Bite Point

Invisalign and Me- ClinCheck movies

I am nearing the completion of the main phase of my own Invisalign treatment, and these cool movies show how my teeth have moved:

 Download Wilson DMD, Richard anterior

Download Wilson DMD, Richard lateral

Download Wilson DMD, Richard mandibular

There are so many positive changes to note.  My "deep bite" where the upper teeth overlap the lowers too much has been corrected.  Crowding and mis-alignment has been corrected into nice even curves.  There is also, if you look closely, a "crossbite" between the two right molars that has been corrected.  The upper teeth should normally lie outside the lowers a bit and my two first molars on the right side were always reversed in this way.  They are corrected here!

One of the best things about Invisalign is the predictive power of these ClinCheck movies.  In our office, when a patient is interested in Invisalign treatment, the process goes as follows.  We make impressions of the patient's teeth and also take specific photographs and ensure that there are up to date x-rays.  We then send all these materials to Align and work with the design team there to design the Invisalign treatment.  We may modify the simulation several times until if meets all of our treatment goals.  Then- the patient is able to see the ClinCheck from any angle for as long as they wish and they can also have input into the treatment and its outcome.  This is far superior to some other esthetic treatments in dentistry where the outcome is harder for the patient to visualize and is more "set in stone" at the end.

What I'm alluding to there is that if you have mild to moderate crwoding, and that is your only issue, conventional orthodontics or Invisalign is a far better treatment modality than porcelain veneers.  Straightening the fronts of teeth with porcelain leaves the underlying crowding and provides challenges to proper oral hygiene.  There are also problems with the forces of chewing being distributed in detrimental ways.  As long as the teeth are essentially intact, it is best to move them bodily into their ideal positions.

http://www.invisalign.com/Pages/Home.aspx

 

Dental Insurance- The Determining Transaction

There are certainly frustrations for those of you who have the benefit of dental insurance.  For it is precisely that- a benefit, something extra in your employment package that reduces the cost of this particular aspect of health and wellness.  Yet many of the exclusions, submission requirements and obstreperous rules about what's covered can confuse and aggravate.  Here are a few examples:

-Composite resin restorations are often not covered as well as silver amalgam ones, in spite of the fact that composite resins have reached spectacularly high levels of technological sophistication in recent years, while silver amalgam technology dates back to 1826.  See http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2009/11/amalgam-politicians-and-all-the-pink-trees.html

-Night Guards, or Bruxing Appliances, seem to be covered or not covered by a formula that involves throwing Yachtzee dice across the table in the auxilliary conference room at the insurance company headquarters.  Your odds are not good- all 5 dice seem to have to come up the same for you to get coverage on this excellent device that prevents damage to teeth, and thus further claims.  Were the actuaries out too late the night before calculating this one?

-Dental implants and their associated restorations to replace missing teeth are usually poorly covered, or not covered at all.  This in spite of the fact that in many situations, the alternative treatment of a dental bridge exposes the adjacent teeth to the risk of decay and impedes oral hygiene due to the connections between the teeth in the bridge.  See http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/01/watch-out-washout.html

-Perhaps the most trying aspect of dental insurance is the issue of yearly maximums.  This is the total dollar amount that the insurance company will pay out for a given patient or family in one calendar year.  The number most typically chosen when dental insurance started geting popular in the mid-1970's was $1,000 U.S.  The most common number that we see now in 2010 is: $1,000 U.S.  Gack!

If we account for inflation, $1,000.00 in 1975 had the same buying power as $4,160.87 in 2010.  Annual inflation averaged over this period was 4.16%.

So why aren't most plans set at a $4,500 yearly maximum?  Why aren't some of the most desireable and even preventive procedures covered well, or at all?  It is easy to direct the full force of our blame on the insurance companies.  After all, they are rich, they have lobbying power, and they inhabit tall buildings like this one:

 

However, dental insurance companies are quite happy to design plans that suit the needs of the companies that buy them.  Each dental insurance company in fact has written many hundreds of variations on their basic plan structures at the request of the companies that decide to purchase their products.  By way of example, if I'm the CEO of a successful tech company who's in the market for dental insurance, and I know that I myself will be needing a dental implant soon due to a failing tooth, I can perfectly well say to my Human Resources person, "Chumway, make sure that our plan covers all dental implant services at 80%, and set the yearly maximum at $3,000."  Problem solved.  I'll pay less out of pocket for my implant treatment.

Yet what does this cost the company as a whole, in increased premiums?  That is the key question.  It may be less than you think.  And if it attracts talented workers, the investment may be well worth it.  This is why we tend to see the best plans purchased by high tech companies (can you imagine what the plans purchased by Google and Facebook look like??), insurance companies themselves, unions, etc. 

The truth here is that the Determining Transaction rests with the employer, not the insurance company.  The employer decides what plan is bought, the insurance company sells it.  A corollary is that employees, whether unionized or not, should be aware of this so that they can have informed discussions with their H/R department when the time comes to consider purchasing new plans or renewing existing ones.

Most of the actual numbers are proprietary secrets of the insurance companies and their actuaries do some very complex math indeed in order to come up with these rates.  However some numbers I heard at a course a few years ago shed some light on the cost of adding bells and whistles.  At the time, the national average actual insurance company payout on policies with $1,000 per year maximums was $178.  The number is so much lower than $1,000 mainly because not everyone uses their dental insurance fully, in fact many insured folks don't go to the dentist at all for years at a time.  The average payout on policies with a $2,000 per year maximum was, however, $187.  So having $1,000 more per year to play with leads to a nine dollar increase in average payout.  This is because of non-users, and also because not everyone has a level of dental disease to require higher levels of payments.  (Many of our patients are being quite well maintained in their oral health, thank you very much!)

So as you can imagine, the increase in premium in order to go from $1,000 per year to $2,000 per year maximum, as determined by the actuaries, is very modest. 

The key question is this: in an era where medical insurance is becoming catastrophically expensive, and will likely escalate even faster after the passage of the recent health care reform bill: will most employers consider any increases in dental insurance premiums, no matter how small?  We can probably agree that this is doubtful.

The Persistence of Wilberforce

I have a remarkable friend who is inspiring because of the degree to which she is bothered by both indifference and intolerance.

 

There is also a great deal of anger and cynicism in our culture at the present time.  Yet anger for its own sake, not directed into positive change, is wasteful and has no value.  And cynicism is a losing strategy.

 

When confronted by any or all of these, if we want to make a difference, the thing is to be as single-mindedly persistent as William Wilberforce. If it's important to us, we have to show up. Again and again and again. All the thought in the world doesn't make a difference if we don't show up and sustain.

 

 

 

 

 

http://en.wikipedia.org/wiki/William_Wilberforce

 

http://www.amazinggracemovie.com/

 

Corporate Interchangeability- Stadium and Team Names

Excerpt from Linchpin, by Seth Godin:

  

We can’t profitably get more average.

We can’t get more homogenized, more obedient, or cheaper. We can’t get faster, either.

We’ve gone against our true nature and corporatized, anonymized, and dehumanized as many of our systems as we possibly can. Even health care is a system now, not a human interaction. We could probably go even further, actually, but I’m betting it won’t be a fun or profitable journey.

If all mortgages are the same, of course they can be chopped up and remixed and resold. But that means all bankers and all homes are the same, and so are all homeowners. Which means the cheap ones or the profitable ones are all that matter.

If all online products at all online stores are the same, then of course I’ll use a price-shopping Web site to find the cheapest product.

If all employees are nothing but a résumé, and résumés can be scanned, then why are we surprised that our computers end up finding us anonymous average people to fill our anonymous average jobs?

If every restaurant on the highway will give me precisely the same cheery service from the same robotic staff, at the same prices, then why does it matter where I stop?

Do we need to be flatter and smaller?

It’s our desire to be treated like individuals that will end this cycle. Our passion for contribution and possibility, the passion we’ve drowned out in school and in the corporate world—that’s the only way out.

Every successful organization is built around people. Humans who do art. People who interact with other people. Men and women who don’t merely shuffle money, but interact, give gifts, and connect.

All these interactions are art. Art isn’t only a painting; it’s anything that changes someone for the better, any nonanonymous interaction that leads to a human (not simply a commercial) conclusion.

This is an excellent and inspiring book- it points us to a way out of being viewed as an interchangeable commodity by corporations that are by nature designed with an imperative to create the maximum profit for their shareholders.  This aspect of corporations is both their strength- it's nice to see our retirement accounts grow in value- and their weakness, as they treat workers as cheap drones and positively revel in externalities  whenever they can get away with it.  (http://en.wikipedia.org/wiki/Externalities)

One spectacular example of the corporate interchangeability model is in the naming of sports arenas and, indeed, the events themselves.  Have a look at the ways in which names of bowl games have been changed to suit the advertising imperative of their corporate sponsors:

  http://en.wikipedia.org/wiki/List_of_college_bowl_games

Here in Philadelphia we have an enclosed arena that has had the following names in recent years:

-Spectrum II was a tentative name during development.

-Renamed Core States Center in 1996 in a sponsorship deal involving $40 million over 21 years.

 -Renamed First Union Bank Center in a 1998 merger.  (So much for the 21 years!)

- Renamed Wachovia Center in a 2003 merger.  It's in the realm of personal opinion, but this is just not an esthetic name for a sports venue.  It sounds more like a vampire-infested Eastern European town in one of those movies that's all the rage among the late teen set these days. 

-Renamed- yet again!- Wells Fargo Center in a 2010 merger:

 

Confusing fans and making signage companies happy by constantly slapping new names on buildings is nothing, though, compared to the striking disharmony in branding when it comes to the colors in the brand logo of team and corporate sponsor.  The Philadelphia Eagles play at red-logo'd Lincoln Financial Field:

 

And yet their team colors are white and green:

 

The Philadelphia Phillies, on the other hand, have the green sponsor Citizens Bank:

 

While their colors are red and white:

 

It's probably true that the respective deals were radically different and that a switch to green-green and red-red would not have satisfied the level of sponsorship that each corporation desired.  Still, having a big green sign on the stadium occupied by a big red team is just, well, asymmetrical. 

 Here's the Lincoln Financial deal: 

Under terms of the deal, Lincoln Financial Group will invest $139.6 million over the next 20 years, through annual payments averaging approximately $6.75 million. In return, Lincoln Financial Group will become the prime corporate partner of the Philadelphia Eagles and receive a wide range of marketing benefits. Lincoln Financial Group's funding for this initiative comes from already committed marketing expenditures and compares favorably to other major market sports sponsorships, such as FedEx Field in Washington, D.C., which cost $7.6 million per year over 27 years.

So far as I can tell, the main marketing benefit that they got out of their $139.6 million is that Philadelphia phootball phans, just before the first construction vehicle arrived on the site to start digging, came up with the marvelous phrase "drinkin' at the Linc".  Guess it was all worth it...

The story behind Citizens Bank Park has a little more substance for us to break down and think about.  From:

http://www.citizensbank.com/about-us/news/citizens/2009/10_30_09_phillies.aspx

In June 2003, Citizens Bank and the Phillies announced a 25-year partnership that included naming rights to the team’s new, world-class ballpark and a broad-based, innovative media package. When the $95 million agreement was announced, both Citizens Bank and the Phillies highlighted their passionate commitment to the communities and neighborhoods that make up the Philadelphia region, stating that an important aspect of the partnership was Citizens Bank’s absolute commitment to expanding an already strong community outreach program.

Those programs have:

• Provided low-income children with more than 213,000 summer meals through more than $64,000 in donations to Philabundance from the Citizens Bank Foundation and Phillies fans.
• Raised more than $4,000 for the Philadelphia Fire Department to buy smoke alarms. 
• Donated more than 3,800 baseball gloves to the Phillies Rookie League, which reaches 5,500 inner-city children in 70 locations throughout the region.
• Cleaned up baseball fields in North Philadelphia, Tioga and Camden where Rookie League teams play.
• Distributed 9,000 game tickets to community groups throughout greater Philadelphia.
• Helped more than 300,000 fans of all ages play the Citizens Bank Games of Baseball, which Citizens Bank created and operates for free in Ashburn Alley at Citizens Bank Park.
• Provided courtesy golf cart rides from the parking lots to the ballpark gates for more than 96,000 fans via Citizens Ballpark Bankers.
• Distributed more than 170,000 free lollipops to those visiting the Citizens Bank Kiosk in Ashburn Alley

The ballpark also has made a significant impact in name recognition for Citizens Bank – one of the city’s largest banks. Surveys show that people who were aware that Citizens Bank named the ballpark are 71 percent more likely to switch to Citizens Bank than those who weren’t aware.

There's a good reason why I question the efficacy of (read: sanity of) all this advertising and sponsorship.  There is a 60-year-plus vast body of research on Diffusion of Innovations, which delves into the ways in which new ideas and technologies spread through social systems of any size.  Here is one of the important conclusions from this fascinating field, from Diffusion of Innovations by Everett Rogers:

The mass media can: Reach a large audience rapidly. Create knowledge and spread information. Change weakly held attitudes. The formation and change of strongly held attitudes, however, is accomplished mainly by interpersonal channels. Interpersonal channels involve a face-to-face exchange between two or more individuals. These channels are more effective in dealing with resistance or apathy on the part of an individual, which is one reason why peer communication is so important for later adopters and laggards.

  

In the Citizens Bank/Phillies example, I believe that the majority of any measureable business success that they're having from this sponsorship comes from their interesting and visceral programs in the community, not from the "broad-based, innovative media package".  Cleaning up baseball fields is just cool, and engages people in the neighborhood.

  

What makes a difference in our world is face-to-face interpersonal communication and meaningful human interaction that has both a commercial and a non-commercial outcome.  Or as John Mayer sings in "Belief",

  

Is there anyone who ever remembers

changing their mind from the paint on a sign?

Growing Your Practice as You Make a Difference- lecture handout

I am presenting this lecture several times in the next two months and wanted to place my handout/suggested reading in an online location that is readily accessible either before or after the talk.

Download Growing Your Practice as You Make a Difference suggested reading

Please note that Greg Orr's article on Diffusion of Innovations, by Everett Rogers, is an excellent and succinct introduction to this important area of research.  Here is the link, posted separately:

http://www.stanford.edu/class/symbsys205/Diffusion%20of%20Innovations.htm

Marketing in dentistry is at its core the diffusion of the concept of your dental practice to the social system around you, and Diffusion of Innovations research illuminates this process at its deepest level.

The last few pages of my handout relate to a separate talk on using the DISC system to improve communication with patients (and staff!)  There was a nice introductory article in JADA awhile back:

http://jada.ada.org/cgi/content/full/138/3/381?ck=nck

Oh and here are some of my favorite images from some of the brilliant minds we will be exploring:

 

 

Dental Pulp Calcification- Spelunking in the Dentin

Our teeth may be almost diamond-hard on the outside, but they have living tissue inside, the dental pulp.  It's a lot like the tissue right under your skin, and the cells inside were involved in growing your teeth when you were but a lad, or lass.  A picture is helpful:

 

The cells build from both inside and outside when a tooth forms; check this out, there's a certain beauty to these images, unless you're taking Histology and facing a test on them:

 

"2" is enamel, the very hard outer part of our teeth that we see normally.  "3" is dentin, the inner part- not so hard as enamel; harder than bone, but somewhat similar.  What's so keen here is that "1" is the layer of cells that is building the enamel and "4" is the layer that's building the dentin.  "5" is then the pulp, the bulk of tissue that is red in the diagram above.

Now- once we turn 18 or so and all our teeth are formed and have come into place in our mouths, what do you think- do these cells all just retire and go on Social Security?  Not at all- they slow down a lot, but they still keep building more dentin, little by little.  You can imagine what that means- the pulp gets smaller, and smaller, and smaller...  So, if I look at my X-rays from back when I was in dental school and then look at mine now, I can see a slight difference- more hard tooth structure, less pulp space within.  When this process goes on long enough we say that the pulp is calcified.  It's a natural part of the aging process, although it occurs at different rates in different people.  I have on occasion delighted an octagenarian who has maintained her teeth and gums well over the years by exclaiming, "From your X-rays, I could think that you're still in your thirties!"

The pulp is, however, somewhat like Jackie Gleason's mother-in-law on the famed series The Honeymooners- rather easily irritated.  (Note: for Audrey Meadows, I'd deal.) 

Cavities cause inflammation in the pulp, and the deeper they are the more severe the irritation.  Our removal of cavities and the act of restoration of decayed teeth, as careful as we are and as well as we can bond to teeth these days, causes inflammation as well.  (Less severe when the cavities are smaller- early treatment is best!)  Trauma is another major cause of inflammation in the pulp.  Teeth that have been fractured or otherwise injured thus show more rapid calcification than their neighbors.

Here is a lower incisor with a long-standing fracture:

 

In the corresponding X-ray you can see that most of the pulps- the darker vertical lines in the centers of the teeth- are of a certain size.  Yet the pulp space on the X-ray of the fractured tooth is almost not visible at all.  This means that the cells inside have built, and built, and built more dentin until they've almost closed themselves out of space entirely.  Kind of a silly thing to do, but they're trying to protect the pulp from infection by walling it off from the dangers of injury or decay.

 
 

Here's the thing though- when a pulp calcifies excessively, yes it has walled itself off from the damaging effects of injury, fracture or decay, but it has also weakened itself in the process.  The pulp has a very delicate blood supply in the best of circumstances, and when this calcification happens it becomes very prone to dying off and getting infected.  Once there is infection in the pulp space, the only effective long-term treatments are root canal therapy or extraction.  (Antibiotics may calm the situation for a time, but they only go where a blood supply can take them and so will not get into the center of a "dead" tooth.)

Also, and this is perhaps the greatest technical challenge that I face in dentistry, canals that become very calcified and oh so small are far more difficult to treat with root canal therapy than wide open ones.  Our technology is great now though, and we can be very successful in treating extraordinarily difficult situations.  Having an operating microscope has changed the whole game- I now practically trip over tiny canals that I used to search after for hours.

Not every tooth with a calcified pulp needs root canal treatment.  We do not treat X-rays, we treat people.  It's just that the odds of pulp infection go up as calcification gets more severe.  And strange things happen... 

-Two teenage brothers are messing around with weights and a tooth gets chipped.  We restore the fracture and all is fine.  Two years later- sudden pulp infection requiring treatment. 

-A "live" tooth beaks and is restored with a crown.  Eight years later- same thing, sudden onset of pulp infection...

It's a cumulative damage scenario and the important thing is not to over-treat but to take all the changes in the dental pulp into consideration.  The signs of calcification on X-rays are one of many factors to be evaluated as we determine the health of our patients' teeth.

Oh and in case you feel like a bit of fifties humor:

http://www.youtube.com/watch?v=oqc3HZuoe7c

 

Our Caries Clock- Avoiding Cavities

Some time ago, we posted our magnificent Caries Clock for anyone to use in order to educate themselves and their families about how to avoid getting cavities:

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

Tooth decay is certainly one of the most common diseases in humans.  Worldwide, most children and an estimated ninety percent of adults have experienced tooth decay, or dental caries.  This is upwards of 6 billion people.

Some of the effects of dental caries are:

-Soft spots in teeth, loss of softened tooth structure as it breaks off or is removed during repair.

-Pain. 

-Infection if the decay progresses into the center of the tooth, the living dental pulp.

-Endondontic (root canal) treatment can eliminate this pain and infection if the tooth is still intact enough to be restorable.

-Esthetic challenges, as many cavities are visible when a person smiles; also gaps show when teeth are lost due to cavities.

-Loss of time from productive work as teeth and possibly infections related to decayes teeth are treated.

-Emotional trauma expecially in children from the treatment of what is by definition a complex and sensitive medical problem.

-Cost.  Tremendous cost can be incurred in treating extensive decay and it's all preventable.

We need three things for a cavity to occur in a tooth.  We need the person, who has to have teeth, we need simple sugars, and we need a particular germ.  Unlike gum disease with its many possible causitive germs, with cavities there are only two main bad guys.  There is primarily Streptococcus mutans, and there is Lactobacillus acidophilus who is kind of like Best Supporting Actor here.  I know, I know, they should name them something a lot simpler, like Elmo and Big Bird or Hall and Oates.  But they don't...  Something involving Latin taxonomies and large quantities of micro-brewed beers at scientific conferences.

What happens is actually pretty simple.  Any time we ingest simple sugars in either liquid or solid form- any time, any sugar- Herr Mutans, in particular, steals some of it from us.  The millions of germs in our mouths (Gack!) grab on to this food like starved football players after practice.  The problem is that Strep mutans happens to kick out insane levels of acid waste products when it metabolizes sugars.  The next problem is that the more we feed sugar to these little beasties, the more of them there are- giving them just what they want increases their population in the plaque in our mouths.  The acid eats into the teeth, both in the grooves on top and on the smooth sides.  Cavities result.  Then, the more cavities there are, the more Strep mutans there is in all those holes... It's a snowball rolling down hill at that point.

Our defenses:

-Keep the plaque in our mouths down to a minimum.  Brushing thoroughly, flossing, using Soft Pics if you don't like floss- all keep the numbers down on Strep mutans and for that matter everyone else in there too.  Fringe benefit- better breath.

-Fluorides strengthen the enamel against this form of acid attack.  Topical fluoride in toothpaste is appropriate for adults whose teeth have already grown.  Not all water supplies have fluoride, so for kids with their teeth still forming a careful check is needed to ensure that they are getting the optimal levels.

-Eating with some regard to frequency of carbohydrate intake is important, and is what our Caries Clock is all about.  We can snack, we can have our chocolate- we just shouldn't have it too darned often.

Here's a neat graph of the acid curve over time:

Sucrose is a common simple sugar, it's table sugar actually, and pH is a measure of acidity.  (Just in case you've protected your psyche by blanking out all memories of high school chemistry class.)  As you can see from the graph, your teeth need time to rest after an "acid attack".

And watch out for what really contains carbohydrates.  People always seem to be aware of the risk from sodas but not from sports drinks.  If it's liquid and tastes really sweet and there's any other ingredient besides sucralose or aspartame in there, it can cause cavities:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2009/12/how-sweet-it-is.html

So can otherwise healthy foods like raisins and dates and most fruit.  These are excellent things to be eating- just don't graze.  And try to clean your mouth after you're finished.

The worst thing you can do for your teeth- and your pancreas, for that matter- is to "graze" on refined sugars all day long.  Eat, then give your mouth time to rest.

Mr. mutans will be very angry about this, but that's his problem.

Periodontal Disease and Bone Loss: These Walls Are Paper-Thin

Periodontal (Gum) Disease is a bacterial disease which wreaks its havoc by setting up a small but highly destructive zone of damage in the gum tissue around our teeth.  As it progresses, it's like a neighborhood that goes downhill after, say, the loss of a few key businesses.  As it gets worse, it does so faster and faster.  In the later stages, the jawbone (New York dentists say "joorbone") that supports our teeth is lost as well.  The patterns of bone loss can be rather horizontal, like a water level dropping:

 

 

(That bone level should be a lot higher on the teeth!)

 Or they can be vertical, like a crevasse:

 

Bone loss from periodontal disease also doesn't happen all over the mouth all at once.  It's very episodic, it happens here and there and once it reaches a critical point, it goes a lot faster.  So we might see one tooth ready to fly across the room if the patient sneezes, it's so loose already, and yet the one next door is anchored like one of Sir Edmund Hilary's Everest-climbing pitons.

Periodontal disease isn't just a local problem, either.  The damaging germs themselves, and the various toxins that they produce, periodically break out into the bloodstream.  There is a growing body of rersearch that shows that all this nasty stuff flying around in our arteries can lodge on the atherosclerotic plaque on our artery walls, triggering an immune response.  If a clot forms, or forms and breaks free, a heart attack, stroke, thrombus or embolism can result.  This is all a strong set of reasons for maintaining a healthy mouth, especially considering that daily maintenance and preventive dental visits are not costly in terms of time and money.  It's the treating and repairing that gets out of hand...

Back to the local neighborhood in the mouth, though.  When bone loss gets severe, there is a big question of how many teeth are affected.  Here, from the same patient, are two quite different situations.

In the first, one tooth has almost no bone.  Dark is "air" or gum tissue, light gray is where the bone is.  Note on the tooth to the right of the one with the severe bone loss, there is just a little sliver of bone left on the side, valiantly fighting off its seriously disturbed neighbor.  Remarkably, if we extract the loose tooth, the one next door will heal beautifully, particularly if bone grafting materials are used in the socket.

 

In the next X-ray, though, the failing tooth has, regrettably, caused terrible problems for its neighbor.  There's no bone left on the side, next to that big dark space.  This is very, very difficult to induce to heal, even with modern techniques.  That tooth next door should probably sue.

 

The bottom line is, preventing bone loss in the first place is essential- and far less expensive than complex periodontal treatment or tooth replacement.  What's even better is that for 85% of the world's population, preventing periodontal disease is very effective and not too difficult.  Only 15% of people are highly susceptible for genetic reasons and must take even greater precautions than most due to how rapidly this serious condition may progress in their mouths.

When I was in dental school, my classmate Dave, once a semester or so, so as not to burn out the joke, would page on the school-wide intercom system for "Dr. Perry O'Donnell".

Perry O'Donnell, and no one in admin ever caught on to the pun...

Leaping Tooth

This post will be Brevity itself.  All I can think of to say is, cue up the Salsa music, this tooth wants to leap up and day-ance!

 

(I actually mean this as a gentle warning about periodontal (gum) disease, and to show the severe loss of supporting bone that should be strenuously avoided through regular dental care and prevention.)