.

Listen to music.

Stress cannot be avoided, but it can be managed and minimized by change.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

Xylitol is a sugar substitute that possesses 40 percent fewer calories than sugar and has been shown to help decrease cavities in teeth, among other things.  However, it is important to know that xylitol, even in small quantities, is very toxic to dogs.

The dental benefits of xylitol have been known since the 1970’s. Xylitol is not metabolized by the decay-causing bacteria Streptococcus mutans (S. mutans), making it nonacidogenic and thus noncariogenic (not decay causing). Studies have also indicated xylitol decreases the levels of S. mutans in both plaque and saliva. As a result, patients who use xylitol have demonstrated a reduction in decay.

Xylitol is slowly absorbed by the human intestines; as a result, it has minimal side effects on humans. Some may experience minor side effects, mainly stomach upset, although this generally occurs after ingesting large amounts of xylitol (four to five times the recommended amount for cavity prevention). There are studies that the body can adapt to higher dosages of xylitol and that symptoms can subside as the body’s tolerance increases.

While the dental community embraces xylitol for its cavity prevention, many people, including dental professionals, are unaware of its toxic potential – not to humans, but to dogs. While xylitol has little effect on insulin production in humans, dogs can experience a rapid and severe increase in insulin production after just a small amount of xylitol ingestion. A dog that ingests a xylitol equivalent of three to four pieces of gum is at risk for hepatic (liver) failure and necrosis (tissue death).

Dogs tend to be scavengers by nature and their likelihood of encountering potentially toxic substances in and around the house is common. The ASPCA web site lists a multitude of substances, many of which are harmless to humans but potentially dangerous to dogs. Chocolate, grapes, raisins, avocado, onion, and citrus fruits make the list. However, xylitol is unique in that it is contained within foods; as a result, consumers may not even be aware that a product or food item contains xylitol.

For dogs suspected of ingesting xylitol, early intervention is paramount. Prompt medical treatment for uncomplicated xylitol-related hypoglycemia can yield a good prognosis. Once Xylitol has affected the liver, it yields a much graver prognosis.

While veterinarians have been aware of the potential danger of xylitol to dogs for several years, that awareness has escaped most of the dental community – and the general public. This has become a more significant issue as more dental professionals promote products that contain xylitol for its human benefits.

It is important for dog owners to know the different foods and products, such as xylitol, that can be harmful to their pets. Make sure to keep these items out of a dog’s reach – and that includes the garbage. If you suspect ingestion of any of these foods, including xylitol, contact your veterinarian immediately.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

Sleep apnea affects an estimated 22 million people in the U.S. and can have serious consequences to their overall health. In fact, researchers have found a link between sleep apnea and many serious conditions like high blood pressure, depression, weight gain, and stroke. But even if you’re getting treatment for sleep apnea, you might not know that certain foods can aggravate it. With the holiday season upon us, keep reading to learn about which foods you can safely enjoy and which ones you should avoid!

(more…)

Most people who visit the dentist hope they leave the dental office hearing the final salutation from the dentist, “Everything looks great!” Teenagers who have made it without any cavities get used to hearing this…..until the wisdom teeth come into play.

Mother Nature is generous when it comes to our teeth. First, we get 20 baby teeth; next we grow 28 permanent teeth; and finally around age 16-18, we start getting our 4 wisdom teeth (unless of course teeth are congenitally missing).

There are usually 4 wisdom teeth, although some may have as few as none. The removal of wisdom teeth is usually recommended for one of the following reasons:

• When the jaw is not large enough to accommodate the wisdom teeth, causing the teeth to become impacted (unable to grow in) or misaligned.
• When wisdom teeth only partially erupt, leaving an opening for bacteria to enter around the tooth and cause infection.
• When there is a chance that poorly aligned wisdom teeth will damage adjacent teeth.
• When the wisdom teeth, because they are difficult to clean, cause periodontal (gum) problems with adjacent teeth.
• When a cyst (fluid-filled sac) forms and destroys surrounding structures, such as bone or tooth roots.

As soon as it is determined that the wisdom teeth are, or will become partially or fully impacted, they should be removed. This usually occurs between ages 16 to 18, as soon as the jaw has attained the majority of its adult size. Although it is less common, there are times when wisdom teeth will fit and do not need to be removed. You need either a large mouth or small teeth for this to occur.

Removing impacted wisdom teeth at this time has several advantages. First, at this age, the roots are seldom fully formed, even though the tooth has become impacted. If left in place, the tooth will not erupt any further into the mouth but the roots will continue to grow.

Removing an impacted wisdom tooth before the roots are fully formed is easier and less traumatic for the patient. Also, at this stage in the patient’s development, the bone surrounding the impacted tooth is more pliable. Typically, patients having wisdom teeth removed in their mid-teens heal more rapidly and have a shorter and less complicated postoperative recovery.

There are many adults who still have their wisdom teeth. In my experience, I have seen very few adults who are able to keep their wisdom teeth for their lifetime. They usually cause some kind of problem, which often times does not hurt, as the problem develops. For example, my father-in-law recently needed a partially impacted wisdom tooth removed (which should have been removed about 50 years ago) and lost the molar in front of it because of the damage it had caused.

Today, the vast majority of patients have their wisdom teeth removed in an oral surgeon’s office. It’s not something anyone really wants to do, but the result in most cases is a lifetime of less potential issues.   If you still have your wisdom teeth, ask your dentist about their status.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

Contrary to what many denture-wearers believe, dentures require regular maintenance, including relines, repairs, and replacement. In fact, the average denture should be relined every two to three years and replaced every five to seven years for the most optimal fitting prosthesis. There are many reasons for this maintenance interval and for regular dental examinations, whether or not the patient perceives any problem.

The first problem has to do with the basic function of the bone surrounding natural teeth. Natural teeth are held in their sockets by thousands of “cables”, called the periodontal ligament that tug and pull on the supporting bone during function. The bone is designed to be strengthened and stimulated in this manner. When the teeth are removed, the bone no longer has appropriate stimulation, and shrinkage occurs unless it is directly loaded again with dental implants. Bone atrophy is accelerated by inappropriate forces caused by loose and ill-fitting dentures.

Relining, or replacing the tissue surface of the denture, helps preserve bone by adapting dentures to the gums as they shrink, but it is only helpful for dentures that are otherwise in good condition, which includes a proper bite relationship. Relining also helps to encourage health of the soft tissues because dentures plastic is porous and becomes heavily laden with bacteria and yeast over time. Relining refreshes the tissue surface of dentures with new acrylic. Sometimes a more advanced type of relining, called rebasing, is the treatment of choice when all of the pink portion of a denture is in poor condition and needs to be replaced.

New dentures should be made when relining or rebasing of dentures can no longer re-establish proper fit and function. Often this is obvious by wear or fracture of the denture teeth. When dentures contribute to headaches or when the patient’s face begins to look “collapsed” or “old”, the need for new dentures is likely.

Lastly, but certainly not of least importance, denture wearers need to stay current with regular dental examinations for inspection of not only the dentures but the tissue for pre-cancerous lesions. Since most people feel they do not need to go to the dentist once they have dentures, many early pre-cancerous lesions are missed.

Everyone is at risk for oral cancer, whether they have teeth or not. In fact, the constant “trauma” and lack of blood circulation caused by chronic denture wear increases the risk for oral cancer development. For this reason alone, annual dental examinations are recommended for denture wearers.

Many patients with older dentures report their dentures fit fine. You can relate this to the fit of shoes. Shoes get broken in over time and seem comfortable. However, the fact is, over time shoes lose their ability to provide proper support. Even though they may be comfortable, they may be causing other problems due to this lack of support.

If you are a denture wearer and have not seen a dentist in a year or more, it’s time to consider a dental visit. Learn about how your dentures are fitting and whether relining or replacing them makes sense. For most, it is also never too late to consider the benefits of dental implants to help preserve bone and secure dentures in place.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

Recent questions from readers answered.

Mary D:  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 $4500! 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 $4500 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. I would look at 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 and there would be no chance of recurrent problems with decay. Dental implants are a highly predictable treatment in this case.

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. Another alternative would be a retainer to hold the position of the other teeth until you are able to replace the missing tooth.

Jim G: 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. 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 T: 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 problems to come. The purpose of a crown in this situation is to protect the tooth. 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.

Please send me more questions to the email below.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

I recently read a book called “A Few Words from the Chair: A Patient Speaks to Dentists” by David Clow. This is a book written by a patient (journalist) for dentists. Here is how the book starts.

“Dentistry offers people so much that they want and need. Why don’t people get it? What would permit someone to have this resource available, and fail to use it? What would cause them to misunderstand it so thoroughly that they fear it more than they fear the consequences of not collaborating with a dentist?”

I have written numerous times on the five barriers that patients face in getting ideal dental treatment: fear, money, lack of concern due to absence of pain, using lack of time as an excuse, and lack of trust. Clow offers a statement that gets to the “root” of the issue. “Dentists and patients have extended interactions but hardly any conversations.”

A dentist may be a great tooth fixer, but also a poor communicator at the same time. When was the last time a dentist sat down with you for an extended conversation to discuss your personal situation, the importance and relevance to getting good dental care, and its significance to systemic health? When was the last time a dentist helped you work through your particular barrier to getting a healthier mouth?

Clow goes on to say to us (dentists), “There are gaps here, and like the gaps you work on in your practice, they are problems. The obvious one is between us, between dentist and patient. There’s another between what I really need and what I think I need. Yet another divides what you think you do and what I think you do. And there’s a serious one between the value most dentists have and the value they feel they can discuss.”

Clow says that we (dentists) spend too much time on things that don’t get treatment done in the chair. Technology is one of those things. Dentists tend to be techno-geeks. We’ve got to have digital x-rays, machines that make crowns in the office, and fancy chairs that give massages. That stuff is okay and serves a purpose for some patients, but what about the patients that aren’t committed to any care?

Our time is the greatest thing we have to offer, yet many dentists overlook this. Anyone can drill on a tooth but not everyone has meaningful communication skills.

Have you ever heard the old joke, “How many psychiatrists does it take to change a light bulb? One- but the light bulb has to want to change.” One of the goals I have every day is to change one person’s perspective on dentistry – to just get one person to realize the importance of a healthy mouth. It is not always easy, but these conversations are often the most meaningful and rewarding parts of the day.

The key for us as dentists is to slow down and have more meaningful conversations with our patients. We are often pushed in the wrong direction trying to run a small business, but it is important for us to realize that the human element – the doctor/patient relationship – will always be the most important part of what we do.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. 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. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.