Bite Point

"NOW Can I have me some chewin' room?"

From the movie that remains, to this day, my favorite comedy, 1965's The Great Race:

Larry Storch's character, Texas Jack, says to Tony Curtis' always-spotless-white The Great Leslie: "Now can ah have me some fahh-tin' room?" in a schtick that repeats several times; sorry, tahmes, each more hilarious than the last. Here's the clip:

http://www.youtube.com/watch?v=Q6Pl71RpFRs&feature=results_main&playnext=1&list=PL1372D1D48A184993

Well, it is hilarious to a guy like me, who appreciates the slower, kindlier humor of that bygone era to today's often highly mean-spirited stuff. So many things in our culture have improved, but I submit that film is not one of them.

And so that Texas Jack clip is what I think of when I see prior dental treatments that fail partly because there wasn't enough "fahh-tin' room", or enough space for the restorative materials that we so often place in and on teeth in order to keep them going after they've been harmed by decay, fractures or just overall wear.

There are many types of dental crowns. The workhorse of the 20th and early 21st Century is the porcelain fused to metal, or PFM. This type of crown has a layer of semi-precious or non-precious metal, cast or milled, covering the tooth. The functional shape and esthetic look is then completed by porcelain layered on top and around the sides. Nine out of ten dentists, and eleven out of ten dental educators, assert that the materials involved in a PFM need to be at least 2 mm thick on the biting surface of the tooth.

Another way of looking at this is, we need to remove enough old filling and tooth to provide 2 mm of clearance between the opposing teeth and the one we're working so hard to restore.

Here is a pair of images of an old crown that I removed and sectioned:

 

The striking thing to note is that the porcelain on top of the tooth, on the biting surface, is very thin. Yes, it wore a bit over the years that this crown was in service. But porcelain wears slower than opposing teeth, when it is properly placed onto the metal. This crown started out on an underprepared tooth. It wasn't given enough fahh-tin' room between the top of the crown prep and the opposing teeth. Thus, the porcelain was very thin. The deeper layers of porcelain are opaquers and coarse layers that are not as effecive as the final ones at holding up to the rigors of chewing day after day. Thus, they wear away quickly and what was at first a thin layer becomes an uber-thin layer that tends to fracture.

It is said that the rate of porcelain fracture in new crowns done in America at this point is about 5% over the first five years. This includes every kind of fracture, from big ones that render the crown unserviceable and in need of replacement down to minor fractures that can simply be polished away. Still, everything we can do in dentistry to minimize treatment failures is important, and ensuring adequate reduction of our crown preps is vital.

Patients- if you ever have a "PFM" crown done and the biting surface shows metal or looks very odd  compared to the beauty of the rest of your crown; say, opaque and flat-looking, rather like a lawn ornament (I'm thinking plastic pink flamingo here); then there was probably an issue with the clearance between the treated tooth and the ones that oppose it. This truly should be corrected before your new crown is cemented into place, only to face a high likelihood of breaking in a short time.

Returning to important matters, the scene in the above Youtube clip must certainly be the greatest bar fight ever put on film. Barstools fly. Bottles are smashed. When the staircases come down, it's just magnificent. And there's that quirky exchange between Lily Ole and The Great Leslie early in the clip:

Lily: "Honey, your smile is downright painful!"

Leslie: "Thank you. Are you a native of Boracho?"

Indignant Lily: "I ain't no native, I was born here!"

But the pie fight... oh yes, the pie fight. Definitely, at 2,357 pies, the grandest pie fight ever on film.

http://www.youtube.com/watch?v=-0BOOgW7rHE

You will not regret watching it!

"Y-o-u  w-o-u-l-d-n-t  d-a-r-e!"

Root Canal Therapy: Take Two! Guest Post by Neha Shah, D.M.D.

Superb endodontist (and awesome human being) Neha Shah DMD writes our latest guest post and explains a pervasive mystery in dental treatment:

Many people are surprised when they hear that they need a root canal on a tooth that has already been previously root canal treated. Wasn't the entire purpose of doing the root canal to not to ever feel pain again in the tooth? Commonly I hear from patients, “All the nerves are out, so how come this tooth is hurting?” The most common misconception from patients is that when a tooth has had root canal treatment, it is as if the procedure has created a force around it so strong that not even kryptonite can penetrate it. However, this is far from reality.

When a tooth has been treated for a root canal, it is in essence "rendered dead". A tooth that has had root canal therapy is essentially void of the living pulp tissue at the core of the tooth and therefore not able to respond to temperature stimulation. So the tooth is not able to tell you if something is hot or cold. However, it is still able to perform other functions of a mature, vital tooth because it still has the basic structures of a natural tooth namely enamel, dentin and cementum. This is what renders it susceptible to all of the threats that a vital healthy tooth is susceptible to. In fact, some may argue that a root canal treated tooth is slightly more vulnerable than a healthy, vital tooth. This means a tooth that has been treated for a root
canal is susceptible to decay (cavity), fracture, and infection just like any other tooth in the mouth. So it is imperative that a root canal treated tooth is properly cared for and protected.

One of the biggest threats to our teeth is BACTERIA. Our teeth are constantly bathed in saliva that have bacteria. These bacteria which are naturally present in our oral cavity are opportunists and when the environment is ripe will attack the basic structures of the tooth. So at every opportunity, at every level from performing the root canal, to sealing the root canal, to sealing the tooth, this basic goal of keeping the bacteria out is practiced by dental health provider and encouraged to patient.

So what is causing that root canal treated tooth to hurt? Infection and Inflammation. For every infection there is associated symptomatic (painful) or asymptomatic (no pain) inflammation. The primary reason why root canal needs to be redone is for what we term "coronal leakage" ("coronal" meaning "crown"). What this essentially means is that bacteria have penetrated through and into a previously disinfected root canal system. Other less common factors that lead to retreatment is a previously untreated canal, undetected root fracture, or persistent infections within the root canal system due to complex anatomy or extraradicular infections. Regardless, the common thread that runs through these causes of failures is again bacteria, "bugs", or microorganisms.

In a nutshell, the etiology is bacteria and the treatment is disinfection. This is precisely the primary goal of retreatment therapy. During retreatment any existing restorations or posts leading to the root canal system have to be disassembled. The root filling material has to be removed and the entire root canal system has to be disinfected. Once the disinfection process has been completed which usually is completed in two or more visits, new root filling material is then placed and once again an opportunity has been set to seal the tooth properly and restore it to full function. In essence, retreatment is like giving the tooth 2nd life. In some
ways you can use the analogy of the life lines from “Who Want’s to be a Millionaire?” #1 life line for a tooth is root canal therapy. #2 life line is your endodontist when (s)he performs retreatment procedure due to reinfection of the initial root canal therapy and your last life line is your endodontist when (s)he performs an apicoectomy on a tooth that has already had root canal therapy more than once. Your million dollar is when you save your self of the aggravation of extracting the tooth and finding a way to replace it with a prosthesis.

To illustrate, here is a case that has failed for many of the reasons mentioned above:

*Coronal leakage
*Missed canal
*Separated files
*Persistent infection due to anatomy
*Inadequate initial debridement

 

 

Once the etiologies were identified, all of them needed to be addressed to set the stage for success.

For the above case, the tooth’s prior root canal had to be disassembled through a permanent crown. Goal of the retreatment for this case was to remove post, remove separated files, locate additional canal, remove existing root filling and fully debride and disinfect root canal system and medicate to create an environment for healing. The last two x-rays show the finished treatment.

You may realize that the tooth behind the one that was treated is in a similar predicament. It too will require retreatment for long term success.

Root canal therapy is a highly predictable, highly successful procedure when the tooth is treated and restored properly. Like any medical/dental procedure, the responsibility of performing the procedure properly lies in the hands of the health care provider but the care and maintenance after the procedure is shared by the patient and the provider. Remember, if at first you don’t succeed, try, try again.

(Dr. Shah practices at TEC Endodontics: http://www.tecendo.com/) 

Thoughts on Writing: Guest Post by Author Elisa Ludwig

Sometimes you meet someone who you just know is capable of doing great things.

When writer Elisa Ludwig and her husband Jesse first came to our practice as patients, this is how I felt about the two of them. As individuals, and as one of those couples who understand that at least some of their strength comes from a healthy dose of "It's us against the world", I knew that they would be increasingly successful over time. They have that spark...

Writers do so many things. Pieces for magazines and online publications. Copyrighting. Editing and other technical services. In some ways, writing fiction that gets published and widely read is perhaps the most difficult goal to accomplish. And Elisa has done just that. I'll link to her two new works at the end. First, let's hear her thoughts on the creative process and the importance of persistence. (I've bolded that part since I love it so much!)

Elisa writes:

My first novel for teens, Pretty Crooked, will be published this March by HarperCollins.

Can that really be true? I can hardly believe it. This dream has been some 15 years in the making.

Even when I got my contract with the official letterhead in fall 2010, the words “debut author” were still an extremely abstract, distant idea. As the months have passed, it’s become incrementally more normal, and my life has evolved to include this new definition.

As my book went to print, there were plenty of tasks involved—edits, copy edits, first pass pages, writing acknowledgements, getting an author photo. I started networking with other authors online. I began attending more events to meet authors, librarians, booksellers and readers. At the same time, I was working on the sequel to Pretty Crooked, going through drafts with my wonderful editor. Some of these activities were fun. Some of them were scary. But all of them had an exciting new sheen. Writing was now my job. It was, in teen speak, for realz.

Through all of this I’ve found that my actual writing process changed in some ways. There was more expectation. I knew people were waiting for my books to be finished (as opposed to me writing them in a vacuum). I had a deadline. I now had a particular person, my wonderful editor, in my head, guiding me.

When writing fiction became my job, and not just something I did, sighing heavily, in cafes on the weekends, I had to be much more disciplined. I had to break my work into chunks, so I could fit it into my normal workday (glamorous though publishing may be, I still need to keep my day job for the time being). I couldn’t really afford to mope around in fits of despair, waiting for creative inspiration. I had to produce.

It all sounds very dry and unromantic. But the funny thing is, I think my writing has improved exponentially as a result. The more I showed up, the more inspired I felt. The more I wrote, the more ideas came: Solutions to my characters’ problems, plot twists, better dialogue. The angst fell away and sitting in front of my computer became a lot more fun.

I’m not saying that you have to be published to enjoy writing—that’s patently ridiculous. But I do think if you can find a way to treat it as work—this is what you do every day, no matter what, because it’s your job—then you will learn to write more efficiently and that creates a positive feedback loop. More writing = more inspiration = happy writer.

http://www.amazon.com/Pretty-Crooked-Elisa-Ludwig/dp/0062066064/ref=sr_1_1?ie=UTF8&qid=1327245124&sr=8-1

http://www.amazon.com/June-of-Rock-ebook/dp/B005DUY8TQ/ref=sr_1_2?ie=UTF8&qid=1327245124&sr=8-2

So proud of my friend and patient! ;}

Write

Read and you may be enlightened. Write and you WILL be empowered.

Respectful and Sustainable

My 150th post. Christmas Eve. Fifth night of Hanukkah. I'm going to go with this:

"When you build something good and decent and sustainable and respectful, you never know how far it will travel, or how much difference it will make. So go ahead and build it. And prepare to be surprised." -AStJS-G

This is a quote from Aloysius St. James Spottisworth-Gack. I explain who he is on my other blog, here:

http://rickwilsondmd.typepad.com/the_man_who_wore_mismatch/

For over 100 years, the powerful structures and forces that we humans create, the corporations and governments that have built our world, find that it suits their aims to treat us very often as interchangeable, temporary, and disposable. They find it expedient to commoditize us.

On the one hand, I'm extremely thankful that we have better government than our medieval and ancient ancestors suffered under. For all its flaws, what we have now is better than serfdom. Or slavery. And without the pooling of capital and human resources that makes a modern corporation, we wouldn't have hospitals and medicines and modern transporation and the Internet and high caliber scientific research... The list goes on and on.

On the other hand, being treated as interchangeable is never pleasant, and often astonishingly harmful to the human spirit. Many have been scarred by mass layoffs, the uncertainty and fear caused by the spectre of downsizing, merge-and-purge or outsourcing. The interchangeable mindset even causes threats to our immediate physical well-being. Love Canal, Bhopal, Exxon Valdez, the BP Gulf oil spill. You can think of many more examples I'm sure.

Much of the interchangeable, temporary and disposable treatment of human beings derives from Externalities- costs or benefits incurred by a party who did not agree to the action causing the cost or benefit. Like pollution, for instance.

My fictional character, Aloysius, understands the true value of human connection and of the affinities he has with his customers, and also with his friends and family. He doesn't take them for granted. He also attempts to minimize his Externalities. And in a world dominated by mass production and mass advertising, he goes against the grain by slowing it down, by not trying to grow so big so fast that he becomes average in the process, and, most importantly, by building his business and his very life to be respectful and sustainable. He respects the precious attention of those who pay it to him.

Aloysius and his wife Victoria also understand that setting out to create positive change in a sustainable and respectful manner can make a tremendous difference in the world around us, at times more than we ever imagined when we started out. Making a difference stands in direct opposition to commoditizing our fellow human beings.

Inspired by the fictional character of my own creation, then, my holiday message is this:

"I am not interchangeable, temporary or disposable. And no business, or for that matter government or person, shall treat me as such. Furthermore, I shall never treat my patients that way. My patients are never interchangeable to me."

The Noxnoys

"Hon, are we going over to the Noxnoys' for cocktails?"

So reminiscent of that suburban middle-class vibe of my youth. But in our office, Noxnoys aren't Dry Martini-swilling neighbors with no food out on their tables but a few nuts and crackers. Some mass-produced orangy cheese spread if we're lucky. No, Noxnoys are something very special indeed. Read on and see why.

 

We see new patients, of course, some of whom have significant dental needs in order to eliminate pain or solve esthetic problems. As we work through planning and then carrying out their treatment, they experience considerable and meaningful gains as they return to the enjoyment of a beautiful smile and a healthy mouth. We have the satisfaction of performing complex and challenging procedures, of seeing them healthy for perhaps the first time in years, and yes, income for our practice is significant where needs are high.

But then we want them to get healthy and stay there, never spending on their dentistry that way again.

This brings me to another situation, that of our existing patients who are essentially healthy and decide upon some elective treatment. Perhaps they replace some old restoration that was done at a time when technology didn't allow the beauty of today's dentistry. Maybe they lighten their teeth. These days, more and more adults (like myself) are deciding to align their teeth with Invisalign or a referral to an orthodontist. These are also significant treatments and events in the life of a dental practice.

Then there are the patients who break my heart. Mostly older adults (like "myself" is rapidly becoming!), they have enjoyed fine dental health for long periods of time in our practice and perhaps in other dental offices that preceeded their time here. Suddenly, they develop some acute illness. Perhaps they have a dry mouth due to medications and the aging process itself. They soothe their throat with lozenges or cough drops that contain massive amounts of sugar; they interrupt their normal oral hygiene because of time spent in hospital and rehab; they become temporarily addicted to things like ice cream, ginger ale and other sweets. In an astonishingly short time, they can wreck their dentition. You wouldn't believe how fast cavities like these can happen in people we know and have been preventing problems in for years:

As I said, these situations break my heart. They are so preventable! I never want to have to perform major non-elective treatments that could have been prevented in the first place in patients I already know and take care of. The key to understanding this in yourself and your family is here by the way:

http://www.smilephiladelphian.com/clock/Caries.php

And then there are the Noxnoys.

You see, some years ago we went to a system where our hygienists, Annette and Maryanne, signal the need for Dr. Sukoneck or I to examine a patient by putting up a little scrap of paper on our doorway. This avoids verbal interruptions and ensures that we will go to that patient as soon as we can, since the paper scrap waves at us insouciantly, perhaps even mockingly, from our operatory door as the minutes pass.

Maryanne took to writing "nox" for "no X-rays" that visit, and "noy" for "no yellow sheet." This "yellow sheet" is our scratch sheet where both doctor and hygienist can write notes about any sort of diagnosis or treatment need.

"Noxnoy" thus means a patient who is up to date on their X-rays and has no treatment needs- a poster person for dental health. And we see many patients like this each and every day.

This makes me happy. When prevention is working, when patients avoid uneccessary and costly dental problems, when cavities and gum disease are being warded off by our mutual efforts at maintaining a clean mouth and avoiding too many bad habits, I am happy indeed to send the Noxnoys off to their careers and homes with no treatment necessary, reserving our highly refined skills for someone new who hasn't been to the dentist in too long a time.

And then watching as they, also, join the ranks of the Noxnoys who only need us twice a year. ;}

Interproximal Cavity Detection With X-rays: Oh, Be Careful!

Cavities between teeth (interproximal cavities) are a very significant problem in our sugar-laden culture. Liquids cause a lot of the trouble; watch out for how often you drink anything with sugar in it, especially drinks like Gatorade that advertise based on health concerns. More here:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/09/our-caries-clock-avoiding-cavities-.html

The excellent DDSGP app for the iPad: (http://www.ddsgp.com/DDSGP/DDS_GP___Home.html)

-shows these types of cavities graphically very nicely:

Here, with my little arrows pointing to them, is the way two moderate-sized interproximal cavity look on an X-ray:

There are two "waves" of the darker areas that indicate decay, one in the outer enamel and one in the inner dentin.

Sometimes, we see shadows that are perhaps not what they seem. This X-ray hints at interproximal decay:

A different view of the same tooth, however, shows normal enamel:

No cavity at all!

This presents a crushing diagnostic dilemma for us dentists, as the overlap and various distortions caused by imaging 3-dimensional objects onto 2-dimensional images can give us false positives.

Eventually, I am confident that 3-D imaging will become routine, de rigueur, au fait and, in fact, our raison d'etre when it comes to using X-rays to take pictures of teeth. (That last French word also happens to be, in my estimation, the very best of the many great beers created by the Dogfish Head brewing concern. "A deep mahogany ale brewed with Belgian beet sugars, green raisins, and a sense of purpose.")

Sorry. Got off track there. Here's the link to my thoughts on that:  

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/10/new-frontiers-in-dental-medicine-x-rays-and-3-d-imaging.html

The 3-D imaging, silly, not the beer!!!

We can also use tactile information (the oft-dreaded but really quite-innocent-if-used-properly dental explorer) and the new Soprolife optical detection unit to help us decide what's real and what's not:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2011/02/soprolife-optical-cavity-detection-system.html

Overall, this is a challenging area of dentistry, when the signal to noise ratio is right on the edge and things aren't so obvious. "Discretion is the better part of valor" and gaining more diagnostic information before touching a tooth with any kind of treatment is the best course of action when we feel we are being fooled by the very specialized kinds of information that X-rays can provide for us.

Hits or Niches (with Joel D Canfield) and TMWWMMS

As any of you who read my blog over multiple posts well know, I am not trying to sell anything here.  My main purpose in writing it is, in fact, to email individual posts to my own patients, to further explain issues, diagnoses, and proposed treatments that come up in the office.  It also absolutely delights me that I apparently reach people all around the world, particularly in India and the Philippines, where I am quite popular.  Who would ever have thought?

Still, Joel D Canfield have written a book together on a topic that we feel quite passionate about.  We wish to free creative people from what can be called The Tyranny of the Hit, that cultural imperative to always strive to become bigger and reach more people.

The problem with that is, to become bigger, you have to become average.  It's like a law of physics, immutable and inviolable.  OK there are exceedingly rare exceptions but we're talking about freeing up your creative process here, so let's look at what's likely, not what's almost impossible.

Here is where you can find our tome:

http://www.amazon.com/Hits-Niches-Marketing-Obnoxious-Annoying/dp/0984094040/ref=sr_1_1?ie=UTF8&qid=1323460894&sr=8-1

http://www.amazon.com/Hits-Niches-Marketing-Obnoxious-ebook/dp/B0062CGIXI/ref=sr_1_2?ie=UTF8&qid=1323460894&sr=8-2

I am also, as it turns out, writing a novel about human-centered versus corporate-interchangeable businesses, among other things.  Actually my intention is to give a fictional treatment to the non-fiction of Seth Godin (www.sethgodin.typepad.com) and other authors.  Those of you who have followed his remarkable mind as it travels among Purple Cows, Tribes, Linchpins and Edgecraft will no doubt want to check out what a fictional exegesis looks like.  Well, here you go:

http://rickwilsondmd.typepad.com/the_man_who_wore_mismatch/

Enjoy!  And meet me down at The Pig & Trebuchet for a pint if you dare...

Environmentally Friendly, Energy-Saving LED Lighting!

I just had to change a fluorescent light bulb here:

Merciful heavens, it was a pain.  I had to move all those boxes, and changing the bulbs is always a nightmare.  I mean, who decided to make the box just a little teensy tiny bit larger than the length of a bulb?  You always have to twist and shout to get it in.  And last time I checked, you can't bend glass, right?

Well I'm fighting back.  Now I have installed my first LED lighting fixture in our office!  It's a Tech Lighting Cirque LED fixture and it is in our waiting room bathroom.

LED lighting fixtures have many advantages.  They use a fraction of the power that fluorescents or incandescents do for the same light output.  They look mahvelous.  And they last over 50,000 hours.  That's easily 15 years, maybe 20, depending on how much they're on versus off.

Let's take a look under the hood first.

These are the LEDs.  That's right, this weird array of orange thingies is where the light is going to come from:

There are two of these in the fixture.

Next, let's look at them all lit up:

Way cool, huh?!  I know, I know, you're thinking, "They don't let him out much."  But let's go on:

That's really a very esthetic lighting fixture.

And by the way, for any of you who are local yokels, with reference to me, here's where I got this baby from:

Lighting Solutions Inc
http://www.phillylights.com/index.php

 

Missing Teeth and Bone Resorption

I like that word: "resorption."  Its official definition is "the destruction, disappearance, or dissolution of a tissue or part by biochemical activity, as the loss of bone or of tooth dentin."

In the case of our jawbones, when teeth are missing the bone tends to resorb or dissolve away.  Sometmes the amount that goes missing is truly astonishing.  The effect is worse when the span of multiple missing teeth is long.  If just one tooth is missing, the adjacent ones keep the bone resorption to a reasonable level, since they are still anchored and need the bone to support themselves.

Here is a good example:

I have marked the image as well.  The bottom black line parallels the bone as it goes from one tooth to the other.  Both adjacent teeth have maintained their bone at nearly normal levels, and the bone in between doesn't even "swoop" up at all.  Most commonly, it does a bit more than this.  Here, though, the sinus floor, represented by the upper black line, has expanded down over the years to thin out the bone from the other side!  There ain't no free lunch in human biology.

When many teeth are missing it's a whole different ballgame.  This panoramic film demonstrates for us:

This patient's lower jaw is still very robust in spite of missing the back teeth.  You can see however that the bone around the remaining front teeth is a lot "higher" than it is in the edentulous, or no-teeth, zones.

The upper jaw, in contrast, is truly a mess.  I tried and tried to use my combined impressions from examining my patient and then this film to draw a line where the bone has resorbed to; it was difficult, though, because the bone is so very thin that it's hard to distinguish from soft tissue on the X-ray.  Here we go:
What do we learn here?  Well, we can see that the resorption of the upper jaw is far worse opposing the areas where there are teeth than where there are not.  In fact, this patient's jaw in the upper front has resorbed all the way up to the anterior nasal spine, which is as far as it can go, as this is part of the main structure of the skull.  You see, alveolar bone, which is the bone that supports the teeth, is negotiable; the deeper supporting bone tends to remain longer in most patients.

This patient wears an upper denture which is surprisingly comfortable.  Yet that denture is what transmits the force from those lower remaining teeth to the upper bone, causing this damage over time.  The entire upper jaw is severely resorbed, but it is worst where it gets hammered by the repetitive forces of chewing.

The key thing to understand nowadays is that there are at least two things that preserve alveolar bone: natural teeth and titanium implants.  An implant not only supports something like an individual tooth, bridge or removable denture; it also gives the alveolar bone a raison d'etre, a reason to live, we might say.

Patients who are missing multiple teeth would do well to consider dental implants for the stability they provide to any dental restoration in the immediate present, and also for the maintenance of bone that they provide for the future.

Now if only Congress thought that way about our tax revenues...