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Minnesota hygienists may soon pull teeth

2008-06-14T04:17:00.000-07:00

Minnesota may be the first state to allow dental hygienists to pull teeth, begin the process of root canal, and drill and fill teeth. The bill, SF 2895, is now in the Minnesota state legislature. This legislation creates a “new” type of practitioner called an advanced dental hygiene practitioner or (ADHP). Under the noble guise of helping the underserved, this bill will allow undertrained and inexperienced individuals to diagnose and treat patients without the supervision of a dentist in most cases. The concept of the ADHP considered in SF 2895 is dangerously wrongheaded, and shows why it is unwise to have lawmakers with no understanding of dentistry and medicine make fundamental changes in the delivery of care to dental patients.

Most dentists are required to attend four years of college with a heavy concentration of science, and four years of dental school before practicing dentistry. Recently, New York has included an extra year, a mandatory residency prior to receiving a dental license, and other states are moving in that direction. Why is the trend more education, and not less? The answer is simple. Dentistry is a complex discipline that requires years of training and experience to become competent. I could fill every page of this newspaper with the potential problems and complications that will arise if SF 2895 becomes law. In fact, SF 2895 is the most shortsighted concept in recent memory.

Let me take just one example of what can happen if the ADHP is allowed to extract a tooth. The first question is if the tooth actually needs to be removed. Can it be saved with root canal? Having never done a root canal or restored the tooth afterward with a crown or cap, there will be no real judgment brought to bear on the issue. What if there is swelling around the tooth? Is it better to drain the infection first (which they are not allowed to do), then remove the tooth, or do both at the same time? Will the ADHP know that if the infection is not drained that the person can die from this complication, even if the tooth has been pulled? What happens when the simple tooth extraction becomes difficult, and the roots break off in the jaw? Not trained or permitted to do what is necessary to remove the root fragments surgically, will there be a dentist or oral surgeon available to complete the procedure in a safe and timely manner? What will the ADHP do if they cannot stop the patient from bleeding, or the sinus is damaged during the procedure? These are just a few of the things a dentist must consider each time a tooth is extracted. In fact, some dentists don’t even do extractions, opting to send these patients to an oral surgeon, who has three to four more years of training than the general dentist.

Bill SF 2895 will result in both harm and supervised neglect of the people unfortunate enough to be treated by the ADHP. This agenda driven legislation will not lower the cost of health care, or improve access, and should not be enacted into law.

Simple procedure can replace missing teeth

2008-06-09T19:50:00.000-07:00

One or several missing teeth is a common problem for many people who have had teeth removed because of advanced tooth decay, gum disease, injuries, and those who may not have developed some of their teeth due to an inherited trait. The three most common ways a dentist can replace one or more missing teeth are a permanent bridge (a series of joined caps), an implant(s), or a removable partial denture. Although the permanent bridge and dental implant(s) have certain advantages when compared to a removable partial denture, in some cases, the removable partial denture may be the best or only choice available.

The type of partial denture I recommend is the Valplast partial denture. Valplast partial dentures are made of a nylon thermoplastic material that has several advantages over the all acrylic or cast metal partial dentures. Valplast partial dentures have no metal clasps and are very lightweight. The material is translucent, so the patient’s own gums show through, giving a very natural appearance. Valplast partial dentures can be used to replace many or just a few missing teeth.

One modification of the Valplast partial denture is called the Nesbit. The Nesbit is used to replace one to three teeth on the same side of the mouth and is much smaller than a conventional partial denture. The procedure can be completed in two short visits, requires no anesthesia or drilling of teeth (in most cases), and the cost is substantially less than either a permanent bridge or dental implants. A Valplast Nesbit is generally easy to get used to, and has a very realistic appearance.

Partial dentures can be a great alternative, but they do have several disadvantages. They are removable and should be taken out each evening to keep the mouth clean and give the gums a rest. They can also trap food and be difficult to get used to for some people. In general, those who have a permanent bridge or implants feel more confident and are less self-conscious about their missing teeth. Even so, I frequently recommend the Valplast Nesbit for patients who are phobic, the elderly, have difficultly tolerating more invasive dental treatment, and those who are looking for the most cost effective treatment available.

How Root Canals Work

2008-06-07T12:06:00.000-07:00

Tooth Anatomy

To understand how a root canal works, we need to have a basic understanding of the anatomy of the tooth. A tooth is hollow, like our bones, and is composed of several layers. The outermost layer (above the gum-line) is called the enamel. Enamel is the hardest and most mineralized substance in the body. Beneath the gum-line, a substance called cementum covers the tooth roots. Under the enamel and cementum is the dentin. The dentin is about as hard as bone, and, unlike the enamel, dentin contains nerve endings. Beneath the dentin is the dental pulp. The pulp is a vascular tissue, composed of capillaries, larger blood vessels, connective tissue, nerve fibers, and cells including odontoblasts, fibroblasts, macrophages, and lymphocytes. The pulp is needed to nourish the tooth during its growth and development. After a tooth is fully mature, the only function of the pulp is to let us know if it is damaged or infected by transmitting pain.

Sometimes the pulp becomes infected. When this happens, it must be removed with root canal therapy. A root canal is the only way to save the tooth. A mature tooth can survive very well without the pulp.

How Does the Pulp become infected?

The most common way for the pulp to become infected is from an untreated cavity. A cavity is formed by acid in a rather unexpected way. Inside everyone's mouth is a legion of bacteria - they are completely normal and there is nothing you can do about them. Some of these bacteria metabolize (eat) carbohydrate-containing foods or beverages and make acid as a by-product. The acid is strong enough to eat through the enamel and dentin. If left untreated, it will eventually expose the underlying pulp to bacteria inside our mouths and it gets infected. The pulp can also get infected from trauma to the tooth. A blow to a tooth can cut off the blood supply to the tooth from our jawbone, and cause the pulp tissue to slowly die. Interestingly, a tooth that breaks within the enamel and dentin during trauma is less likely to need root canal in the future because the fracture may absorb the trauma, sparing blood flow to the tooth.

A third way a tooth can become infected is if there is long standing periodontal (gum) disease around the tooth. Bacteria from the infected gums can enter the tooth through small opening on the root surface (accessory canals) and cause a retrograde infection. Whatever way the tooth becomes infected, the pulp eventually dies, and over time, will cause a painful dental abscess within the surrounding jawbone.

How will I know if I have an infected tooth?

A tooth that becomes sensitive to hot or cold food or beverages or hurts when biting down may indicate an infected tooth. A tooth that becomes discolored or that causes the gums to swell around a tooth may also indicate a dental infection. In some cases, a tooth will have no symptoms, but a dental exam and x-ray will reveal a tooth that requires root canal.

An infected tooth as seen in an x-ray.
The dark circle around the root tip is an advanced dental abscess.

If the tooth is infected, why can't I use an antibiotic to treat it?

If a tooth has an infection of the pulp, the only options are root canal therapy or extraction. As the pulp dies, the hollow tooth becomes a reservoir for bacteria to hide from the body's immune system and any drugs that could fight the infection. In some cases a dentist will prescribe antibiotics during or after root canal therapy to kill bacteria within the jawbone and tissues surrounding the tooth, but recent research has shown that this is usually unnecessary.

What's involved in getting a root canal, and does it hurt?

Root canal therapy is a complex procedure that requires both skill and experience. The dentist numbs the area of the infected tooth with local anesthesia. A clamp is placed over the tooth, and a rubber membrane (rubber dam) is spread over the clamp to isolate the tooth and prepare it for the procedure.

An infected tooth

A small hole is made through the enamel and dentin, and into the pulp. The pulp is then removed with small stainless steel files of increasing diameter. After the pulp has been removed, the inside walls of the roots are shaped, almost like a sculpture. Nickel/Titanium files that fit on a slow speed drill can aid in shaping the canals. During the procedure, fluids (irrigants) such as sodium hypochloride (bleach) and a compound containing ethylenediamine-tetraacetate (EDTA) are used to both kill remaining pulp tissue and bacteria within the roots, and remove dentin shavings produced by the files.

Files are used to remove the pulp

After the pulp is removed and the inside of the roots shaped, the canal is dried with paper cones. The canal(s) are then filled with Gutta-percha. Gutta-percha is a miraculous substance that was first introduced by Bowman in 1867. It is a purified form of Mazer Wood Trees indigenous to Indonesia and Malaysia that is combined with zinc oxide and other materials to form the rubbery filling that is placed into the tooth roots. The Gutta-percha is then cemented into the roots with a sealer that usually contains zinc oxide and eugenol. The goal of the filling procedure is to hermetically seal off the tooth against bacteria.

The tooth is filled with gutta-percha
X-ray of a tooth filled with gutta-percha using the warm vertical condensation technique. Accessory canals are visible.

There are two main techniques to filling a root canal, lateral condensation and warm vertical condensation. Although research is scanty, warm vertical condensation appears to have the advantage of more completely filling the tooth roots, especially the accessory canals.

Root canal therapy is usually not painful. With the effective use of anesthesia and modern techniques, most root canal therapy can be completed in one visit, and within one hour. A tooth will be sensitive for a few days after root canal therapy, and your dentist can prescribe you medication to alleviate the pain. In the meantime, do not eat on the side of the mouth that has the root canal for a few days.

Do different teeth have different numbers of root canals?

Teeth in the front of the mouth called incisors and canines usually have one root, and one nerve canal within the root. Teeth on the side of the mouth called premolars usually have one or two roots and one or two root canals. The upper back teeth (molars) usually have three roots, and three or four root canals. Lower back teeth (molars) usually have two roots and three or four root canals. Generally speaking, the more nerve canals the tooth has, the more complicated the root canal is to complete.

Can any dentist do a root canal?

All dentists are trained to do root canals in dental school; however, skill levels and experience vary widely from dentist to dentist. An experienced general dentist can do almost all root canal therapy successfully, but some general dentists prefer to have a root canal specialist (an endodontist) perform root canal on their patients.

How successful are root canals?

Root canals are successful about 90% of the time when they are done properly. Teeth that have had root canal can become brittle and are susceptible to fracture. In most cases, it is advisable to have a crown (cap) placed over a tooth that has had root canal to rebuild and protect it.

Why do some root canals fail, and how will I know?

A tooth that has root canal can fail if some of the pulp is left inside the roots (a canal is missed), the gutta-percha does not completely seal off the tooth from bacteria, the tooth is damaged during the procedure (perforation), or the tooth fractures between the roots. In most cases, a tooth with a failing root canal will cause pain, usually when biting down.

What can I do if the root canal fails?

In some cases, the root canal can be re-treated. The old gutta-percha filling is removed, the tooth is reshaped and cleaned, and then re-filled. If this is not possible, a procedure called an apicoectomy can be preformed. In an apicoectomy, the tip of the root is surgically removed, and a filling is placed over the cut root tip. If these measures fail, the tooth may have to be extracted.

How Dental Fears Work

2008-06-01T09:55:00.000-07:00

Click on image to see one of Dr. Gordon's patients having a painless root canal.

Does the sound of the dentist's drill make you cringe? Does the sight of the needle make you scared and nervous? If so, you're not alone. It has been estimated that more than half of all the people in the United States will never see a dentist for regular care. Fear of the dentist, or in more severe cases, dental phobia, is the main reason that many people avoid the dentist. And the problem with staying away from the dentist is that small problems soon require major dental treatment!

Where Did These Fears Originate?

First of all, let's acknowledge that many people who are afraid of the dentist have a legitimate reason for their fear. Maybe they recall a traumatic experience when the dentist either caused them pain during treatment or embarrassed them by making light of their fears. These memories tend to be especially acute if the traumatic incident occurred during childhood. Vivid memories of the incident recur whenever the fearful person needs to go to a dentist. I have treated patients in their 70s and 80s who still fear dental treatment due to bad experiences they had as children. Modern dentists are well aware of the impact a negative dental experience can have on children, and fortunately, many of them have had training in child psychology. Using that background, they strive to make the early experiences with dentistry positive ones for children.

The past experience that causes the most fear among patients is the memory of a dentist causing them pain during treatment and then humiliating them when they complained. These patients can remember the dentist saying things like, "This isn't hurting you," or "Stop being a baby." These denigrating remarks compound the painful experience at the dental office. Even though the pain from the treatment fades quickly, the insensitive comments made by the dentist continue to live on in the minds of the recipients of those unsympathetic comments.

There are also large numbers of people who are "afraid of the dentist" or of certain dental procedures but have never actually had a bad experience at the dentist's office. These are people who have heard from others that dentistry is painful -- and they believe it! This type of learned fear is called vicarious learning and is quite common.

Unfortunately, there is good reason for people to accept this premise on face value because it is sometimes reinforced by family and friends and also in the media. This is very similar to how we feel when we see a plane crash on the TV news. The vivid pictures and tragic personal stories stir our emotions. But have you ever stopped to think that you rarely hear about the more than 20,000 safe take-offs and landings every day, or the incredible safety record of the airline industry? Likewise, few people share their successful dental experiences. Instead, research has shown that people are far more likely to share and embellish a negative dental experience. I know from years of treating patients the power of vicarious learning. Many times I have to suggest that a patient with a dental infection get a root canal to save a tooth. Right away, the fearful patient will say something like, "No way, put me to sleep and I'll have it pulled. I won't go through a root canal." When this happens, I ask them if they've ever had a root canal before, and if it was a bad experience. In most cases, the answer is no. I then ask them why they think it will be painful. They usually respond that they heard somewhere or from someone (a friend of a friend) that a root canal is painful.

In addition, I sometimes hear fearful parents in my waiting room unknowingly establish with their children negative stereotypes regarding dental treatment. They might say things like, "Tell the dentist if he is hurting you," or "If you don't stop misbehaving, it will be your turn to go to the dentist next time," and other things that are likely to instill a fear of dentistry.

Dentists and dental treatment are sometimes portrayed in a negative light in the media and in commercials we see on TV. We have all heard stories in the news about AIDS, dirty dental drills and water, etc. Unfortunately, these stories are sometimes one-sided and can misrepresent the facts; this results in unnecessarily frightening people about the safety of dental treatment. Likewise, commercials often use the fear of dental treatment, especially root canals (the replacement of the tooth's pulp with an inert material) as the punishment in their contrived scenarios. People who fear the dentist will tend to hone in on negative stories regarding dentistry to help reinforce how they feel. I agree wholeheartedly with Burt Decker, author of "You've got to be believed to be heard", when he says, "People make decisions based on emotion, and then justify them with facts." So, as you can see, fear can be a learned phenomenon.

What Are These Fears About and How Do You Address Them with Your Patients?

The first step in overcoming any fear, including fear of the dentist, is to define the fear. Fear of the dentist involves everything from mild anxiety before or during a scheduled dental visit to high levels of stress and emotional discomfort, manifesting itself as nervousness, sweaty palms or tears. When the anxiety becomes so intense that the person will do anything to avoid going to the dentist, the fear becomes a phobia.

Before you worry that your dental fears are approaching phobic levels, remember that fear or apprehension about dental treatment is a very common reaction. In fact, of the thousands of patients I've treated, the vast majority expressed at least some fear or anxiety before dental treatment. Even I, as a dentist, experience some anxiety before I am about to be treated by another dentist! Fear of the dentist is nothing to be ashamed of, and the good news is that fears and phobias about dental treatment can be overcome in most cases.

People fear the dentist for a variety of reasons. I have found that the three most common fears are associated with:

The potential for pain during dental treatment

Fear of being scolded about the condition of their mouth

Fear of loss of control during dental treatment

How Can I Overcome My Fear of Pain?

The first step in overcoming fear of the dentist or dental treatment involves gathering accurate information to help you judge the veracity, or truth, of those fears. Knowledge can be a powerful weapon against fear. In fact, many people fear death because it is "the great unknown." A comforting component of many religions is the promise of heaven and other rewards in the afterlife. Although I cannot promise you that your dental experiences will be "heavenly," I can promise that it won't fall at the other end of the spectrum! Learning about how dentists deal with people's fears is a good starting point in alleviating a fear of the dentist, himself.

Most people have at least some fear of pain or injury in life -- and that's a good thing. It prevents us from touching a hot stove (more than once) or driving a car into oncoming traffic. Fear is a protective and instinctive emotion that helps keep us safe. It should come as no surprise that when we are confronted with a situation or environment that we believe to be painful, we try to avoid it. Some people who avoid regular dental care do so because they believe that all dental treatment is painful.

So what is the truth about dentistry and pain? I won't tell you that dental treatment is never painful -- on rare occasions, it is. But I will tell you that most of the time, dental treatment is either completely painless, or only slightly uncomfortable. And be reassured by the fact that most dentists are acutely aware of the impact of pain on their patients. Many dentists pride themselves on being "painless practitioners." A dentist who causes a patient pain will sometimes lose that person as a patient, and there is a good chance that the person will tell many others about the bad experience they had at Dr. So-and-So's office. Causing people pain during treatment is no way to build a dental practice and most dentists know that!

How Do Dentists Reduce or Eliminate Pain During Dental Treatment?

Dentists have many ways of reducing discomfort during dental treatment. The first step dentists take is to evaluate the treatment required to decide if anesthesia, given as an injection, is needed. There are many dental procedures that can be done comfortably without anesthesia, using modern dental technology. For example, shallow cavities on the side or biting surface of the teeth can be treated with a dental laser or an air abrasion unit, a new device that emits a gentle spray of an air-and-powder mix that smooths away tooth decay. These devices can silently and painlessly treat cavities a high percentage of the time without anesthesia. If anesthesia is needed, strong topical anesthetic gels or patches are used to greatly reduce the discomfort associated with injections. Dentists also use very thin needles and inject the solution slowly to further reduce discomfort.

The most important way a dentist reduces or eliminates discomfort during dental treatment is to make sure that the patient's mouth is as numb as possible during treatment. The approach I initially take is to begin treating the tooth very slowly. I will ask the patient, "Are you feeling this?" If the answer is yes, I either give them more anesthesia or wait a few minutes and test again. It takes some people's mouths a little longer to become numb. I recommend that you always signal your dentist to stop if you are having pain. If the dentist doesn't listen, you need to find a new one!

What If I Still Feel Pain After the Anesthesia Is Given?

In some instances, you may still feel varying degrees of pain even after everything feels numb. There are a few reasons for this, including inaccurate placement of the anesthesia, not enough time allowed for the anesthetic to work or severe infection in the area interfering with the potency of the anesthesia. The dentist can remedy these situations by redirecting the anesthesia (giving more), waiting longer before beginning treatment or postponing the treatment and prescribing an antibiotic to reduce the infection.

Another important issue is that different people have different thresholds for pain. I have had patients who have expressed genuine discomfort from a routine dental exam, and others who easily tolerated root canal or dental surgery without anesthesia (though I don't advise it).

Over the years, I have discovered an interesting irony when treating fearful patients. The vast majority of these patients have a very high pain tolerance. When you think about it, it sort of makes sense. Fearful patients often avoid dental care and endure years of discomfort from their teeth. It seems likely that if they had a poor tolerance for pain, they would visit their dentist the moment a tooth became sensitive. Because of this, once a fearful patient develops trust with their dentist, the fear quickly evaporates. The fearful patient soon learns that dental treatment is not nearly as uncomfortable as the pain they go through every day with infected teeth.

When I have patients who tell me they are afraid of the pain, I make them a promise. I say that I will not perform the procedure (extraction, root canal, etc.) if they are feeling pain -- plain and simple. On rare occasions, I will even reschedule the patient for a different day if the treatment cannot be comfortably completed.

What Can Be Done About Pain After the Treatment?

Some dental procedures can cause discomfort after the anesthesia has worn off. Fearful patients are often concerned that they will be in pain following a dental procedure. These procedures include dental extractions (pulling teeth) and other minor dental surgery, root canal therapy, periodontal (gum) surgery and multiple dental fillings. Dentists are just as concerned with managing pain after treatment as they are during it. One of the first things dentists do is to make sure that they perform the procedure as gently as possible. A dentist with a forceful technique can put excessive pressure on the teeth and gums, which can cause greater discomfort later on. Dentists can also use anesthesia that lasts longer (bupivacaine) or give pain medication like ibuprophen (Advil, Motrin) prior to some procedures, because these measures have been shown to reduce pain after treatment.

Dentists are also licensed to prescribe potent narcotic drugs that are highly effective in reducing or eliminating any discomfort after dental treatment. The final step the dentist can take is to call the patient at home after a potentially painful treatment. This is something that I have done for years. I like to see how my patient is doing, if the medication is working, or if the patient has any questions about the treatment. Some dentists do this, and I suspect more will in the future. Aside from being the right thing to do, research has shown that people's perception of pain is less when the dentist calls them at home to find out how they are doing.

Most dentists realize that pain is a very subjective thing. What this means is that a person's emotions have a large impact on their perception of pain. For example, if a patient gets the feeling that the dentist is insensitive or lacks compassion, there is a good possibility that other concrete measures the dentist uses to reduce pain will be less than successful. On the other hand, a dentist who makes a worthy effort to reduce all discomfort associated with dental treatment, and empathizes with his or her patients, will have much better results.

What If I'm Afraid My Dentist Will Scold or Embarrass Me?

Some patients fear being chastised by the dentist for neglecting their mouths. They might nervously comment that "I know I should have come earlier" or "Is this the worst mouth you ever saw?", expecting the dentist to reprimand them like a disapproving father or a marine drill sergeant. It is no wonder that people with these preconceived notions fear going to the dentist. This fear seems to have originated years ago when some dentists thought they could "help" their patients by lecturing and/or insulting them. Most dentists today realize that this is a poor approach that ultimately backfires by either driving people away or building up a barrier of resentment. I look at it this way: the patient is coming to me for help. He or she has likely had bad dental experiences in the past, has been out of work and/or lost his/her insurance, hasn't been educated about modern dental treatment, or is not particularly concerned about the comfort or appearance of their teeth.

Whatever the reason, the important thing is that the person is coming in for dental care now.

What Should the Dentist-Patient Relationship Be Like?

Ideally, the role of the dentist is to understand what the patient's expectations are, improve their dental health and then to educate them in how to avoid dental problems in the future. To achieve these goals, communication between the dentist and patient is of the utmost importance.

People who seek dental care often come from vastly different educational, cultural and socio-economic backgrounds. I have found that most dental patients fall into three main camps. Some are not interested in saving their teeth, and just want to have a tooth removed every now and then when they are in pain. Others are highly motivated to preserve all of their teeth and want to keep them in the best condition possible. Still other patients have never been educated about what modern dentistry can achieve but can become (with education) motivated to improve the comfort and appearance of their teeth.

The bottom line is that most dentists do not browbeat their patients about the condition of their teeth. That may have been common years ago, but is not nearly as prevalent today. If you are worried about how a dentist will react to the condition of your mouth, try to remember that a dentist has seen everything from black and broken teeth to no teeth at all. Your teeth won't shock the dentist. If it does, or if your dentist insults you, find a new dentist. There are plenty of dentists out there who do care about helping their patients.

What If I'm Afraid of Losing Control During Treatment?

Some people who fear dental treatment are those who are used to being in control at home, work and in personal and professional relationships. In today's lingo, these people are sometimes referred to as "control freaks." Despite this negative label, these controlling people are often highly intelligent and very successful. For instance, you may have heard the statement that "doctors make the worst patients," but other professionals, including lawyers, teachers, engineers, high level business executives, etc. could just as easily be put into this category. Although that statement is a generalization, it is accurate to say that some of these high-powered people can be difficult patients because they are accustomed to controlling their environment.

When people who are used to being in a position of power are put into a situation where they must relinquish that power to their dentist, anxiety, confrontation and avoidance are the most common reactions. The first step in overcoming this fear is to tell the dentist that you want to know what he or she is doing and why. Ask your dentist to explain X-rays, show you your mouth with an intra-oral camera, give you handouts or in-office presentations, or any other information to help you have a more active role in your dental care. When you know what the dentist is doing and why, you will have a greater sense of control during the procedure. It is also important to ask the dentist how you should signal if you are having pain or any other uncomfortable sensation. Many dentists tell the patient to raise their hand if they are having pain, and the dentist will stop. I have had patients tell me that they had a dentist continue working on them even after they repeatedly raised their hands. This is not a dentist that you want treating you.

It's a good idea to test your dentist -- even if you're not having pain -- to see if he or she will indeed stop. The dentist who follows through with that promise is what we call a "keeper.

One technique I like to use is to let the patient have some input as to what procedure they want done first. Many times, there is no urgent need to have cavities on the left side of the mouth treated before those on the right side, or one crown (cap) done before another. I believe that it is perfectly appropriate for you to ask your dentist if you can have a particular procedure done first or last. If there is no urgent need, the dentist may comply with your wishes. Allowing you to help "call the shots" can be an effective way to reduce tension if a loss of control is your main source of anxiety. (Please note that some dental procedures must be done before others for your benefit. Your dentist should give you a good, jargon-free explanation to help you understand why).

Whether you fear pain, being scolded or losing control, take heart with the knowledge that these fears can be overcome. The first step is to make an appointment with a dentist who has a reputation for being both skilled and compassionate. This appointment should be for consultation only, not treatment. Discuss your fears with the dentist. You should know in only a few moments if this dentist has what it takes to help you overcome your dental fears.

Krazy glue, great for dentures, helps stop bleeding

2008-05-30T10:07:00.000-07:00

After more than six decades, this super sticky substance has found a new role in the treatment of dental patients.

Krazy glue is a convenient product that can temporarily repair broken dentures, help stop bleeding after dental surgery, and I've heard it also has hundreds of other every day uses. The active ingredient in Krazy glue (also Super glue) is a chemical called cyanoacrylate. Cyanoacrylate was discovered by Dr. Harry Coover while working for Kodak Research Laboratories to develop an optically clear plastic for gunsights in 1942. After more than six decades, this super sticky substance has found a new role in the treatment of dental patients.

The most common use of Krazy glue is for repairing or replacing denture teeth. Krazy glue can temporarily repair a broken denture tooth, and also refasten a tooth that has come off a denture. In some cases, Krazy glue can fix a denture that has broken in half, but this is also a very temporary measure. People who need lasting denture repairs should see their dentist or dental laboratory technician as soon as possible.

A recent study in the Journal of Oral and Maxillofacial Surgery has shown that medical grade cyanoacrylate can help stop bleeding in patients who have had several teeth removed and were taking the blood thinner warfarin. For many years, it was "standard operating procedure" for physicians and dentists to have patients stop taking their warfarin for a few days before a surgical dental procedure. The reason is that warfarin can cause a person to bleed more after dental surgery. Warfarin and other blood thinners are used for a variety of medical reasons. They are principally used to prevent stroke, heart attack, thrombosis and embolism (stationary or traveling blood clots that can block blood vessels killing body tissues). For this reason, the patient's physician and dentist must decide if taking a person off warfarin is more hazardous than keeping them on their medication.

The need to stop patients from bleeding after oral surgery is especially important when a patient is taking warfarin or any other blood thinner. The use of medical grade cyanoacrylate in addition to packing and stitching the mouth after oral surgery has shown promise in a current study. This finding could allow patients to stay on their blood thinners more often when oral surgery is required, and prevent the potential risks of taking them off their medication.

Use caution with narcotic pain medication

2008-05-28T11:53:00.000-07:00

Narcotic pain medication like codeine, hydrocodone, and oxycodone are necessary and helpful drugs when used to control pain, but are also potentially addicting or lethal if abused.

Recent revelations regarding an area physician and the alleged over prescribing of narcotic pain medication serves as a good lesson for the use of restraint when treating patients. Physicians and dentists are given the enormous responsibility of prescribing all types of medications, including narcotic pain medication. Narcotic pain medication like codeine, hydrocodone, and oxycodone are necessary and helpful drugs when used to control pain, but are also potentially addicting or lethal if abused.

Dentists will often need to prescribe potent narcotic pain medication either before are after dental treatment. If a patient comes to the dental office with a toothache, and the dentist does not have time for the required treatment, a dentist may prescribe antibiotics and pain medication until the patient can be rescheduled. Certain dental treatment, including removal of teeth, root canal, gum surgery, biopsies, and other surgical treatment can sometimes cause pain for several days during the healing process. To effectively manage this pain, it is often appropriate for the dentist to prescribe narcotic pain medication.

Despite the need for narcotic pain medication, dentists should always be prudent with their use. As a rule, I try to avoid the prescription of oxycodone (Percocet) for dental pain because it has a high potential for addiction. I will most often prescribe hydrocodone (Vicodin) for severe dental pain because it is less addicting and relatively easy for the body to metabolize. I also limit the amount of narcotic pain pills I prescribe from between eight to twelve, enough for two to three days. Narcotic pain medication should only be taken when pain is intolerable. In many cases, over the counter pain medication like ibuprophen (Advil), naproxen (Aleve), or acetaminophen (Tylenol) will be sufficient to relieve pain related to dental treatment.

Although narcotic pain medication is sometimes needed to alleviate the pain associated with dental treatment, caution should be taken with its use. Narcotic pain medication should never be taken with alcohol, when driving a car or when operating heavy equipment. Always read the directions and warnings provided by your dentist and pharmacist when taking this type of medication.

Having A Tooth Pulled? Consider The Risks

2008-05-10T12:27:00.000-07:00

Click image to watch Dr. Jerry Gordon extracting a tooth on two of his patients.

Having a "tooth pulled" also known as an extraction, is a procedure that is classified as oral surgery by the dental profession. When we think about it, we may find it hard to believe that we are actually having "surgery" when we go to the dentist for an extraction. The procedure involves the dentist using anesthesia to numb the area, and then using surgical instruments to free a tooth from the jawbone. In some cases, pieces of the gum and jawbone will need to be cut away to remove a tooth. Considering the trauma that often accompanies an extraction, I often wonder why some people are quick to suggest that I pull a tooth instead having a root canal, a far less aggressive, as well as tooth-saving procedure.

Having a tooth extracted is not a procedure that you or your dentist should take lightly. To give you an idea of the potential risks associated with the procedure, I will share with you an excerpt from a consent form that a patient signs before an extraction is performed: Potential risks of the treatment include (but are not limited to) bleeding, swelling, pain, infection of the extraction site (dry socket), and damage to other teeth or tissue (gum or cheek) in the mouth. More remote risks include jaw fracture, temporary or permanent injury to the TMJ (jaw-joint), temporary or permanent numbness of the mouth, and life-threatening complications to the treatment or anesthesia. Due to the potential risks associated with an extraction, you should always make sure that your dentist has a complete understanding of your medical history. This includes all of disorders that you may suffer from, as well as all of the medications that you are taking. Some of the ailments that may be of particular concern to your dentist include heart disease, bleeding disorders, diabetes and other diseases affecting the immune system. Some of the medications that can increase the risk during an extraction include many of the medications used to treat hypertension and diabetes, cortisone, and blood thinners (anticoagulants) that are often used after a person has had a stroke, or used to prevent one. Please also inform you dentist about any over the counter medications you may be taking. For instance, aspirin can increase bleeding significantly after an extraction, so should be avoided for at least 5-7 days prior to treatment.

The safe completion of an extraction requires a dentist with both technical skill and excellent knowledge of the medical risks associated with the procedure. In some cases, it is wise for your dentist to discuss your medical condition with your family doctor who can have input into the procedure. With certain types of extractions, including wisdom teeth that are lodged into the jawbone, teeth that are fractured, and those that have unusually curved roots, a dental specialist known as an oral surgeon may be consulted or referred to by your dentist. An oral surgeon should also be considered for a person who has serious and complicated medical problems and requires an extraction.

The Flipper; a "whale" of an option

2008-04-28T11:28:00.000-07:00

Click image to see Dr. Jerry Gordon making a denture for one of his patients.

A bridge and implants can cost significantly more than a removable partial denture, and may not be viable options for some patients. In certain cases, a removable partial denture may be the best or only choice available.

Missing teeth is a common dilemma for many people who have had teeth removed because of extensive cavities, gum disease, injuries, and those who may have never developed some of their own teeth due to a hereditary trait. The three most common ways for a dentist to replace one or more missing teeth are a bridge (a series of joined caps), an implant(s), or a removable partial denture. Although a bridge or dental implants may be more comfortable and cosmetically pleasing than a removable partial denture, there are some drawbacks. A bridge and implants can cost significantly more than a removable partial denture, and may not be viable options for some patients. In certain cases, a removable partial denture may be the best or only choice available.

The typical cast removable partial denture, or "cast partial", consists of a metal base that has acrylic teeth attached to it. Metal clasps are the hook-like structures that help hold the removable partial denture in place. Although the cast partial can be a bit cumbersome, it has been used successfully for decades in the dental profession. Another type of removable partial denture is the all-acrylic variety, sometimes referred to as an interim (temporary) removable partial denture or a "flipper". The flipper sometimes gets a bad rap by the dental profession because it is not as sturdy as the cast partial, but on the other hand, it has several advantages over it. The flipper can be made in a few days with only two dental visits needed. The cast partial usually requires at least a month to create and involves about four visits. The flipper is lightweight because it has much less metal (typically only a metal clasp or two) making it more comfortable and aesthetic than the cast partial. I sometimes recommend the flipper to a person who needs teeth replaced later in life and has never worn any other type of removable partial denture in the past. The flipper tends to be easier to get used to. Finally, the flipper usually costs about half as much as a cast partial.

The decision of how to replace missing teeth is one that you should explore with your dentist. There are many options available, all with certain advantages and disadvantages. Although a bridge or dental implant(s) may be preferable to some people, the flipper should also be considered because it is a great low cost way to replace missing teeth.

Tongue piercing problems related to time and design

2008-04-23T11:36:00.000-07:00

Tongue piercing can also interfere with speaking or swallowing, and dental problems created by the piercing will require treatment.

Tongue piercing has grown immensely over the last several years. This trend, seen mainly in adolescents and young adults, can present considerable dental and medical risks. The dental dangers include chipping of teeth and gum problems, which may be directly related to size of the piercing and the length of time worn. The medical complications can include infection, allergic reaction and excessive bleeding.

Tongue piercing can cause a variety of dental problems. The most common are chipped teeth and having the gum pull away from the teeth. A recent study showed that 50% of people who had worn a long barbell stem piercing (longer than 1.59 cm) for more than two years had gum pull away from the inside of their lower front teeth. Chipping of the back teeth occurred in nearly half of all people who had worn the piercing for more than four years. Tongue piercing can also interfere with speaking or swallowing, and dental problems created by the piercing will require treatment.

The main medical dangers involved with tongue piercing are infection, metal allergy and bleeding. In fact, The National Institutes of Health has identified piercing as possible route for the transmission of hepatitis. In the case of tongue piercing, the bacteria rich mouth can cause an infection at the piercing site. Untreated, the infection could cause swelling to the throat, and prevent a person from breathing. Tongue piercing can cause an allergic reaction, excessive bleeding during or after the procedure and breathing complications if the ornament is swallowed.

Tongue piercing has become a popular part of our culture. Proper sterilization techniques and the use of gold jewelry can reduce the risks of infection and metal allergy. Even so, tongue piercing can cause a variety of dental and medical problems and should be avoided.

Get the scoop on treatment for gum disease

2008-04-13T11:29:00.000-07:00

The main ways to treat gum disease is with deep cleaning under the gums, gum surgery, bone grafts, and antibiotics.

Periodontal or gum disease is an infection that causes bleeding gums, bad breath, loose teeth, and teeth that fall out. A bacterial film called plaque that continuously forms around the teeth and gums causes gum disease. An estimated 56 million Americans suffer from gum disease, and is the main reason that people lose their teeth.

Gum disease is treated a number of different ways, depending on how advanced it is. The main ways to treat gum disease is with deep cleaning under the gums, gum surgery, bone grafts, and antibiotics. Oral hygiene technique and instruction also plays a critical role in the treatment of gum disease.

Gingivitis, the earliest stage of gum disease, is the only one that can be cured. Gingivitis can be cured with improved oral hygiene, which includes brushing properly at least three times a day, for about three minutes each time, and flossing at least once a day. Antiseptic mouth rinses such as those containing Chlorhexidine Gluconate (Peridex) or those containing thymol such as Listerine can also help eliminate gingivitis.

Early gum disease is treated with a procedure known as scaling and root planning. The dentist or dental hygienist uses thin curettes and gently removes the plaque and tartar under the gum-line. The tooth roots may also be smoothed, to make it more difficult for plaque to adhere to them in the future. This procedure is rarely painful, but some patients may prefer local anesthesia to numb the area prior to treatment. The gums will heal in a few weeks, and the previously red, puffy gums will usually appear healthy; tighter and more stippled, like the surface of an orange.

Moderate and advanced gum disease is usually first treated with scaling and root planning as mentioned above. After the gums heal, the surgical procedure is scheduled, partly because the dentist cannot effectively remove plaque that remains deep under the gum-line. Treatment usually involves a quarter of the mouth at a time (from the last molar in the mouth, to the front [central incisor] tooth on the same side). The dentist numbs the mouth in the area that requires treatment. The gum is then gently separated from the bone, and the remaining plaque and tartar are removed, along with areas of diseased gum. In many cases, gum disease leaves the bone choppy and irregular, which requires it to be smoothed and shaped. If there are vertical areas of bone loss, for example, the dentist may consider a bone graft. The material used for the graft may be either artificial, synthetic, or from natural sources. The grafting material is placed into the area of bone loss, and a membrane, often Gortex, is used to cover the graft. The gum is then stitched up, and bubble gum like packing is placed over the area. Gum surgery is usually not painful. Believe it or not, I have had patients actually sleep through the procedure. There will be varying degrees of discomfort, however, after the anesthesia wears off. The dentist will usually prescribe narcotic pain medication as well as an antibiotic in some cases. Discomfort will generally persist for a few days. The patient returns in about one week to have the packing and stitches removed. If a graft was used, the patient may have to wait six weeks for removal of the graft membrane and specialized stitches.

After the packing and stitches have been taken out, the antiseptic mouth rinse Peridex is often prescribed for several weeks after surgery to promote healing. The teeth in the area that have been treated may be sensitive to cold for weeks or months after treatment. This is because the tooth roots are now exposed to the rest of the mouth. The dentist can use in-office desensitizers, prescribe high concentration fluoride gels, and recommend desensitizing toothpastes such as Sensodyne or Crest for Sensitive teeth to combat the sensitivity to cold.

Antibiotics are sometimes used in conjunction with surgical or non-surgical treatment of the gums. The most common antibiotics used are tetracycline, amoxicillin, and metronidazole. These drugs are used to kill some of the bacteria associated with gum disease.

The goal of surgical gum treatment is to bring the gums back to a level where the patient can effectively remove most of the plaque by himself or herself when brushing and flossing. After any gum treatment, the patient should come to the dentist every three months for maintenance. The dentist can then remove any plaque or tartar missed by the patient. There are several products on the dental market that are placed around the gums and provide a controlled release of antibiotics. One product that I use is a minocycline powder called Arestin (www.arestin.com). The ease of use and effectiveness make it a very useful adjunct in the treatment of periodontal disease.

Even though there is no cure for gum disease, appropriate gum treatment by your dentist can greatly reduce the likelihood of losing your teeth at an early age. How much time can gum treatment buy? That is hard to say exactly because there are so many factors that influence the outcome. One common estimate is that gum treatments can double the life expectancy of a tooth. In other words, if a tooth was going to last 15 years without treatment, gum therapy may extend it to 30 years.

Need a new dental bridge? Ask a few questions

2008-04-03T11:31:00.000-07:00

If your dentist suggests that your bridge should be replaced, you should ask him or her why. If you are not satisfied with the answer, ask if he or she would mind if you took the x-rays to another dentist or to a dental school for a second opinion.

Recently, a woman came into my office for a second opinion about her dental condition. Two other dentists had told her that she needed a new fixed bridge for her upper teeth. (A fixed bridge is a series of crowns or caps that are joined together to rebuild existing teeth and also to permanently replace missing teeth. The procedure usually yields excellent results, but the cost can be substantial.) To evaluate her situation, I took a few x-rays of her teeth, and then did a clinical (hands-on) evaluation. My conclusion was that her bridge, although 25 years old, was in very good condition, and that replacement was not needed. She then showed me her dentist's estimate for the unnecessary bridge, with a cost of seven thousand dollars.

After she left my office, I wondered how many other people faced a similar situation. I consider dentists to be highly ethical people as a group, but there are always a few exceptions. So what can you do? The first thing is to be armed with some information that can help. What you need to know is why a bridge should be replaced and how long a bridge should last. Some of the main problems that may require a bridge to be replaced include: deep cavities that get under the crown margins (the area where the crown ends and tooth begins), severe gum disease that weakens a tooth or teeth that support the bridge, and breakage of the porcelain or metal that gives the bridge its structural support. Some patients may also want a bridge replaced to improve its appearance, as when the gum recedes to expose the dark and unattractive crown margins.

If your dentist suggests that your bridge should be replaced, you should ask him or her why. If you are not satisfied with the answer, ask if he or she would mind if you took the x-rays to another dentist or to a dental school for a second opinion (x-rays are one great way for a dentist to evaluate if a bridge is still in good shape). If your dentist is resistant and unwilling, that might be a red flag, and you should consider getting that second or third opinion before making any treatment decisions.

Finally, it is important to know how long a bridge should last. Although every case is different, it is reasonable to expect that your bridge should last at least 8-10 years. I have seen some bridges have lasted for as long as forty years or more- believe me; they're out there. So here's what you can do to increase the longevity of your bridge. First, it is very important to maintain good oral hygiene. Next, I would also suggest that you avoid hard and sticky foods (pretzels, hard candy, caramels, chewing gum, etc.), and also use a custom athletic mouthguard if you are involved in contact sports. Lastly, make an effort to see your dentist for examination and a professional cleaning at least twice a year.

Dentists not more likely to commit suicide

2008-03-23T11:39:00.000-07:00

You may be surprised to learn that there is little evidence that dentists are more prone to stress-related suicides than the general population, according to an article in the June 2001 issue of the Journal of the American Dental Association (JADA).

There are few things that we all know for certain. We know that the sun rises in the east, and sets in the west. We know that there is no escape from death and taxes. We also know that among all the stressful professions in the world, it is dentists who have the highest suicide rate. Many people accept this myth as common knowledge, and it seems to resonate. Here's why. Some people feel stress when they go to the dentist, and it is only logical to assume that the dentist also feels a great deal of stress as a result. This stress, taken to an extreme, could lead to suicide. You may be surprised to learn that there is little evidence that dentists are more prone to stress-related suicides than the general population, according to an article in the June 2001 issue of the Journal of the American Dental Association (JADA).

Like an urban legend, something that is repeated enough times over and over again begins to be accepted as the truth. "Since 1933, both the public and professional media have repeatedly portrayed dentists as being suicide prone," said Roger E. Alexander, D.D.S., professor, Baylor College of Dentistry, The Texas A&M University System Health Science Center, Dallas. Over the past twenty years, there has been little attempt to verify this claim, despite the fact that there are plenty of valid statistics on this important issue. According to the Centers for Disease Control, suicide took the lives of 30,575 Americans in 1998 (11.3 per 100,000 population), and more people die from suicide than from homicide. In 1998, there were 1.7 times as many suicides as homicides, and overall, suicide is the eighth leading cause of death for all Americans, and is the third leading cause of death for young people aged 15-24. Clearly there is no shortage of statistics on suicide, but there appears to be no evidence that dentists are at any higher risk than the general population, according to the journal's study.

While I won't argue that dentistry can be stressful at times, I think it's fair to say that people in any occupation can feel stress at one time or another. It is also important to point out that it is mental disorders (particularly depression and substance abuse), not stress, that are associated with more than 90% of all cases of suicide. Fortunately, recent research has not confirmed a high suicide rate among dentists, despite decades of misinformation.

Antibiotics needed less frequently and in lower doses to prevent a heart infection after dental treatment

2008-03-13T11:33:00.000-07:00

For many years, the American Heart Association (AHA) has mandated that dentists give patients antibiotics before and after almost all dental procedures.

For many years, the American Heart Association (AHA) has mandated that dentists give patients antibiotics before and after almost all dental procedures. The reason is that bacteria within the mouth during dental treatment can travel through the blood stream and cause a dangerous and sometimes-fatal heart infection called subacute bacterial endocarditis (SBE). Patients who are considered at high risk for developing SBE are people with artificial heart valves, have had SBE in the past, and have congenital (occurring at birth) heart defects. People at moderate risk include those who have damaged heart valves from diseases such as rheumatic heart disease, and who have mitral valve prolapse with regurgitation. People suffering from endocarditis develop fever, fatigue and shortness of breath. Untreated, the condition is often fatal. The theory is that by taking antibiotics before and after dental treatment, you can kill the bacteria before it can infect the heart of susceptible patients.

In today's fast-paced culture, we are sometimes geared to look for the quick fix, the cure in a bottle. This has given some people the impression that antibiotics are akin to vitamins- but they are not. Antibiotics can cause dangerous allergic reactions as well as produce resistance strains of bacteria, rendering many of our antibiotics useless for future infections. Early during my residency at Mount Sinai Medical Center, I studied research that showed that more people at high or moderate risk for SBE got sick and died from taking the antibiotics prior to dental treatment, than from SBE itself after having dental treatment without antibiotics.

The AHA recommendations have been under sharp scrutiny over the last few years, and an article in the November 1998 issue of the Annals of Internal Medicine by Brian L Strom, MD, MPH has cast even more doubt on the need for antibiotics prior to dental treatment. Recently, the AHA altered their recommendations, reducing both the amount of antibiotics required as well as the number of dental procedures it is required for. Now patients at high and moderate risk for SBE need only take antibiotics before their treatment. Adults should take 2 grams of amoxicillin 1 hour prior to dental treatment. Those adults allergic to penicillin or its derivatives should take 600 milligrams of clindamycin 1 hour prior to treatment. Erythromycin, which used to be the amoxicillin alternative and caused many patients upset stomachs and diarrhea, fortunately is no longer recommended.

Antibiotics are required prior to dental treatment that is expected to cause bleeding. The most common of those treatments include dental extractions, periodontal (gum) treatment, dental cleanings, placement of dental implants, and orthodontic bands for braces. Antibiotics are no longer required for dental fillings, crowning or capping of teeth, most anesthetic injections, removal of stitches, conservative root canal treatment, impressions, taking of x-rays, fluoride treatments, and polishing of the teeth.

Patients at risk for SBE can reduce their chances of getting this dangerous infection by seeing their dentist every 6 months and practicing good oral hygiene, brushing 3 times a day and flossing once a day. Your dentist may recommend you rinse with an in-office antiseptic mouth rinse prior to treatment (Peridex) if you have poor oral hygiene and are at high risk for SBE.