Made in China
May 29, 2012
I just returned from my semi-annual journey to my dental lab in Georgia where I meet with a group of dentists who share both the laboratory we use and the passion for excellence in what we do. The topic of dental restorations made overseas came up. Mr. Terry Fohey, certified dental technician and owner of NuCraft Dental Arts, one of the finest dental laboratories in the country, believes that a dental patient should have the right to know where the materials are coming from that are being put in their mouth.
China and other countries can claim to use specific materials, but there are no regulations in place to verify the information. There are also no regulations that allow a dental patient the right to know where the materials came from that are being placed in his/her mouth.
With the help of a State Senator from Georgia, Mr. Fohey is proposing legislation requiring dental laboratories to disclose to the dentist the material contents and point of origin of every dental restoration. It would also require the dentist to disclose the information to the patient should the patient ask. Would it make a difference to you whether or not your crown was being made in the United States or not?
Why are some dentists and dental laboratories farming out dental restorations overseas? Like everything else in the world, money is the reason. I get advertisements in the mail daily of dental laboratories able to make crowns for ridiculously low prices. It apparently sounds enticing to some practitioners.
Wonder why some dentist’s fees are higher or lower than others for this service? There are actually many factors that go into the creation of a fee for a procedure that requires a laboratory expense. The patient never sees the laboratory expense in most cases because it is built into the total fee. Clinical experience, clinical skill, office overhead, time required, and nature of the practice are all things that go into the creation of a fee.
The cost of the laboratory procedures also greatly affects the cost for the dental procedure. Let’s take crowns for example. I have seen laboratory fees advertised as low as $39 per crown and know of other dental labs whose fee is a few hundred dollars per tooth. Some patients would accept a lower quality product going into their mouth for a lower cost and others would not.
There are even machines you can buy that can fabricate crowns while you wait. There are many choices. It is basically up to the dentist to decide what he/she feels is in the best interest of the patient based on knowledge and skill.
In my experience, laboratories that cost more tend to make a better product. That better product which gets put in your mouth is a direct reflection on the dentist placing it. Excellent lab work, however, does not make up for less than perfect clinical skills. I have been in practice for 16 years. It took me a good 7 years to find a laboratory that meshed with what I try to accomplish for my patients…..and believe me, it was painful getting there.
We live in an ever-changing world. I try to buy American as often as possible, but realize that it is not always feasible. Mr. Fohey summed it up this way, “This bill is simply about disclosure. It does not restrict anyone from importing dentistry. Instead, it just makes us all play by the same rules.”
7 Traits of the Ideal Doctor
April 26, 2012
What makes for an ideal doctor? Patients shared their views in a study which appeared in an issue of Mayo Clinic Proceedings. It’s based on nearly 200 patients treated at the Mayo Clinic in Arizona and Minnesota.
In phone interviews with people who had no professional ties with the Mayo Clinic, the patients described their best and worst experiences with their Mayo Clinic doctors, with confidentiality guaranteed. The doctors seen by the patients came from 14 medical specialties.
Who made the list?
Here are the seven traits listed by the patients, along with the patients’ definitions of those traits:
• Confident: “The doctor’s confidence gives me confidence.”
• Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
• Humane: “The doctor is caring, compassionate, and kind.”
• Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
• Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
• Respectful: “The doctor takes my input seriously and works with me.”
• Thorough: “The doctor is conscientious and persistent.”
That list isn’t in any particular order. The researchers didn’t check whether confidence was more important to patients than respectful treatment, for instance. The Mayo Foundation funded the study.
The traits covered doctor’s behavior, not technical know-how. That finding “does not suggest that technical skills are less important than personal skills, but it does suggest that the former are more difficult for patients to judge,” the researchers write.
They add that patients may tend to assume that doctors are competent unless they see signs of incompetence, the researchers add.
One patient put it this way in the study: “We want doctors who can empathize and understand our needs as a whole person. We want to feel that our doctors have incredible knowledge in their field. But every doctor needs to know how to apply their knowledge with wisdom and relate to us as plain folks who are capable of understanding our disease and treatment.”
The opposite of those seven traits would be: timid, uncaring, misleading, cold, callous, disrespectful, and hurried. Can healthcare ever be high quality if the patient-doctor interaction is any of these? Technically, the care can be high-quality but is it really a place that you want to be treated?
Holistic Dentistry
March 9, 2012
For whatever reason, I have had a group of patients migrate to my office from a “holistic” dental practice in a different part of the state. The Merriam-Webster dictionary definition of “holistic” is –“relating to or concerned with wholes or with complete systems rather than with the analysis of, treatment of, or dissection into parts. Holistic medicine attempts to treat both the mind and the body.”
Most of us are probably more familiar with the term “holistic” in the medical world than in the dental world. I have done a little research on “holistic dentistry”, and to be honest, I have a lot more research to do. In the future, I plan on writing more about my research on this subject.
I make most of my clinical decisions in practice based on peer-reviewed, published scientific evidence. I like facts. However, I am also an avid student of the psychological and emotional side of what I do. My initial research into “holistic” dentistry has found both things that I am attracted to as well as borderline quackery.
For the purposes of the column this week, I am going to comment on the Holistic Dental Association’s philosophy taken from their website. I have commented on each individual paragraph below:
We believe that Holistic involves an awareness of dental care as it relates to the entire person.
Most people are now well aware that the mouth and the rest of the body are connected. We know that there are connections between dental health and systemic health as it relates to things such as heart disease. The holistic approach seems to go beyond this.
We believe that health care practitioners and recipients should be provided with appropriate information to make informed choices that will enhance personal health and wellness while feeling loved, accepted, and understood.
Much of the “holistic” approach is a frame of mind. Different people need different amounts of information to make an informed decision for their particular situation. It is the communication and relationship between the patient and the doctor that is most important.
We believe that Holistic Dental Association membership provides physical, emotional, and spiritual support while we expand our awareness and skills.
No comment.
We believe our educational growth should be nurturing, affordable, and encompasses basic information, experiential knowledge, and leading edge ideas.
Experiential knowledge means knowledge gained from direct experience. I would agree that many of the things we do are based on our own experiences and often that information can benefit someone else. However, I do not see anything in this statement that relates to published scientific data.
We believe in openly sharing resources. We believe in an inter-disciplinary approach to health that facilitates the individual’s innate ability to heal her/himself.
Most organizations, when it comes to learning, are open to sharing resources. Most practitioners use an inter-disciplinary approach to provide what they feel is best for the patients. The last part of the statement is the more “holistic” part.
I will share more about specifics in “holistic” dentistry in the future.
The Survey Results Are In
March 1, 2012
A few weeks ago I posted a survey on my office Facebook page that I mentioned in this column. The question was – If someone offered you $1 million, would you allow all of your teeth to be removed? If you haven’t taken the survey and would like to, please go to the Facebook page listed at the end of this column. If the numbers change on this survey I will report them at a later date. For now, here are the results:
75% of respondents were female
12% are missing more than 2 teeth not including their wisdom teeth
75% of respondents consider themselves dentally healthy while the other 25% consider themselves “sort of” healthy
62% visit a dentist every 6 months
100% would not take the $1 million to have all of their teeth removed.
Although there was not one person who would allow all of their teeth to be removed, let’s look at who took this survey. First, it appears that most respondents were readers of this paper and probably frequent readers of this column. I would make a blanket statement that frequent readers of this column put their health relatively high on their priority list.
However, only 62% visit a dentist at least every 6 months. The national average is around 50%. It does surprise me that only 62% of those who are “more dentally educated” see a dentist at least every 6 months.
When I am quick enough to use them, I like to use analogies. I analogize with cars frequently. Teeth and cars are two things that we use daily and often take for granted until something goes wrong. Would you drive your car until something happened without ever changing the oil? What could possibly happen if you did that? It would probably mean catastrophe. You would probably be told that the car is junk and you need a new one or it would be very expensive to fix.
I see the same thing the mechanic sees. Failure to perform routine maintenance will lead to problems. The extent of the problems will depend on factors such as how well the car was built, how often it is used and/or abused, and how well YOU take care of it. Those who take meticulous care of their car and get regular routine maintenance will keep their car much longer and have many fewer problems along the way.
I was also a little surprised that no one would take the million for their teeth. For $1 million you could have as many dental implants as you wanted to replace the teeth and still have plenty of money left over. However, it is a long road that apparently no one is willing to go through.
In case you were wondering what my answer to the question would be, here it is. As a dentist, knowing what would be involved to take a dentally healthy person’s teeth out, I would also not take the million. The physical, and more importantly emotional toll that this would put on me is hard to put a price on.
We all take too many things that we rely on daily for granted. Think about the things in life that are important to you. Think about what it would mean in your life if they weren’t there. The moral of the story – take meticulous care of the things that are important in your life.
Wanna Be a Dentist?
February 15, 2012
I’m sure you have heard that dentists are always at the top of the list for suicide, divorce, and substance abuse. I did a little research just to verify that is actually accurate…..and yup, it is. I could go into why I think that is the case, but I’ll let you ponder that one on your own.
Despite the many challenges of this profession, if I could do it all over again, I would still choose to be a dentist. I didn’t decide to go to dental school until late in my senior year of college. People ask me all the time, “What in the world made you decide to look inside of mouths every day?” Believe me, I asked myself the same question when I decided to apply to dental school. It was a last minute decision.
Today, I am glad I went into a profession that allows me to problem solve and can be both easy and challenging. I guess it is my approach. I see myself as an educator and a health care provider who wants to help people decide to what level of health they wish to achieve. I have also made the conscious choice to enjoy what I do every day. When things occur that I do not enjoy, I try not to focus on the negative. It is always a work in progress.
For a dentist, and for that matter anyone in any profession to be successful, they must know themselves and have standards they are able to communicate with passion and energy. One thing is very clear, behavior, with its impending results, is a choice. We make choices every minute of every day. What we choose to do with the paths presented to us is a choice. Being frustrated with your job, trying to copy others instead of discovering yourself as well as dental care is a choice.
All dental care is elective. There is nothing that you have to do. That is what makes this profession the most fun and rewarding for me. A dentist who worries about how much of a particular procedure they do, or tries to sell dentistry as a commodity will become frustrated. That is why there tends to be a high burn-out rate in this profession. It should be about education. It should be about people and caring about their health.
It is also about building trust with people. If any of my patients out there ever had a thought that I was trying to “sell” them something, there is an issue with trust there. I use the car analogy often. First, you decide that you are buying a car. It is only after you decide that you are buying a car that you pick the style, the brand, and the options. It is with that information that you make a decision on what car you are buying, based on what you want and feel is right for you. I look at dentistry the same way.
Dentistry combines health care, artistry, psychology and business all into one. As in any job, there are good times and not so good times. There is always room for improvement in all aspects of the profession and the options for continuing education to improve are limitless.
If you, or if you have kids in high school or college who are wondering about what to do with their life, introduce the possibility of a career in dentistry. Ask your dentist if they would talk to you or them about the profession or even do mentorship. It’s a wonderful profession.
What Your Mouth Says
February 2, 2012
A few weeks ago there was a large article in The Wall Street Journal entitled, “If Your Teeth Could Talk.” It was a basic review of some of the connections between oral and systemic health and also offered some newer research that I was unaware of.
I have written many times on the growing evidence linking periodontal (gum) disease with many systemic issues. The fact of the matter is the mouth is truly the gateway to the rest of the body. While some early signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalance and drug issues can show up in the mouth long before the person discovers that there is a “problem”, an unhealthy mouth also puts you at greater risk for things like heart disease, stroke, diabetes, and pregnancy complications.
A study done at New York University in 2009 reported that 93% of people who have periodontal disease are at risk for diabetes. The issue is inflammation and the fact that periodontal disease and diabetes exacerbate each other. Inflammation from periodontal disease, a chronic non-symptomatic disease, makes it more difficult for people with diabetes to control blood sugar levels. High blood sugar accelerates tooth decay and gum disease, which elevates inflammation. It is a vicious cycle.
However, more recent studies show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes. The estimates are that six million Americans have diabetes and don’t know it. The risk of not treating either disease can have irreversible consequences.
If you have ever had a planned surgery you probably were asked about your dental health, how often you visit a dentist and asked to get “clearance” from your dentist prior to surgery. The reason for that is because the type and quantity of bacteria present in uncontrolled gum disease is much higher than in periodontally healthy individuals. Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere. Far too often patients come to me a month before surgery and say they need to get their mouth in shape prior to their procedure….an often impossible task.
There are also an increasing number of people on medication and the number of medications they are taking. Many drugs, including but not limited to blood thinners, bisphosphonates (ex. Fosamax), blood pressure medications, antidepressants and chemotherapy drugs can all have effects on the mouth that can be devastating if not closely monitored.
This is all “real” stuff. I deal with these issues in the office every day. I use this analogy a lot, “Periodontal disease is like diabetes, it is not curable, but in most cases it is controllable.” For most patients, good home care combined with good professional care can control this disease. Just as in the lottery, “you can’t win if you don’t play”. However, the consequences for not playing the dental game are more risky.
If you didn’t take the survey last week that I discussed, go to the Facebook page below to take it. I will be reporting the results in the next couple of weeks. So far, not one respondent would give up their teeth for a million dollars. Would you?
What would you do?
January 10, 2012
In last week’s column I talked about the trend over the past few years of dentistry taking on a new look. This” new” look is a resurgence back to the days of prevention and maintenance and involves less elective procedures such as cosmetic veneers.
There are still many patients who would like to improve the appearance of their smiles with these elective procedures but are postponing treatment due to the economy. There are also many people who have taken professional dental care completely off their radar for the same reason. This group is in danger of many future dental problems.
I have a hypothetical question to propose. This question assumes you are not missing more than (2) of your natural teeth (not including wisdom teeth) and under the assumption that you are dentally healthy. Here is the question:
If you were offered 1 million dollars to have all of your teeth removed, would you do it?
Obviously this is not realistic but I want you to think about how important your teeth are to you. For that same $1 million, would you give up driving or riding in a car for the rest of your life? Would you give up your bed and resort to sleeping on the floor the rest of your life?
Teeth, cars and beds are things we use all day long. They are an important part of our lives and are often taken for granted. I know there are denture wearers out there who would encourage people to take the million bucks…..but there is no comparison between natural teeth and plastic.
Now, with that million, you could replace the teeth with a number of different options. Typically those options are a denture, an implant-supported denture, or multiple implants with teeth (crowns) attached. If you wanted to come out of this with the most minimal expense, you would be getting a poorly fitting denture the day your teeth were taken out (there is a lot of estimation when all the teeth are present and a denture is being made), months of healing and then a better fitting denture would be made for you.
If you chose the last option and wanted to replace your teeth with implants, you would need to have all your teeth removed, that same poorly fitting denture made, the same months of healing, and then multiple appointments to finish. The total treatment time would be about a year. Of course you would have to pay for this; but you do have the million dollars from having all your teeth removed.
Realistically, no one is going to offer you a million dollars to take all your teeth out. My point is meant to be simple. A healthy mouth is such an important part of life. Think of the discomfort, aggravation, inability to smile confidently, inability to eat properly and enjoy food. The quality of life is undoubtedly better with natural teeth. However, a million dollars is a lot of money. The question definitely made me think.
So, I would love to hear what you would do. I have set up a survey on my Facebook page (www.facebook.com/dentalhealthforlife). Take the survey and I will report back on the findings in a few weeks.
In the meantime, please visit a dentist regularly. Maintenance of dental health is so important. Don’t wait until you have a “problem”, because often times that problem is a sign of many bigger issues. Life is better with teeth!
Looking Forward
January 6, 2012
The end of 2011 is here and it is time to reflect on the good and not so good of the past year. We are in a very unstable time in the history of our country and the world. Even if 2011 was not the best year for you, there are always things that we can find to be grateful for.
“If you continue to do what you’ve always done, you will continue to get what you’ve always got.” I’m not exactly sure where this quote came from but it is a good way to reflect on the past year and think about the year to come. I also always publish the list below every year because it is a great compilation of some of the most important things in life.
These 21 suggestions for success are authored by H. Jackson Brown, Jr. I have a framed picture of these hanging in my office and read them every day. I get comments about them all the time from people saying how much they like them. Cut this column out, hang it on your refrigerator and read it frequently.
1. Marry the right person. This one decision will determine 90% of your happiness or misery.
2. Work at something you enjoy and that’s worthy of your time and talent.
3. Give people more than they expect and do it cheerfully.
4. Become the most positive and enthusiastic person you know.
5. Be forgiving of yourself and others.
6. Be generous.
7. Have a grateful heart.
8. Persistence, persistence, persistence.
9. Discipline yourself to save money on even the most modest salary.
10. Treat everyone you meet like you want to be treated.
11. Commit yourself to constant improvement.
12. Commit yourself to quality.
13. Understand that happiness is not based on possessions, power or prestige, but on relationships with people you love and respect.
14. Be loyal.
15. Be honest.
16. Be a self-starter.
17. Be decisive even if it means you’ll sometimes be wrong.
18. Stop blaming others if it means you’ll sometimes be wrong.
19. Be loyal and courageous. When you look back on your life, you’ll regret the things you didn’t do more than the ones you did.
20. Take good care of those you love.
21. Don’t do anything that wouldn’t make your Mom proud.
22. (my own) Strive for optimal health……and that includes dental health.
Read this list often and take these suggestions to heart. They will be sure to make your 2012 great. Happy New Year!
Bridge vs. Implant
December 28, 2011
Over the past few weeks I have had numerous new and existing patients who have had the need to replace single and multiple teeth. Based on the conversations I have had with these patients, there seems to be some common misconceptions about replacing teeth. I would like to share my thought process that I communicate with patients when they are forced to decide between different treatment rationales.
Let me start by using an example of a new patient I had in yesterday. The patient presented with the chief complaint of pain. The diagnosis was an infection of a previously root canal treated tooth which was deemed non-restorable. The only treatment was extraction. The teeth adjacent to this tooth are in good condition. There are four treatment options: extract and leave the space, extract and replace missing tooth with a removable appliance (partial denture), extract and do a fixed, cemented bridge (non-removable), extract and replace missing tooth with a dental implant.
Extracting the bad tooth and leaving the space is always an option. There are, of course, esthetic concerns as well as concerns about other teeth moving and loss of function. Replacing the missing tooth with a removable partial denture is an option but is not one that most people choose due to the fact that they have to wear something in their mouth. That leaves the last two options that most people contemplate: a bridge vs. a dental implant.
Fifteen years ago, when I started practice, the standard of care was to replace the missing tooth with a bridge. A bridge is a laboratory fabricated restoration where the teeth on either side of the missing tooth (abutments) are prepared for crowns. An impression is taken of the prepared teeth and the final product, a one-piece “3-tooth” porcelain bridge, is cemented onto the two teeth that were prepared. The advantages of this are: typically can done quicker than an implant and if the abutment teeth need crowns anyway, all is accomplished with that one procedure. One major disadvantage is that if you get decay on one of the abutment teeth, the entire bridge is typically lost. So, if you are prone to decay (especially if you do not visit the dentist on a regular basis), a bridge is probably not the best solution. Another disadvantage is that if the abutment teeth do not “need” crowns, a bridge requires perfectly good teeth to be ground-down. Because the bridge is one piece, flossing requires a special tool to thread the floss under the bridge.
Today, I would consider a dental implant to be the standard of care. A dental implant is a titanium “post” that replaces the root of the missing tooth. A single crown is then placed on that “post”. The procedure is typically less invasive than removal of a tooth. You cannot get decay on a dental implant. If something goes wrong with one of the teeth on either side of the dental implant, you only have to deal with the one tooth and not three teeth as in the example of the bridge. The teeth are all separate so flossing is normal. The cost of a single dental implant vs. a 3-unit bridge is about the same.
Although there are other things to consider, I am out of space this week. I encourage your questions.
Interdisciplinary Dentistry
December 21, 2011
Last week I was invited to attend the annual North Eastern Society of Orthodontists (NESO) meeting in Boston. You may ask why I attended an orthodontic meeting when I am not an orthodontist? The reason I was invited was because of the strong interdisciplinary component of the meeting. What is interdisciplinary dentistry?
I’ll use the example of a 38 year old woman I saw just yesterday as a new patient. She had not been to a dentist in a couple of years and wanted to have her teeth cleaned. She saw one of my hygienists, had her teeth cleaned, and then saw me for an examination. My examination of new patients usually includes a set of photographs of the teeth. Over the years, this has proven to be invaluable for me to be able to discuss a patient’s dental status. It is much easier to show and explain than just explain.
I evaluate 4 areas in every patient. Those areas are the biology, esthetics, function and structure of the teeth. The biology is the health of the gums and bone that support the teeth. This is important because this is the foundation of good health. I always evaluate the esthetics of the teeth because the smile is the most prominent feature of the face. The function of the teeth is an evaluation of how the muscles, joints and teeth are working together – does the patient have any muscles or joint (TMJ) issues and do the teeth show any signs of wear? Lastly, the structure of the teeth is the condition of the teeth themselves – what is the patient’s dental history and what is the condition of the existing restorative dentistry in the patient’s mouth?
As I was taking this new patient on a “tour” of her mouth, I simply described what I saw. As often happens, my patient started asking a lot of questions. The bottom line is that she always wondered why she had repeated dental problems and had a list of things she did not like about her teeth. Her dentists in the past had never looked this deep into her dental issues, so she was never given the opportunity to do anything about it. In the past, if there was a problem, the problem would get the quick fix, a crown or a filling, and life would go on until failure occurred again.
This patient, who came in just to have her teeth cleaned, announced that she was ready to fix her teeth correctly. As her dentist, I need to be able to deliver the level of care she expects. This is only possible with effective collaboration between a group of dentists. Her treatment will probably be phased over the course of a few years. It will require collaboration between me, an orthodontist, a periodontist and an oral surgeon. This is interdisciplinary dentistry.
Much of the NESO meeting was about treatment like this. The dentist must have the educational background of the many different disciplines of dentistry and be able to communicate their findings in simple terms that patients can understand. Doing a complete exam and reporting findings is the obligation of the dentist to the patient. This at least gives the patient the opportunity to choose the level of health that is right for them as an individual.
When it comes to actually doing the dentistry, it is essential that the general dentist, the quarterback of the team, has the right players assembled to make the entire treatment a homerun.
