J. Peter St. Clair, DMD Blog

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.

A couple of weeks ago I discussed the different types of materials that are being used today to “fix” teeth. I broke them down into two main categories – direct vs. indirect materials. Direct materials are things like silver amalgam and tooth-colored resin/composite that are placed directly into the tooth after the tooth is prepared. Indirect restorations are things like crowns, gold and ceramics in which the tooth is prepared and a manufactured restoration is cemented or bonded to the tooth.

Whatever your feelings are on amalgam, there is no disputing that it proved to be a very successful material over a long period of time. Despite this, it has not been used in most of Europe in decades and is used relatively infrequently in the United States. Its replacement, tooth-colored composite resin has made much progress in its ability to look good, allow more conservative treatment, and hold up well if used within the recommended parameters. However, it falls short when restorations get larger, cusps of teeth are involved, and/or when patients have bruxing/grinding issues.

In my experience, most patients don’t ask too many questions about the materials that will be used to “fix” their teeth. However, I think it is a conversation worth having. The expected lifespan of the materials being used in your mouth is good information to know to help you make a decision about your treatment. If you had a moderate to large silver filling to be replaced (that’s been there for 30 years) and the dentist told you that your new composite resin had an expected lifespan of 5-10 years, would you be okay with that?

I was recently at a training session for my CAD/CAM (computer-aided design/computer-aided manufacturing) machine which produces indirect restorations. The presenter discussed the fact that we live in a challenging time for our dental restorations. Teeth are under a lot of stress with the normal functions of eating. Throw in additional stress from grinding and an acidic environment from all the carbonated beverages we drink or gastric reflux issues people unknowingly have, and teeth are at a disadvantage.

This is why I think it is so important for patients to be more active participants in their treatment decisions. My first thought when I am determining what type of restoration to propose in any given situation is – What can I do that is the most conservative, yet adequately protective, keeping in mind that I want as much tooth around as possible for the next time this tooth needs to be fixed?

CAD/CAM technology allows the dentist to perform less invasive, longer-lasting dentistry. Tooth-colored direct composite resin is great for smaller to moderate sized fillings and should be used whenever cusps of teeth are not involved. The traditional crown (which covers the whole tooth) should be done less frequently with the use of CAD/CAM technology, which allows more conservative restorations to be done in one visit.

Ask your dentist about the materials being used to make your restorations and if you have any choices. If you have the time, google dental “onlays” to see what more conservative dentistry looks like.

One of the most important things you do when visiting a new physician or dentist is to fill out a medical history form. Many patients balk at filling out these forms, and in my experience, a high percentage of patients fill them out incompletely. There are many risks involved with not including all prescribed and self-prescribed medications.

The most frequently prescribed medications by therapeutic category are anti-hypertensives (blood pressure), cholesterol regulators, antiplatelet and anticoagulant agents (blood thinners), respiratory agents, antiulcer drugs, antidepressants, hypnotics, and anti-diabetic medications. In addition to including any of these medications on your history form, it is also very important to include any over-the-counter (OTC) drugs, as well as vitamins and supplements.

Many patients regard questions about current or previous medications as irrelevant to dental treatment and sometimes even obstacles to treatment. However, there are many drug-drug and drug-disease interactions that can occur with medications prescribed in the dental office. In addition, it is equally important to know everything that is being taken in the rare event of a medical emergency in the dental office.

Analgesics, such as acetaminophen, ibuprofen, and naproxen, are commonly prescribed or recommended in dental therapy. Acetaminophen, which is primarily metabolized in the liver, is dangerous for patients who take certain medications, such as anti-seizure and anti-depressants, as well as for those who consume moderate amounts of alcohol. Interactions with even small doses of acetaminophen can lead to liver toxicity. In addition, acetaminophen should not be used in patients on anti-coagulants as it may enhance the effects of the blood thinning agents.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can also react adversely with many of the same drugs. Prolonged use of NSAIDs can cause gastrointestinal ulceration or perforation and reduced kidney function. They should be avoided if you have pre-existing gastrointestinal or renal disease. NSAIDs have also been known to reduce the efficacy of certain blood pressure medications, interfere with the cardio-protective effects of daily low-dose aspirin, and should be avoided in the last trimester of pregnancy.

Antibiotics, such as penicillin or amoxicillin, can also interact with frequently prescribed medications. For example, these antibiotics may inhibit vitamin K formation and potentiate the effects of anticoagulant medications. They are also thought to decrease the efficacy of oral contraceptive agents.

Although you should be questioned at each visit to determine if your health status or medication list has changed, always let your dental hygienist or dentist know if there have been any changes. Review the list of medications, and anything else you take, even if you don’t consider it important, to make sure it is accurate.

Research shows that babies are born without any harmful bacteria in their mouths. However, once bacteria colonize in the mouth, children are more prone to cavities in their baby teeth and permanent teeth. How do they get the bacteria? Caregivers.
Most parents don’t know that they can pass harmful bacteria from their mouth to their baby’s mouth. The most critical time is during the child’s first 2 and one-half years of life. Most children are born without a single tooth. Can bacteria passed to children without teeth affect their decay potential for their whole life? According to research, the answer is yes.
If you have a history of poor oral health, including many fillings in your mouth or gum problems, you are much more likely to transfer these harmful bacteria to children. How? Typically, this takes place through common parental or caregiver behaviors such as sharing utensils or cleaning a baby’s pacifier with your own saliva.
Prevention starts as early as 6 months into a pregnancy. Research shows that expectant mothers who chewed gum containing the sweetener xylitol are much less likely to have decay-causing bacteria in their saliva. So, take-home point number one is; it is essential for expectant parents and caregivers to keep their own mouths healthy. If you reduce the bacterial levels in your own mouth you are not only benefiting yourself but also that of your unborn child. Visiting a dentist regularly, even more often when you are pregnant, improving your homecare, and using products that specifically reduce bacteria, are all essential.
Here are some things to consider after your child is born. First, eliminate as many potential ways of transferring saliva to your baby. Do not share utensils or let grandma or grandpa lick a cloth to clean around a baby’s mouth. Wiping your baby’s gums with a clean cloth after meals is also good practice to help reduce bacterial levels.
Once a child starts getting teeth, diet plays a significantly greater role. Minimizing snacks and drinks with fermentable sugars is key. This starts with the bottle. Bottle syndrome, also known as baby bottle tooth decay, occurs when teeth become exposed, at length and frequently, to liquids containing a form of sugar. All liquids that contain sugar can cause bottle syndrome, including breast and cow’s milk (which contain the sugar lactose), formula, fruit juice (which contains the sugar fructose), soda and other sweetened drinks.
Decay is caused by the constant presence of milk, formula, or fruit juice in a child’s mouth during the night, during breastfeeding, during naps, or for extended periods during the day. The liquid pools around the teeth and gums, providing food for the bacteria in plaque. The bacteria produce acid as a byproduct when they consume the sugar. This acid attacks your child’s teeth and causes decay.
When your child feels comfortable with a toothbrush, brush their teeth and gums twice a day with an extra-soft toothbrush. Use a pea-sized amount of toothpaste without fluoride until your child is old enough to spit. If your child doesn’t like toothpaste, it’s fine to brush without it.

Prevention starts before babies are born. It starts with taking care of your own mouth. Visit your dentist regularly and strive for optimal health.

Many patients and dentists face a decision-making process when it comes to keeping a natural tooth with root canal therapy vs. removal of a tooth and replacing it with a dental implant. The introduction of dental implants has proved to be a pivotal technology in dentistry. In a profession that strives to help patients keep their dentition, the point when it becomes necessary to opt for dental implants is a judgment call.

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Dentists are taught the skills in dental school and beyond to diagnose and treat dental decay, gum disease, tooth loss, and other things to help preserve teeth for a lifetime. A more mystical area of dentistry for many dentists is the ability to identify, communicate and treat bite-related problems that occur over long periods of time.

The term in dentistry for how the teeth come together is called occlusion. The masticatory system is composed of the teeth, the joints (TMJs), and muscles. How the teeth occlude and what a person does with their teeth, determines what happens to the teeth, muscles and joints over time. If these three things are not working together in harmony, something has to give; teeth wear down, joints and muscles can become sore, etc.

Would you want to know that there is a potential problem or prefer to have it ignored and deal with the consequences when and if they should arise?

The fact of the matter is – every person is different and does different things with their teeth. How do you compare a 90 year-old with all of their teeth with minimal wear to a 30 year-old with 25% of their tooth structure missing (unknowingly in many cases)? Both individuals eat, sleep and breathe but present very differently. Theories abound; there is no question that some people put greater forces on their teeth when they sneeze, swallow, chew and sleep than others.

Greatly underdiagnosed, these forces help cause things like teeth wearing, teeth breaking, TMJ/muscle soreness, tooth loss, tooth sensitivity, gum recession, and poor sleep patterns. Many dentists (including myself) see the signs but often choose to avoid a challenging conversation with a patient about a disease process that is not fully understood. Unfortunately, ignoring these signs is not in the best interest of the patient. It is the obligation of the dentist to raise the patient’s awareness of these forces and to discuss strategies to combat them. It is only through this awareness that patients will be able to decide if they want to do anything about it or not.

Keep in mind that many of the bodies functions, including the forces put on teeth, occur without any cognitive thought. Patients will often say, “I know I grind my teeth in my sleep when I’m stressed”. Things like stress may have some effect on this, but is it important to look beyond specific instances and evaluate the bigger picture of what is really going on.

For example, breathing is perhaps the most essential of all life functions. If you are not getting the proper oxygenation when you sleep, there are some crazy things your body does as a defense mechanism to get air. Sleep-related breathing disorders are underdiagnosed and undertreated and may just be one of the leading causes of tooth wear and TMJ problems.

I am finishing my “mini-residency” at Tufts this week in dental sleep medicine so I will be bringing this topic up again in future columns with updated information. If you have any questions about this topic, or any other, please send me an email.