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.
Amesbury Nixes Fluoride
December 5, 2011
Last week, Amesbury residents voted in a relatively narrow margin against the re-introduction of adding fluoride to the public water supply. Fluoride has been added to many public drinking water supplies all over the country for decades in an attempt to combat dental decay. The theory is that ingested systemic fluoride strengthens the developing teeth and makes them less susceptible to decay.
I would bet you would think that I am a proponent of public water fluoridation given my profession. I am not. In fact, I think it is unethical, unnecessary, ineffective, unsafe, inefficient, and unscientifically promoted. Although there is not enough space in this column to go into this in depth, let me give you an example of each.
Public water fluoridation is unethical because it violates an individual’s right to informed consent to mass medication. It is okay to put substances in the public water to make it safe, but not to medicate, and especially not a heavy metal that accumulates in the body. Public water fluoridation is also unnecessary because people, including children, can have healthy teeth without being exposed to systemic fluoride. This is different than topical fluoride which I will touch on later in this column.
Public water fluoridation is ineffective as research has shown that fluoride’s benefits are primarily topical and not systemic. Countries that have halted water fluoridation generally do not see increases in decay. It is unsafe as systemic fluoride accumulates in the pineal gland and in bones, making them more brittle. Also, where the fluoride comes from is an interesting topic of discussion. Many municipalities get their fluoride from China.
Public water fluoridation is inefficient for many reasons, one being that more and more people drink bottled water (which is loosely regulated) and most of the public water ends up washing dishes, in the shower or watering the lawn. If ingestion of fluoride did make sense there are better ways to make it available to people who want it. But, is it really necessary?
Lastly, public water fluoridation is unscientifically promoted. As stated by the US Centers for Disease Control, “Laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children”. I am a proponent of topical fluoride such as the fluoride found in toothpaste. And, as we age, the decay rate often increases due to exposure of more root surfaces of the teeth which are more susceptible to decay.
Research continues on the effect that fluoride has on teeth, both systemically and topically. The research also continues on the effects that ingested fluoride has on the rest of the body. There is also mounding research on products other than fluoride that show promise in combating dental decay.
I have a fair number of patients on prescription level topical fluoride that I feel are more susceptible to decay. My protocol may be changing soon due to pending research. However, one thing is certain, those with a good diet, impeccable homecare, and who visit a dentist at least twice per year, are much less susceptible to decay no matter what they brush their teeth with.
It Starts Before They Are Born
November 9, 2011
Research shows that babies are born without any harmful bacteria in their mouths. However, once bacteria colonize in the mouth, children are more prone to cavities in their baby teeth and permanent teeth. How do they get the bacteria? Caregivers.
Most parents don’t know that they can pass harmful bacteria from their mouth to their baby’s mouth. The most critical time is during the child’s first 2 and one-half years of life. Most children are born without a single tooth. Can bacteria passed to children without teeth affect their decay potential for their whole life? According to research the answer is yes.
Here’s a shocker…..If you have a history of poor oral health, including many fillings in your mouth, you are much more likely to transfer these harmful bacteria to children. How? Typically, this takes place through common parental or caregiver behaviors such as sharing utensils or cleaning a baby’s pacifier with your own saliva.
Prevention starts as early as 6 months into a pregnancy. Research shows that expectant mothers who chewed gum containing the sweetener xylitol are much less likely to have decay-causing bacteria in their saliva. So, take-home point number one is, it is essential for expectant parents and caregivers to keep their own mouths healthy. If you reduce the bacterial levels in your own mouth you are not only benefiting yourself but also that of your unborn child. Visiting a dentist regularly, even more often when you are pregnant, improving your homecare, and using products that specifically reduce bacteria, are all essential.
Your baby is born, now what? First, eliminate as many potential ways of transferring saliva to your baby. Do not share utensils or let grandma or grandpa lick a cloth to clean around a baby’s mouth. Wiping your baby’s gums with a clean cloth after meals is also good practice to help reduce bacterial levels.
Once a child starts getting teeth, diet plays a significantly greater role. Minimizing snacks and drinks with fermentable sugars is key. This starts with the bottle. Bottle syndrome, also known as baby bottle tooth decay, occurs when teeth become exposed, at length and frequently, to liquids containing a form of sugar. All liquids that contain sugar can cause bottle syndrome, including breast and cow’s milk (which contain the sugar lactose), formula, fruit juice (which contains the sugar fructose), soda and other sweetened drinks. It is caused by the constant presence of milk, formula, or fruit juice in a child’s mouth during the night, during breastfeeding, during naps, or for extended periods during the day. The liquid pools around the teeth and gums, providing food for the bacteria in plaque. The bacteria produce acid as a byproduct when they consume the sugar. This acid attacks your child’s teeth and causes decay.
When your child feels comfortable with a toothbrush, brush their teeth and gums twice a day with an extra-soft toothbrush. Use a pea-sized amount of toothpaste without fluoride until your child is old enough to spit. If your child doesn’t like toothpaste, it’s fine to brush without it.
Prevention starts before babies are born. It starts with taking care of your own mouth. Visit your dentist regularly.
Google YOUR Dentist
November 7, 2011
It amazes me how far technology has come in the course of my lifetime. To think that I made it through my whole educational career without a cell phone and without the use of the internet is mind-boggling. I also never thought that my children would get to the point where I was asking them how to do things.
For many of us, technology consumes us. I spilled coffee on my cell phone this past weekend and spent the better part of a gorgeous day running around trying to replace it. I felt like I couldn’t live without it. Another morning this week my website was down and I could not post some new information on it. I panicked and spent over an hour on the phone with tech support trying to resolve the issue.
Technology is not going anywhere. In fact, it seems like it gets more and more complicated every day. I feel like I can’t keep up. Do we really need to keep up? I guess that depends on the individual.
One of the simplest forms of technology is the use of Google. You can Google anything and have an unlimited source of information instantly at your fingertips. However, just like listening to the news, it is up to the viewer to decide how to use the information. Much of the data we hear on the news or view on our computer is distorted somehow or other.
In my world, Google has replaced the phonebook. I can’t remember the last time I looked in a phonebook. Other than finding someone’s local phone number, the phonebook has very limited information. Today, if I am looking for a service and have not had a personal referral from someone I trust, I “Google it”. Even if I had a personal referral, I do my research on the computer.
Need a dentist? Google it!! As I have said in previous columns, a personal referral is usually the most reliable way to find a dentist, but just because your friend likes the dentist doesn’t necessarily mean you will. Do your own research. Most dentists have a website. You can learn a lot from a website and it is just that much more information to help you make your decision.
One of the more recent additions to the digital world is the use of reviews. Reviews are comments written by individuals on various products and services. Google has its own review system and there are many more out there including Yelp, Trip Advisor, Citysearch and AngiesList. Although reviews can be helpful, they should be used to get a flavor of what other people are saying about a product or service. Every product or service should have good and bad reviews: that is reality.
In the dental world, many dentists, including myself, use a service to collect reviews from patients. In my office, an e-mail is automatically generated and sent after appointments. It gives people the option of writing a review about their appointment or our office. These reviews are then published to the web as well as evaluated by my staff to help improve the service we provide.
No matter what you are looking for, there are people out there in cyberspace who have commented on it. Take them for what they are worth, but I think they are helpful.
Is Dentistry Becoming a Commodity?
November 3, 2011
There was a time when it would have been unusual to see an “advertisement” for a health care professional. In dentistry, dentists used to be able to hang out a shingle and patients would come. Today, it is the opposite. We are bombarded with advertising and it is very rare to see a “from scratch” practice open.
Times change, and that is okay. My concern is that dentistry and the dental profession are moving towards a more commodity-based service and away from a relationship-based, well-respected profession.
It used to be that dentists were among the most respected professionals. Dentists always received high marks for honesty, including high ethical standards, and trust. Today, those numbers are dwindling. In our newer consumer-driven society, the dental professional is seen by more as a provider of goods and services rather than as a health professional attempting to build long-term relationships with patients.
Technology is partly to blame for this. Technology is the step forward in dentistry. Today we have the ability to use better materials that are prettier and faster to deliver. However, these same improvements in dentistry are also being used as marketing tactics for dentists. Advertisements, in print, radio, television and the internet for specific procedures are driving the profession to a more commodity-based service.
Low-cost dentures, same-day crowns, and discounts for specific procedures such as Lumineers or veneers are among those things being advertised. When is the last time you saw an advertisement that touted building a relationship based on mutual respect and trust? It is my opinion that we are headed in the wrong direction.
Dentists are small business people. We need to have a healthy business to continue to provide quality care. However, most of the things that are marketed to us have to do with how to run a business or how to perform more procedures in less time that result in greater profits. Rarely do we receive materials that promote learning how to help us better meet our patient’s needs and build relationships. It is up to us as individual dentists to maintain a proper balance between providing ethical treatment and the “selling” of our services.
Dentists and other health care professionals require an accumulation of a large amount of knowledge, extensive institutional and clinical training, and testing of competency and skills. It is with all of this training that we are then obligated to follow a certain code which in part reads, “The Association (ADA) believes that dentists should possess not only knowledge, skill and technical competence but also those traits of character that foster adherence to ethical principles.” The term “profit” is not mentioned anywhere in the code.
As I stated earlier, dentists are small business owners and need to make a profit for us to survive. However, we need to work harder to maintain a balance between potential financial rewards and professional and ethical care. Only doing what is in the best interest of our patients will move us in the right direction.
But I Have Dental Insurance
October 14, 2011
It should come as no surprise that the insurance industry is out to make a profit. It’s a business just like any other business. Any place an insurance company can cut costs or deny a claim is more of a profit to them and that is their goal. Unfortunately, this is not always in the best interest of the patient.
When my son was born 15 years ago he could not keep anything in his stomach. We went through a battery of tests to determine the problem. Not once did I think, “I wonder if the insurance is going to cover this?” When the diagnosis was made and it was determined that surgery was needed when he was only 10 days old, not once did I think to check with the insurance company to see if it would be covered. When all was said and done the insurance company said that we owed $10,000. I had the normal reaction that anyone would have – How could I owe $10,000 when I have insurance?
Dentistry is a little different. There are not too many situations where a life or death threatening has to be made or the dependency on insurance coverage needs to be assessed immediately. Many dental insurance companies suggest that a pre-determination of benefits be submitted prior to any work being done. The reason for this is to control what is being done and to delay the payment of a claim. The longer an insurance company delays a claim the longer they have their money and they know that longer time periods lead to the possibility of the patient not following through with the work.
I recently had a claim rejected by an insurance company for periodontal scaling and root planning (a.k.a. deep cleaning). This is a procedure done on people with periodontal disease to remove calculus (tartar) and bacteria below the gum level. The claim was submitted with the necessary documentation showing clear evidence (in my professional opinion) of periodontal disease and the need for treatment. What does this say to the patient? The patient put trust in the doctor to make the diagnosis and suggest the necessary treatment but the insurance company basically said that the treatment wasn’t needed. Not needed? How do you explain that to a patient?
What happens if I say, “Your insurance company said that you do not need this procedure, so I guess you don’t need it?” Two things happen. One is that the patient does not get the treatment needed, determined by someone sitting behind a desk who has never even seen the patient. The other is a huge increase in liability. When the patient’s periodontal disease continues and the person ends up losing teeth, who is responsible? You would logically think that it would be the insurance company who denied the treatment. This is not the case. The ultimate liability falls on the dentist for not managing the disease.
Patients need to be educated on their conditions. We live in an insurance dependent world. Just remember – your insurance company doesn’t care about you the same way your doctor does.
The Silent Epidemic
September 8, 2011
With more than 24 million diabetics and 57 million pre-diabetics in the United States, nearly a quarter of the nation’s population has already been affected by this disease. The connections between dental health and diabetes have never been more critical.
As an indication of our general health, the rapidly rising rate of diabetes should be ringing alarm bells everywhere. The litany of health implications from diabetes is a long and grisly list. It is the sixth leading cause of death in the U.S. That is probably vastly understated because as many as 65% of deaths from diabetes are attributed to heart attack and stroke. People with diabetes have about twice the overall risk of death as those who don’t have the disease.
Complications from diabetes cuts years off productive lives and interfere with the quality of those lives through a host of debilitating health effects. Heart disease and stroke rates are as much as four times higher among diabetics. Nearly three-quarters of diabetics have high blood pressure. Each year, diabetes causes blindness in as many as 24,000 Americans. It is the leading cause of kidney failure, nervous system disease, amputations – the list goes on.
This isn’t meant to be a scare tactic. These are simply the facts and, yes, they are sobering. But if you have diabetes or are pre-diabetic, you may want to brace yourself. Because we are going to talk straight about oral health and diabetes, two diseases that can twist each other into a tight downward spiral of amplifying negative health effects. Unless they are halted by your physician and your dentist working in tandem as a health care team, together with your commitment to hold up your end of the bargain, these effects can continue to compound.
The facts about the connections between oral health and diabetes are even more alarming than those about diabetes alone. Here are just a few:
Diabetics are twice as likely to develop gum disease. This is especially true if your diabetes is not under control. The gum disease then worsens your diabetes through an automatic response that your uses to fight the infection.
People with gum disease are 270% more likely to suffer a heart attack than those with healthy gums.
People who have diabetes and sever gum disease have a premature death rate nearly eight times higher than those who do not have periodontal disease.
Those who have gum disease and diabetes together are more than three time likely to die of combined heart and kidney failure.
In people who have type 2 diabetes, gum disease is a predictor of end-stage kidney disease.
In people who have pre-diabetes – blood glucose levels that are higher than normal but not in the diabetic range – gum disease makes it more likely that they will become diabetic.
Once established in a person who has diabetes, the chronic infection that causes gum disease makes it more difficult to control diabetes, and increases damage and complications in blood vessel disease.
We will continue this discussion next week and talk about some things you can do to help this problem.
