J. Peter St. Clair, DMD Blog
Is Seeing Believing?
October 24, 2012
Last night I heard a commercial for a cholesterol medication in which the person playing the doctor says, “I wish my patients could see what I see.” I believe there are two ways to look at that statement.
The commercial showed an image of animated artery walls clogging with particles of plaque clinging to one another making the opening of the artery smaller and smaller. This is a visual that is easy to understand.
The second, and more subtle way to take this statement, is the doctor wishing that patients could see what happens to patients over time with and without compliance to taking medication or changing their diet. If patients could only understand and use the vast experiences of the doctor to make better decisions for themselves, wouldn’t everyone choose to do all the “right” things for a better and healthier life? Conventional wisdom would say “yes” but reality says something different.
I have been photographing teeth for over 18 years. When I tell a patient that I am going to take a series of pictures of their teeth the response I often hear is, “I just had x-rays taken.” When I explain that they are pictures and not x-rays it is not uncommon for the patient to ask, “Why?”
I had a new patient in yesterday for a consultation who said these exact words. The patient then said something that I also hear frequently, “No one has ever done this before.” My response is that I take pictures of teeth for two reasons. The first is for my own documentation and the second is to be able to show the patient what is in their own mouth.
Showing a patient visual images of their own teeth is by far the most powerful tool I use in practice. How many times have you been to a dentist where treatment is explained and recommended but you can’t see it? A picture is truly worth a thousand words.
When I started displaying the images and giving the patient above a tour of her own mouth the patient said, “Wow, that doesn’t look good. I can’t believe that is in my mouth.” I hear that a lot too. After the “tour” I continued to explain why things look a certain way and what to expect in the future. I proposed both long and short-term plans for the patient to consider. Photographs are invaluable for this exercise and most patients appreciate being able to see what I see.
The next part of my consultation is to try to get the patient to look beyond the pictures and envision where they want to be 5, 10, 20+ years down the road. My goal is to bring my own experience of knowing, based on all the patients I have seen in practice, where the patient is headed and give them the opportunity to potentially change the course of their future.
This approach may be different for some people. It is easy to get overwhelmed by any new approach and I always encourage patients that this is the beginning of a relationship and decisions to do or not do something do not have to be made today. My new patient said, “I am X years old and I don’t know if I am even going to be around in 10 or 20 years.” Crystal ball or not, it still seems like a long time to me.
You, as a patient, should look beyond today and make choices for ANY aspect of your health based on where you want to be in the future. Take advantage of the knowledge you gain from all your experiences and make decisions that you feel are right for you.
The Soda Ban
October 5, 2012
On Sept. 13, at New York City’s Mayor Michael Bloomberg’s urging, New York City’s Board of Health approved what’s believed to be a first-of-its-kind ban on the sale of supersized sugary beverages. In six months, if there’s no lawsuit filed to block it, containers of Coke, Pepsi and sugar-laden flavored drinks larger than 16 ounces will be outlawed at restaurants, movie theaters, food carts and sports arenas. Business violators would be subject to a $200 fine.
This ban doesn’t stop someone from buying two 16-ounce cups or bottles of soda. Nor does it apply to convenience stores or grocery stores. And, of course, New Yorkers are free to drink however much they want at home.
It is said that at worst, the new soda ban will inconvenience some hard-core soda drinkers. However, my contention is whether or not this is the right way to approach the war on obesity? Critics contend that this ban is an assault on our freedom to choose. I have mixed feelings on the subject. Does the ban on large beverages and the previous Bloomberg-inspired ban on trans fats lead to a ban on the number of hamburgers one can purchase at the same time?
Last week, the American Dental Association (ADA) gave a thumbs-up to Mayor Bloomberg’s initiative. ADA president, Dr. William Calnon said, “Health professionals, including dentists, have long stressed the importance of a healthy diet; yet obesity and lack of exercise — associated with chronic diseases and conditions such as heart disease, cancer, diabetes and hypertension remain high.”
On the ban itself Dr. Calnon said, “When it comes to a ban related to a particular food or beverage, is a stick rather than a carrot approach the best way to get people to adopt healthier diets? Perhaps not, but the attention alone that the mayor’s ban has generated on this issue is certainly a huge step in the right direction.” Dr. Calnon seems to believe that the attention to the subject is worth more than methodology. Most of us are aware that super-sizing anything is probably not in the best interest of our health. If we ban certain food products to fight obesity, should we make exercise mandatory?
As with any lifestyle choice, the lessons need to start early in the home. What we choose to buy in the grocery store to provide for our families on a consistent basis is the backbone of the impressions our children get, which will help them make better choices on their own. Our children need to grow-up in an environment where we respect what we put in our own bodies and take care of ourselves with exercise. It seems to me that banning or limiting what can be purchased is an attempt to make up for the lack of discipline in the home. But, will that work?
Is the limitation of allowing smoking in public places the reason for a decrease in smoking? Smoking in public places puts others at risk and is the main reason, but smoking in general has decreased because of the increased awareness of health risks. Does the ability to buy a 32-ounce soda have a direct effect on anyone surrounding the person buying it?
I’m all for increased awareness of what science has shown is good or not good for us. Armed with that information, we have the personal responsibility to make choices that we feel are right for us as individuals.
Is Your Insurance Expiring?
September 27, 2012
I don’t know how you feel but I think this year is just flying by. I guess I feel like that every year. Only three more months left in 2012. For those of you with dental insurance, only three more months to use your dental benefits before they disappear and go toward the bonuses for the insurance executives. That is kind of a joke and it is kind of not.
As you know, if you have dental insurance, you have a yearly maximum amount of money that can be used for dental care. Although that yearly maximum (typically $1000-1500 per year) has not changed for 40 years in most situations, if you don’t use the money the insurance company keeps it. That’s right, if your insurance company doesn’t write a check out for your dental care, they keep whatever you don’t use.
On that note, if you have dental work that needs to be done, now is the time to do it. The only catch is that because many patients wait until the end of the year to use their dental insurance benefits, it is often difficult to get an appointment. Therefore, those reading this column will be one step ahead of everyone else. The big rush generally occurs in the next couple of weeks so book your appointments now.
This is especially true for patients who need multiple things done. Let me use a specific example. Let’s say your dentist has told you that you need a crown on a tooth but the tooth will need work done by a periodontist or even the dreaded root canal prior to doing the crown. Getting the “pre-crown” work done at the end of this year will allow you to finish the crown in the beginning of next year and maximize your insurance benefits.
It has always seemed crazy to me that we have to play these games with dental insurance, but that’s the way it works. If you have been told that you needed some work done and haven’t done it, call your dental office or insurance carrier to see what remaining benefits you have.
Just for clarification, as this is an area that patients sometimes get confused on, your yearly maximum is yours and not your spouse’s. If you and your spouse have dental insurance and a $1000 yearly benefit, you get to use $1000 and your spouse gets to use $1000. If you go over your maximum you cannot use any of your spouse’s benefits.
For those without dental insurance – you are not missing out on too much. Yes, dental insurance is nice to have, especially if your employer is paying most or all of the premiums. However, people tend to get into the frame of mind that if they do not have dental insurance they can’t go to the dentist.
I had a patient in just yesterday that had not been in for 5 years because he said he did not have insurance. Five years later the patient needs more work done than the insurance benefits will cover. It’s not worth it.
One thing is for certain, regardless of whether you have insurance or not, regular visits to a dentist is the key. If your goal is health you can’t do it alone. If the cost, or the fact you don’t have dental insurance is what is holding you back, talk with an office that offers financial arrangements that work for you. The longer you stay away the more difficult it is to catch up.
Have a great autumn. Beat the rush and schedule those appointments.
Routine Change
September 10, 2012
Summer is unofficially over with the passing of Labor Day. For many, especially those heading back to school, this means a change from the summer routine. One of the routines I changed this past summer is to read more outside of my typical dental journals. The latest book I read was the revised edition of “The Slight Edge” by Jeff Olson. I highly recommend this book for anyone looking to change their routine to make positive improvements in their life.
We all have our own routines. Routines are important for both mental and physical health. Some think my daily routine is crazy, but if you look at them, most people’s daily routines look crazy to others. In “The Slight Edge” the author discusses that change or improvement in our lives comes one day at a time. It is the small decisions that we make daily, that we often consider insignificant, which mold who we are.
When our routines are broken by a vacation or lack of motivation, it is always difficult to get back into it. I’m sure you can relate. I am always thinking of different ways to change my routine to spend more time with my family, eat healthier, and have more “free” time. Changing routines is probably one of the hardest things to do. However, changing routines is probably one of the most important things to do. Striving for improvement in our lives by changing our routine usually improves the quality of life.
Going to the dentist is a routine. It is not part of your daily routine but it should be part of your overall routine for staying healthy. One of the biggest challenges I see in the practice of dentistry is changing people’s routines.
When someone comes into my office with a problem and has not seen a dentist for one, five, ten, or twenty years, it is easy for me to “fix” the problem they are having and get them back to a comfortable state. That comfortable state however, does not necessarily mean health. That comfortable state usually means status quo, which often times translates into the fact that there are other problems brewing, just waiting to become a crisis. The thing that is not easy to do, for any dentist, is to get those people to come back – to change their routine.
For some people it is financial, but for the vast majority it is the lack of pain or lack of concern. Regardless of the reason, it always comes back to changing routines. Our priorities dictate our routines. Priorities need change just as much as routines. If our priorities include health, we will spend money on a gym membership or home fitness equipment, go to the doctor or dentist on a regular basis, and eat things that are healthy. If the lack of pain is the reason you don’t exercise or frequent the doctor or dentist, it can lead to everything from the loss of teeth to the loss of life. If long-standing hypertension could have been controlled by regular exercise and/or medication doesn’t that beat an early heart attack? If long-standing periodontal disease, which doesn’t hurt and 75% of the population has some form of, could have been controlled by regular visits to the dentist, doesn’t that beat losing your teeth?
Changing your routine to improve your quality of life is worth every penny you may spend on it. As Jeff Olson says in his book, “You can’t change the past. You can change the future. The right choices you make today, compounded over time, will take you higher and higher up the success curve of this real-time movie called ‘your life’.”
Feel Good
September 4, 2012
Last week I was on vacation. There are many definitions of vacation but the first one I found when I looked up the definition is – “a period of suspension of work, study, or other activity, usually used for rest, recreation, or travel.” I think that is a fairly good definition but for me it is missing one key point.
Most of us look forward to vacation. For some it might be a time to relax or “unwind” or maybe sleep in and be lazy. For others, like myself, I look at it as having time to do things I love to do or to put it a different way – things that I am passionate about.
I know what you are thinking – but you are a dentist….aren’t you passionate about that? I have been a dentist for 18 years and there is no doubt that I love what I do. The fact of the matter is, it is difficult to stay interested in anything without growth. I take a lot of continuing education in dentistry to continue to learn and grow in my profession. However, like most people, I have interests outside of work that I look forward to during vacation.
Every weekend is a vacation. I look at it that way because I always want to have a “vacation” to look forward to. Whether we are working or we are in school, we all look forward to time away from our daily routine. Having said that, whether it is a weekend or a longer vacation, I get up at the same time, generally go to sleep at the same time, and I exercise, which is all part of my daily routine. For me that is important because it allows me to spend the same amount of time doing some of the other things that I am passionate about.
So, what’s the key point that I think is missing from that definition of vacation? I think it should include the idea that we want to do things that make us feel good. If you aren’t feeling good you are feeling bad. If you feel bad you are not growing, and if you are not growing you are going in the other direction, which is not good!
While I love what I do on a day-to-day basis during the week, I am passionate about learning. I like to learn and grow in my profession but I like learning in general. I believe that is the key to growth and feeling good.
My father is a good example of this. He has been a veterinarian for 50 years! That is a long time to do the same thing. He still loves what he does, although he does it a lot less these days, but he always learning….not just about veterinary medicine but about other things that he is passionate about. At 75 years old he is still learning and growing.
I had a patient in the other day who is truly passionate about bike riding. While that is not his profession, it is obvious that he loves bike riding and is constantly striving for improvement and growth. Bike riding for him makes him feel good. And that is the key point – when you feel good you are happy and we all want to be happy.
There are things that we have to do in our day-to-day lives that don’t necessarily make us feel good. Many of those things cannot be avoided. However, in general, we should try to avoid those things that do not make us feel good. For example, I do not watch the news very often any more. If you watch the news on a regular basis I would bet you know why.
So, if you find yourself not as happy as you would like to be, stop and write down a list of the things that bring joy to your life. Make time to do more of those things, or even just one. Pick something that you want to learn more about and “grow” with it. I truly believe that happiness is a choice.
Spleep Apnea – Part 1
August 22, 2012
Why is a dentist writing about sleep problems? More and more dentists are getting training in this area of medicine because they can be of help in the treatment of some of the problems associated with sleep-related issues. There also seems to be a large part of the population who are un-diagnosed or are diagnosed but have issues with treatment modalities they are using.
Sleep problems need to be diagnosed by a trained professional. Although there are many dentists who are providing treatment for sleep apnea, there are certain channels to consider for proper diagnosis. For example, a sleep study is a must in diagnosis and a dentist alone cannot provide this.
What is sleep apnea? It is a serious, potentially life-threatening sleep disorder that affects approximately 18 million Americans. It comes from the Greek meaning of apnea which means “want of breath”. People with sleep apnea have episodes in which they stop breathing for 10 seconds or more during sleep. Since many people see their dentist on a regular basis, if there is any concern of sleep apnea, the dentist can work closely with a physician to implement and manage a prescribed therapy.
There are two major types of sleep apnea, both of which can severely disrupt the regular sleep cycle.
Obstructive sleep apnea is when the muscles in the walls of the throat relax to the point where the airway collapses and prevents air from flowing into your nose and mouth. However, as you continue to sleep you also continue to try to breathe. This is the most common type of sleep apnea.
Central sleep apnea is the other type. This is when breathing interruptions during sleep are caused by problems with the brain mechanisms that control breathing.
What are the symptoms associated with sleep apnea? People with sleep apnea usually do not remember waking up during the night. Some of the potential problems may include morning headaches, excessive daytime sleepiness, irritability and impaired mental or emotional functioning, excessive snoring, choking/gasping during sleep, insomnia, or awakening with a dry mouth or throat.
So, what is the difference between snoring and sleep apnea? Unlike mild/moderate snoring, individuals with sleep apnea stop breathing completely for 10 seconds or more, typically between 10 and 60 times in a single night. If the person sleeping in the same room hears loud snoring punctuated by silences and then a snort or choking sound as breathing then resumes, this could be sleep apnea.
Studies have shown that people with diagnosed sleep apnea can be so fatigued during the day that, when driving, their performance is similar to that of a drunk driver. If left untreated, sleep apnea can lead to impaired daytime functioning, high blood pressure, heart attack, or stroke.
Next week we will discuss the diagnosis of and treatment options of this potentially life-threatening disorder.
One Patient’s Story
July 25, 2012
This is the story about a woman I met recently named “Carol”. Carol’s story is the reason I do what I do every day and brings me back the next day. The interesting thing is that it has absolutely nothing to do with performing the actual physical work of dentistry.
Carol is in her 70’s and for most of her life has gone to the dentist infrequently. She presented to my office a couple of months ago for a second opinion. At our first appointment Carol brought her most recent x-rays, a treatment plan from another dentist, and a page-long list of questions. She was well-prepared for the complimentary consultation I was giving her and seemed to know exactly what she wanted.
About 8 years ago, Carol visited a dental office that touts itself as “holistic”. Carol had about $10,000 of dentistry done at that office and unfortunately had not seen a dentist since. Her reason for visiting that particular office was because she was/is very concerned about her health and believed that a “holistic” office could provide her with what she was looking for. Now, only 8 years later, her teeth were falling apart.
Carol had eight crowns done on her upper back teeth at that time. The crowns, still in her mouth, were failing due to recurrent decay. More importantly to Carol, her front teeth were in severe breakdown. Carol had her mind made up; she wanted full dentures.
Carol sought out a local dentist, presented her desires, got a written treatment plan with fees, and then came to me for a second opinion. She brought that treatment plan with her and it appeared very reasonable – take out all remaining teeth and place full dentures. The first thing I noticed was that Carol had 6 lower front teeth that have been decay-free and have had excellent bone supporting them for 70 years. However, her mind was made-up, she wanted everything taken out. She did not want to have to deal with maintenance of teeth any more.
Over the next two consultation appointments I had with Carol, we discussed many different treatment options. We thoroughly reviewed the advantages of keeping these lower front teeth each time we met. Carol brought a list of questions to each of these meetings, which we discussed in depth. It was decided – Carol was moving forward with full dentures.
We have had two more appointments since then. Because of the location of the dental laboratory that I use, those appointments were spread-out over a few weeks. At this point, we had done some procedural steps to get her ready for full dentures, but the teeth are still there. They would not get taken out until the dentures were ready to be delivered.
At each appointment I discussed a different aspect of why it would be such an advantage to her to keep those lower front teeth. Her mind was not changed. Yesterday, Carol walked into my office to tell me that she has decided that she wants to keep her lower teeth.
Okay, so what’s the point? The point has nothing to do with what Carol’s final treatment is. Carol has every right to decide on what she feels is right for her.
The dentistry Carol received 8 years ago was good technical dentistry on the teeth that were treated. However, the “holistic” dentist did not treat her as a whole person and left the rest of her mouth destined for failure.
The local dentist she got the treatment plan from provided a very reasonable treatment proposal. They had one visit, decided on treatment and her next step was to go to the oral surgeon and have all her teeth out.
Far too many times I see patients and dentists rush into treating teeth. Taking the time to engage in conversation and treat the person as a person and not a tooth is less common than it should be in my opinion. My point of this story is not that I got Carol to do what I felt was best for her, but that I gave her my time, answered all her questions, and allowed her to decide what was best for her. She needed the time.
There are few things we have to rush into in life.
Media Spin on Dental X-Rays
July 22, 2012
For the past couple of months, every dentist in the United States has had to deal (in some form or another) with the story on the front page of the Cleveland Plain Dealer newspaper entitled, “Dental X-rays Linked to Brain Tumors in Yale Study”. The story made national headlines, and why wouldn’t it with a title like that?
The reporter did publish excerpts from a meeting with ADA (American Dental Association) spokesperson Matthew J. Messina, DDS to get the dental communities’ perspective; however that was published on page A-4. As Dr. Messina explained, “Like a courtroom trial, the prosecution went first. Page 1 included the first six paragraphs of the article. The ADA’s defense was well presented, but after the ‘jump’ to page A-4. It required that a person be committed enough to understanding the story, to be willing to actually open the paper and read the article to the end. And that is one of the problems that ‘we’ will always face as a profession.”
For the rest of us who don’t live in Cleveland, or read the Cleveland Plain Dealer on-line, we got our story from the national news media. All I heard was that dental x-rays cause brain tumors. As a consumer and someone concerned about my health it raised an eyebrow. As a dentist I knew there was more to the story.
Here are the facts as presented by Dr. Messina:
How common are the brain tumors? (Six per 100,000) How did the researchers find a link between dental x-rays and brain tumors? (They asked people with brain tumors to remember how many x-rays they had over their lifetime) Is there a problem with this type of study? (Yes, it’’ called “recall bias”) Are dental x-rays different today than they were even 10 years ago? (Yes, the amount of radiation in current dental radiography is dramatically less than in years past) What should patients do with this information? (Talk to their dentist about any concerns so that their dentist can give them accurate information and reassure them)
While there is strong evidence that ionizing radiation may cause cancer, the question remains whether low doses lead to an increase in risk. Regarding dental x-rays, the effective dose is far below the yearly exposure received from natural background radiation. In the case of brain tumors, the cerebral (brain) region is not even in the primary radiation field of most dental x-rays. This was not even considered in the study.
Where do we go from here? If you are in the approximately 50% of the population that does not see a dentist on a regular basis, this information does not mean that much. If you are in the other 50% that understand that oral health means so much more than having your teeth cleaned or a tooth filled, I would recommend the ALARA rule (as low as reasonably achievable). Dental radiographs are a safe, essential and effective tool in identifying dental decay, gum disease, pathology, as well as monitoring proper growth and development.
As a society it is my hope that we are willing to move past the skimming of all the information that is available to us and ask questions when things relate to us. We (dentists) as a profession will continue to work towards educating our patients and providing the safest, most effective care.
The Top Ten
July 13, 2012
This season is often the time there is an influx of new patients being seen in dental practices. Many of the new patients I have seen this spring are people who have not been to a dentist in five or more years. Here is a list of the top ten reasons these patients say they have stayed away from the dental office:
10. Fear of pain
9. Missing work time
8. Moved and haven’t “found” a new dentist
7. Have been out of work
6. My dentist retired
5. Can’t find an office I am comfortable in
4. I don’t like the dentist
3. Economy
2. Lack of concern
And…….the #1 reason people have stayed away from the dentist – Didn’t have insurance.
One of the new patients I saw yesterday (a 40-year-old) said to me, “I haven’t been to a dentist for over five years because I didn’t have insurance. I haven’t had any problems but now I have insurance”.
After examination, this patient was very glad to hear he did not have any cavities. He was not so glad to hear that he had moderate periodontal (gum) disease. When questioned on his familial history he said, “My mother has dentures and I know my father is missing some teeth but I think he’s okay”.
Despite the fact that most people do not know the details about their familial dental history, most seem to know if their parents had/have their own teeth, go to a dentist on a regular basis, and a general knowledge of any problems they have encountered. I always ask this question because it is a good general guideline as to potential dental issues facing the person sitting in front of me.
Luckily for the new patient described above, he will be able to regain most of his dental health with appropriate non-surgical periodontal therapy. However, he was made aware that he has bone loss that will not come back, and because of his genetic pre-disposition for periodontal disease (which affects some75% of the population), life-long maintenance, including hygiene visits every 3 months will be essential to maintain his fragile periodontal status.
And……if his goal is to be healthy and keep his teeth for his life-time, this means every 3 months for the rest of his life…..regardless of whether he has insurance or not. We talked about the annual cost for this maintenance with or without insurance and he was surprised to hear how affordable it is to maintain health.
As I have predicted, due to people staying away from the dentist, dental emergencies are on the rise. I have seen more emergencies (broken teeth, pain, etc.) this spring than I can remember in the recent past. Emergency room dental visits have risen at a staggering rate…..and just so you know, the hospital cannot do anything for you other than prescribe pain medication which often helps only minimally.
I urge you not to put off dental visits. If you have any of the “excuses” listed above, I would suggest re-prioritizing and putting your health at the top of the list. Many dental offices offer complimentary….FREE…initial visits. Talk to the dentist and dental staff about your concerns. There are ways to manage any of these concerns. If the dental office you go to does not listen or does not have a solution, move on to another office. Get a plan that is manageable for YOU!
Is there a Dental Link to Alzheimer’s?
July 9, 2012
Alzheimer’s disease (AD) is one of those diseases you would not wish on anyone. I have it in my family. My grandfather died from it about 30 years ago.
Since its discovery more than 100 years ago, there have been many scientific breakthroughs in AD research. In the 1960s, scientists discovered a link between cognitive decline and the number of plaques and tangles in the brain. The medical community then formally recognized Alzheimer’s as a disease and not a normal part of aging. In the 1970s, scientists made great strides in understanding the human body as a whole, and AD emerged as a significant area of research interest. This increased attention led in the 1990s to important discoveries and a better understanding of complex nerve cells in the brains of AD patients. More research was done on AD susceptibility genes, and several drugs were approved to treat the cognitive symptoms of the disease.
More recently, researchers have found long-term evidence that periodontal (gum) disease may increase the risk of cognitive dysfunction in healthy individuals, as well as those who are already cognitively impaired. The evidence shows that gingival inflammation may contribute to brain inflammation, neurodegeneration, and Alzheimer’s. My own observations in practice show that as the disease progresses, home care becomes more challenging for patients, which leads to more inflammation, and may contribute to progression of the disease.
Previous research has shown that patients with AD had a significantly higher level of antibodies and inflammatory molecules associated with periodontal disease in their plasma compared to healthy people. One of the tests used to evaluate cognitive function is called the Digit Symbol Test, which is part of the standard measurement of adult IQ.
Researchers found that periodontal inflammation in tested subjects at age 70 years old was strongly associated with lower test scores. Participants with periodontal inflammation were 9 times more likely to test in the lower range in this particular test compared to participants with no periodontal inflammation. Amazingly, this strong association held true even in those subjects who had other risk factors linked to lower testing scores, including obesity, cigarette smoking, and tooth loss unrelated to gum inflammation.
Obviously, the research will continue. Another obvious fact is that I continue to read more and more connections between poor oral health and systemic issues. And, the last obvious fact is that I am trying to educate patients on a daily basis about the significance of good oral health. The mouth is the link to the rest of the body.
I had three patients this week who flat-out refused to accept the fact that they have a problem because they have no pain. They think I am trying to pull the wool over their eyes. I say it over and over; lack of pain is not a good indicator of a problem. Your teeth can be practically falling out and I would be willing to bet you have no pain. Dentists wish that gum disease did hurt. It would be easier to get patients to improve their health.
