J. Peter St. Clair, DMD Blog
Politicians and Light Bulbs
August 11, 2011
I know what you’re thinking; politicians and light bulbs? That’s an oxymoron. I thought the same thing when I heard this one. It’s back in the news because the date the incandescent light bulb goes out is rapidly approaching.
Congress passed an energy bill which controls the type of light bulbs all Americans must use by the year 2014. It bans the use of the incandescent light bulb and requires the use of those squiggly fluorescent bulbs. I know what you’re thinking again; that’s not so bad….they’re energy saving and that’s good, right?
In addressing the House of Representatives, Rep. Ted Poe of Texas noted that there was nothing in the Constitution that allows the government to control the type of light bulbs Americans use. Other than the lack of constitutional authority, Rep. Poe goes on to say, “These light bulbs contain mercury. So, they have to be disposed of in a certain way. According to EPA rules, you are supposed to take them to a local recycling center.”
Again, that’s not so bad, right? Recycling is good. He goes on to say, “Thanks to Congress, nothing is easy. If you throw them away at home you are supposed to seal them in two plastic bags and place them in the outside trash. Otherwise, the bulb may break and pollute the landfill, of all things. These bulbs are made of glass so they are fragile. If one breaks it or drops it you have to follow simple rules thanks to Congress. And according to the EPA, here’s what you do if you break one of these light bulbs. And I quote, ‘Have people and pets leave the room and don’t let anyone walk through the area. They must evacuate the room. Open a window and leave the room for fifteen minutes or more. Shut off the central heating and air conditioning system. Carefully scoop up glass fragments and powder with stiff paper or cardboard and place them in a glass jar with a metal lid.’ Obviously that’s readily available. I continue, ‘Use sticky tape such as duct tape to pick up any remaining small glass fragments and powder. Wipe the area clean with a damp paper towel or disposable wet wipes and place them in the glass jar. Do not use a vacuum or a broom.’”
He continues, “If you break one of these light bulbs in a high-rise where the windows don’t open, will the EPA police haul us off to jail because of improper disposal procedures? If we dropped one of these light bulbs we would have to evacuate the House of Representatives according to the EPA light bulb law.”
The warnings on these light bulbs say that they may cause interference to radios, televisions, wireless telephones, and remote controls. They are also ONLY made in China. So, not only are they only made in China but they contain mercury. Let’s see……another product that we don’t produce that we will rely on….and they contain mercury….which is obviously not good for the environment….but is still legal to stick in teeth. I am not aware of any warnings on the packaging of amalgam (silver) filling material and this contains 50% mercury. I will discuss more about that next week.
Thank God for politicians.
A Healthcare Provider’s Greatest Gift
July 25, 2011
Don’t you hate to wait? I took my to get the oil changed a couple of weeks ago and there were three cars ahead of me. A man graciously opened my car door and escorted me to the “waiting room” like it was a 5-star resort, which it definitely was not. I sat there and waited and waited, constantly looking through the glass at the garage bays to monitor the progress. As I sat there I was thinking, “can’t they move any faster; there seems to be a lot of standing around doing nothing going on.” Then of course I realized that there was more to the story as there was someone under the car and “behind the scenes” doing something they were waiting for. I waited patiently from then on realizing I had no real control on how long it takes to change oil in a car.
One of my pet peeves in dental practice is running behind. I hate to make people wait. However, the reality of it is that things don’t always go the way you planned. Most patients are very understanding. Occasionally I’ll hear over my shoulder, “Doctor, your next patient would like to know how much longer it will be?” I’ll usually jokingly respond, with my current patient on their back in front of me, “Mrs. Smith, I’m sorry, I have to rush through the rest of your difficult filling because I have another patient to see.”
I believe the philosophy of practice revolves around treating the person as a whole and not just a tooth. It means patients, their overall health & well-being, must be foremost in the practitioner’s mind. Yes, it also means cleanings, fillings and crowns. These are often inescapable outcomes to dental disease – but, under what context are these services being provided?
Too often the dentist views a patient as just a mouth. The goal is to fix as many problems in as many mouths in as short a time as possible. The patient becomes the object of the “fix” instead of a participant in the treatment. How degrading is it for a patient to experience that type of environment? Where is the quality, attention and care when the dentist is busy running room to room? Although for some, this is the type of care they desire because the fees are often lower in this type of setting.
The dentist also suffers. How satisfying can it be for a dentist who sees 40 patients a day? What kinds of relationships can that dentist build with his or her patients? How can that dentist spend the necessary time with the patient to really know the patient’s needs and desires?
In a truly health-centered practice, each patient should be treated as a unique, whole person. Each patient should be treated with dignity and respect. The dentist gives each patient his/her most important gift: TIME.
Taking the time to listen; taking the time to do a complete examination; taking the time to teach the causes of existing and potential dental problems and taking the time to explain alternative treatments and modes of prevention. It means that each patient be given the opportunity to choose the highest level of health consistent with their values and life circumstances.
The Patching Theory
July 20, 2011
I would like to discuss some situations I have had over the past week with a few new patients. The common theme with these patients was the idea of “patching” things vs. treating for predictable long-term success.
There are many different ways to “successfully” practice dentistry. Success as defined by Webster’s is, “a favorable or satisfactory outcome or result.” Success can also be short-term or long-term. In dentistry, short-term success can be anything from a day to a few years. If you have a front tooth break and the dentist fixes it but it breaks a week later, it was successful for a week. The patient usually doesn’t look at it as being successful at all. The question is what problem caused it to break again? In this situation it usually has to do with bite related or structural issues and not with the fact that the dentist didn’t “bond” the tooth correctly.
I look at long-term success in dentistry as being anything over 10 years. However, there are many situations in dentistry where a short-term solution can lead to a longer-term success. But when it eventually fails (and everything fails at some point), the present fix of the current problem may involve more extensive treatment.
Let me use a specific example that we see every day in the dental office. I am sure many of you can relate to it. Let’s say you have a molar with a large filling and a piece of tooth breaks off while eating. The dentist tells you that he/she can patch the tooth with some bonding material at a cost of $200 or do a crown on the tooth for $1200. With that amount of information most people, understandably, would choose the patch if the outcome would be to “fix” the tooth. Five years go by and everything is great until another piece of tooth breaks off of the same tooth. The dentist now tells you that there is not enough tooth structure left to do a crown and the tooth needs to be extracted. The only problem is that it is a molar and you need it to chew, so you decide to replace it with a dental implant to the tune of $4000. Some may choose not to replace it, which is free, but you have just lost function. What happens if you have a bunch of teeth with big fillings that have been “patched” over the years?
Patients love dentists who patch teeth. They get a quick fix that costs a lot less….in the short-term. This is very understandable. When given the choice, I too would always like to spend less money to fix something than more. However, investing in a fix that gives you a long-term success is usually always a good investment.
I do believe that you should always be given a choice. They’re your teeth, not the dentist’s teeth. One of the problems is that there are those dentists who have very “successful” practices who don’t give the patients the choice. Their philosophy may be that patching is the way to go. That is fine. For the more progressive dentist, giving the choice to the patient means education….. and education takes a lot of time. Spending time talking with patients seems to be a lost art in the dental world.
I’ll say it again….. they are your teeth and you are the one who makes the decision on what is done with them. Just remember, investing in more predictable long-term care will usually mean having more teeth when you are older or spending much less over time. Studies show that the quality of life decreases with every tooth lost. Invest in your teeth; it’s better than any other investment out there right now. Your teeth don’t depreciate in value.
The Golden Years
June 28, 2011
The Golden Years are much more “golden” if your teeth are in good shape. One of the most difficult areas I have had to address in my time as a dentist are issues concerning aging patients, specifically those who require assisted or nursing care.
Whether you are the one making decisions for someone else or you are older and can make your own decisions, it is easy to let home care and regular dental visits decrease as time goes on. Dental health needs to stay at the top of the priority list for many reasons. Quality of life and the link between oral health and systemic health are two big ones.
Patients I have seen for the past 15 years will come in and say, “I don’t need to fix that. How much longer do I really have to live?” And every time I respond the same way, “If you told me that you knew you weren’t going to be around next year I’d say I would agree with you…..but you’ve been saying the same thing for 15 years.” It’s worse when the patients lose key teeth when they had the opportunity to keep them for their lifetime.
When an elderly patient has a multitude of dental issues in which some significant decisions need to be made, I consider the following issues:
• What is the general health status?
• How old is the patient?
• What is the general prognosis medically?
• Has the patient ever worn anything removable in their mouth?
• What is the minimal amount of dentistry that can be done that will not alter the patient’s quality of life?
• What are other treatment options to maintain or improve the patient’s quality of life?
The general health status of the patient plays a big role in deciding how to approach a patient’s dental care. People who have medical problems and are well controlled are usually okay to receive general dental care. If a person is in good physical and mental shape it is hard to use age as a determining factor for dental care.
The most important factor which I believe needs to be considered is about quality of life. Studies have shown that loss of teeth results in a loss in quality of life. Some people with dentures have told me that they can eat anything. Others would pay anything to have their teeth back. The point is the enjoyment of eating. There is no one who could argue that eating with false teeth is as enjoyable as eating with real teeth.
In my opinion, the worst thing you could do to a 70+ year old person (or for that matter anyone, but the older you get the worse it is) is to remove teeth and make them wear something removable in their mouth. Dentures can be very difficult to adjust to and it is even harder when you are older. The problems with dentures not staying in, the patient not wanting to wear them, and impacting a patient’s nutritional intake are all issues that are much more difficult for the elderly.
The best way to avoid having to deal with major issues as you get older is to make sure you take care of your teeth while you’re younger. If someone you love ends up in a nursing facility, one of the most important things you could do for them is to make sure they get proper dental care. This includes the use of some home-care products on the market that greatly decrease the risk of dental caries.
Stressed Out?
June 21, 2011
Are you stressed out? It seems that stress levels in people are on the rise. 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 published last summer 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 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 oral 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. 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 make any necessary recommendations.
I’ll leave you this week with a quote from A. Cornelius Celsus’s DeMedicina. He wrote this around the birth of Jesus Christ, 2000 years ago. He was a Roman author and medical historian.
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.
Still good advice 2000 years later.
Decay – 100% Preventable
June 7, 2011
I spent last week in Boston for the annual meeting of an organization I belong to called the American Academy of Cosmetic Dentistry (AACD). It was a great meeting. In the four days I was there I took eight classes, went to a Red Sox game, did a Duck Boat tour, and had dinner in the North End. It was great to be a “tourist” in Boston. I learned more about the history of Boston and a great deal of information to be able to provide better care.
There are a wide variety of courses to take at a meeting like this. Most of them are obviously related to cosmetic-based dentistry, but there are other courses offered. Of the eight classes I took, this one particular course struck me the most. It was on current research of dental decay. I know what you are thinking, booooooring; I did too before I took the class. I learned so much and want to share some of the material I learned with you.
Dental caries (decay) is on the rise. It is the #1 disease in children; it has a genetic component and has systemic effects. There are over 19,000 different bacteria that have been found in mouths and every person has about 1,000 different types. Not all of them cause decay and many of them have also been found to grow on artery walls.
Why the increase in decay? Most of it has to do with dietary trends. If you haven’t noticed, our society is getting fat. We snack more, eat more sugar/carbs, drink more soda, have more gastric reflux, take more mouth-drying medications, etc. Dental caries is a pH specific disease. The right bacteria, plus sugar, create acid which breaks down the enamel of the teeth. Add an already acidic environment and it is even worse. It is a 100% preventable disease. The problem is that changing behavior can be very hard to do.
It is time for the dental professional to take a different approach when treating this disease. More focus needs to be shifted to prevention of decay rather just treating it. Filling teeth is treating the result of the disease but does nothing to prevent it. The dentist needs to take a more active role in assessing individual’s risk factors. In the dental world this is referred to as CAMBRA, which stands for Caries Management By Risk Assessment.
Based on assessing an individual’s risk factors such as quality of home care, quality of salivary flow, medication issues, and dietary issues, a caries-preventive strategy can be established. There are many new products on the horizon to help combat and virtually eliminate this disease. However, dentists must take some responsibility and be open to a different management of this disease. They must also be able to motivate people to change habits, which is difficult. The bottom line is that if you want to be decay-free you can be.
For those at higher risk, there are some great products currently available and others to come. Everything from new toothpastes and gels with ions in them to rebuild tooth structure, sprays to neutralize pH and probiotics are on their way. Right now you can use things like sweetener replacement Xylitol, which by itself is cavity-fighting, but also works synergistically with fluoride. Prescription level toothpastes are also available and there is strong research for the topical application of fluoride varnish, the same stuff the kids get, for adults.
The evidence is very clear – this is a 100% preventable disease. Next time you go to the dentist and find out you have a new cavity, stop blaming the dentist or yourself, and ask to get a specific protocol for prevention of this disease based on your specific risk factors.
Getting Ripped Off? – Part 3
May 29, 2011
For the last couple of weeks we have been discussing an online column that was forwarded to me called “Is Your Dentist Ripping You Off?” If you missed any of the columns, be sure to look them up online. This week I wanted to discuss more of the comments readers made after the column was published.
Many of the comments are rants from obviously angry people. As I read through the 9 pages of comments, it is obvious that people are mad about the cost of dentistry and things in general. It is also obvious that many of the contributors have a very negative opinion of the profession. This is a disturbing trend.
What does the following comment say about this particular person’s view of dentistry? “It is about time dentists got investigated. They over charge, they underpay and take advantage of their staff. Why do they use dangerous toxic materials like mercury in fillings?…….and the unnecessary braces they subject little kids to. They actually x-ray the whole head. This industry is ripe for massive investigations. Hopefully it will happen before more people are damaged by unnecessary or shoddy work.”
In addition to this comment being highly inaccurate, it is coming from someone who is probably angry at life in general, let alone dentistry. The point is that this is the trend. People are losing trust in professions that used to be well respected. Why? Life isn’t getting any easier. The cost of living seems to be continuously rising and loyalty and trust are slipping away as a consequence of just being able to make ends meet. As disposable income decreases, people are spending less on things they do not feel are essential.
I discussed a comment last week from someone who was complaining about the cost of a crown. What if you need 10 crowns and the cost is $15,000? Let’s get one thing straight – no one needs crowns. You may need a crown or 10 to save your teeth but you always have the option of taking the teeth out. That would cost a lot less. Someone might say – I can’t justify spending $15,000 on my teeth. There are people who will spend $40,000 on a car that they drive for 5 years and trade in for $10,000. Most people use their teeth more than they use their car and the teeth don’t depreciate. It is the responsibility of the dentist to educate the patient so that the patient can make the most informed decision on what is right for them.
Unfortunately, dentistry is not getting cheaper and the broken system we call dental insurance is not getting any better. So, for now, dentistry is one of those things you have to decide where to place on your priority list. Just keep in mind that your health, including the health of your teeth, has a direct effect on the quality of your life.
Now, as far as this trend of losing trust and loyalty, you have to make a decision about where dentistry falls on your priority list first. If your dental health is not important to you, you could be the one making all the negative comments about dentists and dentistry, probably do not go to the dentist on a regular basis, and will most likely suffer the consequences. If your dental health is important to you, seek someone you like and trust as a person. If you find that person, they will make sure to take good care of you. You have a choice.
Getting Ripped Off? – Part 2
May 22, 2011
Last week I told you about an online column that was forwarded to me called “Is Your Dentist Ripping You Off?” Basically, the author was questioning why there can be such a discrepancy in fees or treatment plans between dentists. The author also gave suggestions on how to pick a dentist and did note, “Don’t select a dentist on price alone.”
This week I wanted to discuss some of the comments that readers made after the column was published. It is interesting to note that there were people on both sides of the debate. The first comment came from a dental assistant. She says, “It is fair to comparison shop but remember that cost is not always the best evaluation tool. It is a much better idea to check around with people you trust to see if they like their dentist.” She goes on to say, “Most dentists like their patients to be informed about their health and partner in all decisions. In our office, patients are always given the optimal solution as well as the options and their pros and cons.”
I would agree with these statements but would add that you, the potential patient, make the ultimate decision as to who your dentist is. Just because someone else “likes” a particular dentist does not mean that person is right for you. Although it is impossible for you to be able to evaluate the clinical skills of a particular dentist, which is unfortunate, the most important factor is that you trust who you are going to.
Here is a comment from another reader. “What’s disgusting is that the dentist pays the lab about $450 for a crown and marks it up 200% or more. What happened to the accepted profit margin for a business of 20-30%? What a rip.”
Can dentistry be expensive? Absolutely. Who is to blame? Is it the insurance companies that have not raised their yearly maximums since 1970? Is it the dentists who are price gouging? Is it the dentists who are over treating? Is it the government? I think of solutions for this all the time but always come up dry. There are so many factors. I have never heard one solution that fixes all the problems. If you have one, I would love to discuss it.
Here are some of the issues. Today, as I understand it, the cost of an undergraduate education at Tufts University is about $52,000 a year. That’s over $200,000 to get a bachelor’s degree. To be a dentist you have to spend at least four more years in school. Tufts Dental School is currently around $75,000 per year. That is another $300,000 to bring the total cost of 8 years of education to over $500,000. That is a tough nut to swallow on graduation day with no job, no income, no house and a beat-up car. I’m not saying you should feel badly for those poor dental graduates; I’m just saying it is a factor.
Any small business owner will tell you that running a small business is a challenge. Dentistry is no exception. The average overhead for a dental practice is tough to say because it depends on where you are in your career, what type of office you have, and where you practice. However, I can tell you it is high. Again, we dentists are not looking for sympathy: I’m just saying it is a factor.
There are other factors for cost such as the perceived level of expertise of a particular dentist, the quality of the laboratory used (which makes a huge difference), continuing education expense to keep current,demographics, etc. I will discuss more of these next week when I review some other interesting comments.
Are You Getting Ripped Off?
May 12, 2011
If you are an expert in a particular field it tends to mean you know quite a bit about that subject. It doesn’t mean you are always right, but you can usually at least have an intelligent conversation about your field. When a “journalist” writes a story about your area of expertise, I would be willing to bet, the expert (you), often cringes about the content. So goes the latest thing I have seen written about dentists and dentistry.
“Is Your Dentist Ripping You Off?” is the title of an online column that was forwarded to me. One of the best parts of this type of column are the comments to follow from such a wide range of people. Dentists commented, patients commented, hygienists and assistants commented, and many who don’t go to the dentist commented. Over the next few weeks I am going to take little pieces of the column and the comments and discuss them. I think it will make for some interesting discussions that I hope you will weigh in on.
Let’s lay the groundwork with summarizing the column itself. The author describes a “person near and dear” who returned from the dentist and was told they need two crowns for around $3000. The author called some other dentists in the area and found that there was a range of fees. Some of her comments follow:
“When I look at this bill, I wonder why I obsess about the weekly price fluctuations of Cheerios or the shrinking size of a can of tuna. All the economical choices a family makes in a year can be wiped out by a trip to the dentist.” She continues by questioning how there can be such a range in fees.
“So how can the first guy explain why his price is $450 higher? The office assistant told me ‘not all dentists are created equal,’ and of course, this dentist is one of the best in the area, using a great lab. But how can someone who is not a medical professional know if their dentist is worth their fees?”
I think these questions are excellent questions and are things that many people wonder about. Of course, there is no easy explanation. We will get deeper into that in another column. There is no doubt, dentistry can be expensive, but is it relative to everything else in life?
One of the most important suggestions the author had was, “don’t select a dentist on price alone.” While I believe this is true, the next logical question would be – What other factors do you use in selecting a dentist or health care provider? The author provided some other good information.
“Fees are one part of evaluating a dental practice, but you want to have confidence in the office, the people there, how they sterilize instruments, and the training and continuing education of the dentist. Does he or she seem to be looking out for your best interests over the long haul? What’s the dentist’s philosophy for keeping your teeth healthy for a lifetime?”
That is great advice. I would add to that looking at the practice website, reading testimonials of existing patients, and asking to visit the practice and meet the dentist and staff before committing. That should be done at no charge.
Next week I will discuss some of the comments written after this column. That will be interesting. Looking forward to your comments as well.
To Seal or Not to Seal
May 9, 2011
If you have kids and you take them to the dentist, I am sure you have heard about sealants. I don’t know what the statistics are, but I would assume that most dentists recommended dental sealants. In case you are unaware, a dental sealant is a flowable resin generally placed on permanent 6 and 12-year molars. It is placed on the top of the tooth in the grooves of the teeth. Its purpose is to help prevent decay from forming in this area, which happens to be the most common place for dental decay to occur. It does nothing in the prevention of decay between teeth or on any of the other 20 teeth in the mouth – although the molars are generally the first teeth to decay.
Make sense so far? Now for the controversy. In my opinion, sealants have a very limited application. Let me take a step back and give you some information to help you see where I cam coming from.
There are actually many different techniques to place sealants. The way I was taught in school, and the way many if not most sealants are still placed, is that if that little picky thing that everyone hates doesn’t stick in the tooth, the tooth is cleaned and the sealant is placed. The first problem is that the little pick is not very accurate – about 57% according to studies I have seen. The statistic shoots to over 90% accuracy with the aid of laser cavity detection. This is a relatively inexpensive tool that sends a beam of light into the top of the tooth and measures density of tooth structure.
So yes, there are teeth that get sealed that have decay. However, according to studies, sealing over minimal decay is clinically acceptable. These studies say that the sealant can actually stop or prevent the decay from progressing. Would you want that in your mouth?
That is not the main problem though. Once that sealant is placed, the laser detection tool is ineffective. You then have to rely on x-ray detection, which is also not very accurate, unless the decay is moderately large. I cannot tell you how many teeth I have done moderate size fillings on that had clinically acceptable sealants in place.
The main problem is that a sealant is a dental restoration and ALL restorations leak over time. Whether it be a filling or a crown, they all leak and allow bacteria in which may potentially cause decay. So, my position is, why would you place a restoration on a seemingly healthy tooth? A healthy diet, good home care, and regular professional care are the keys to dental decay prevention. So, do sealants prevent decay? They aid in not getting stuff stuck in the grooves of teeth which can cause decay, but they do not guarantee you won’t get decay.
For the few adults out there that still have sealants in place and don’t have decay, you probably wouldn’t have decay even if the sealants hadn’t been there. I would rather have a healthy tooth remain restoration free and be able to be monitored by a laser. If decay is detected early with the laser, the tooth can have a very conservative tooth-colored restoration. This can then be monitored clinically and by x-ray.
