Bite Point

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...

 

Wear and Discoloration on Lower Front Teeth

Commentors Jane and Robin on my post:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2011/12/orthodontics-proper-function-and-tooth-wear.html

-were likely referring to differential wear of the lower front teeth.  The top edges of these teeth show very readily in most people when they speak and smile.  Thus, if the enamel has all worn off, the effects of that wear are seen often and blatantly. 

The main effect is one of darker color, as the inner dentin of the tooth is not only naturally darker, but more prone to stain than the enamel.  There are also contour issues since these teeth get all flattened on their tops.

Like this:

Bleaching, or whitening, doesn't completely remove this dentin stain.  Veneers are an excellent esthetic solution, but are costly and lower front teeth are inherently very small and under great stress on their upper edges- not the ideal indication for porcelain veneers.

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/05/repetitive-stress.html

It is far, far better to align one's teeth when relatively young and then retain them.  It is also best for those who grind their teeth excessively to wear a night guard appliance or to wear orthodontic retainers with an anti-grinding mechahnism built in.

Orthodontics, Proper Function and Tooth Wear

Front teeth are for many things: chewing, eating; they are heavily involved in speech; smiling, and the incredibly important creation of facial expressions.

Also for pictures in American magazine advertisements.  Those teeth are, unfortunately, mostly the shade that we in the field call Ghastly-White, which is several degrees lighter than the paper the magazine is printed on.  Ah, the modern marketer.

In any event, teeth are supposed to function in a certain way, and part of that function is for the front teeth to open up, or disarticulate, the back teeth when we slide to one side.  This action protects the back teeth and their cusps from excessive wear and damage by preventing them from gnashing into each other all the time.  Visceral memories of Psalm 37:12 come to the surface.  It's best quoted in the venerable King James version: "The wicked plotteth against the just, and gnasheth upon him with his teeth."

Reese, our beautiful tooth model (ah, if only you could see the rest of her!), demonstrates her lovely Canine Rise for us:

Many conditions prevent "Anterior Guidance", this vitally important function of The Front Six.  Crowding is one of them.  A benefit of doing Invisalign treatment is that we can turn the "ClinCheck" software simulation around and see the inner aspects of this function in ways that cannot be visualized directly in the mouth.

Have a look at this remarkable image, looking from our precarious perch on the tip of the tongue, which has courteously agreed to remain still for a moment as we mull on what we see:

The Canines, labeled "C", don't touch each other at all.  The incisors, four per arch in between them, either touch the opposing tooth far too much, predisposing them to wear and chipping, or they don't touch at all.

This would be akin to driving your car on two wheels all the time, a feat which one of my high school friends tried, with a fair degree of success, to do.  We tried to stay out of his passenger seat whenever possible.  And just as uneven tire wear resulted on his 1976 Deeply Upsetting Metallic Green Chevy Malibu, so too will our front teeth fracture and wear unevenly if they don't line up properly.

Further, this patient's back teeth are likely going to suffer even more than the front ones, as they clash much more during chewing and speaking than they would if her front teeth were doing their job and protecting them.

Here is the ClinCheck simulation of the final alignment of my patient's teeth:

So much better!  These teeth are going to mutually protect themselves and suffer a tiny fraction of the wear and fractures that they would experience if left to be all forlorn and misaligned.