Dentists who focus on profit get bogged down in short-term, piecework thinking.
Dentists who focus on making a difference and solving problems for their patients will, in the long term, do just fine as far as profits are concerned, but will accomplish a great deal more for the community in which they practice.
Also, and this is the subtle part, the practices that focus on making a difference are robust and bullet-proof. Such practices create affinities; the profit-focused ones just deal in transactions.
I'd far rather create an affinity than merely perform a transaction.
New research in cariology--the study of tooth decay, cavities--is impressive.
Here's the essential thing: While it is still certainly true that the germ Strep mutans metabolizes the sugars we eat and drink, and creates acid metabolic byproducts that decay our teeth, what drives the entire process is acidic saliva. What I mean is, some of us have lower pH (more acidic) saliva than others.
Correcting this condition, meaning raising the average oral pH, if it were possible, would do several useful things: *Decrease acidity, and thus decrease caries (cavities),tooth erosion and abfractions. *Down-regulate the various sugar-metabolizing, acid-producing oral bacteria. *Up-regulate the various protein-metabolizing, non-acid-producing oral bacteria. Which are beneficial to have about.
As usual, both diet and genetics have a role in this salivary pH issue. And while it can be changed with diet, I'm not sure we even know precisely what diet would be best, and of course that might conflict with something else medical for the person. Fortunately there are other ways to manage low salivary pH. Most involve the amino acid arginine, which does the beneficial things I mention above. So one could eat arginine-rich foods.
I believe I have acidic saliva to an extent, and I'll explain why. I just don't get caries because: *My frequency of eating & drinking refined carbs is infrequent throughout the day, *My main carb of choice is chocolate, which dissolves away quickly and is not all that cariogenic, and *I'm constantly flossing and brushing and so on. There wouldn't be any caries if there were no plaque germs at all, right? So less plaque is less risk.
The reason I assert that I have acidic saliva (I plan to test it soon) is that I tried the baking soda test. First, you taste some water. I love how water tastes when I'm thirsty, but otherwise, not so much. And at home we drink tap water, filtered with a Brita filter in the fridge. So it's cold and clean, but I often feel like I'm forcing it. Now, I took a cup of hot water and mixed in as much baking soda (sodium bicarbonanate, a very basic/alkaline substance) as would dissolve, and then some. Then I took a swig of the supernatant liquid and rinsed for 30 seconds. After spitting it out, I took a deep breath and noted a series of odd odors; this was the protein-metabolizing bacteria coming into play. Then here's the test: I drank some water. It tasted sweet, pure, amazing, like it had come out of an Alpine spring! That's how people with high oral pH perceive water all the time. Me, I don't dislike water, but water never tasted like this before!
So now we see that I have to consider raising my own oral pH.
Also, a note regarding fluoride. Certainly fluoride protects against caries by strengthening the mineral structure of our enamel, as we learned. However, fluoride minimizes the effects of acid demineralization. Altering the oral pH helps treat the cause, a much more useful thing to do.
There are two new preventive oral care products I recommend highly.
The first are Basic Bites. What they do is use arginine and other ingredients to raise our oral pH for hours at a time. The baking soda only does it for half an hour or so. The idea is to have a Basic Bite once or twice a day.
I did a little experiment on myself. I tested the pH of my saliva and found it to be 6. This is dangerously on the acidic side!
I then chewed a delicious Basic Bite. I mean, these things are good. Even better, the Basic Bite raised my pH to 8: nice and alkaline.
Very low risk for cavities. Not that I ever had many cavities, but that's because I clean my teeth well and enjoy sweet food and drink in moderation. Having acidic saliva means I'm naturally at risk for cavities, and that I had to behave that way to avoid them.
The second is Synedent. This is a remarkable and unique rinse. What apparently happened is that about a decade ago, a researcher noticed that, unique so far among all land and aquatic animals studied, shrimp absolutely do not form a biofilm on their exoskeletons. Bacteria can "land" there, but they cannot stick and form colonies and weave the polysaccharide nets that we now term a biofilm. Why this would be from an evolutionary standpoint is hard to say. However the U.S. military got very interested in this and developed a battlefield wound spray, so that wounds would not get infected during and after treatment. That's a lot better than waiting for infection to start and then using antibiotics!
They released the research to civilian companies recently and Synedent is an oral rinse that resulted. The idea is that it disrupts the formation of biofilm around the teeth, on the tongue and cheeks and so on.
Now, this is anecdotal and a sample size of one, but I started using Synedent a few weeks ago after a prophy and lo and behold--I do not have any noticeable plaque or calculus forming. None at all. And this is especially striking because I tend to form a lot of supragingival light calculus in the lower anterior. I attribute this to not drinking enough water at work and then eating chocolate at lunch. Not for lunch, mind you! But at lunch, yes. Now? No calculus at all.
Thus, for anyone who has had an issue with cavities I would recommend both Basic Bites and Synedent. You order both online from their websites. And floss, and modulate your carbohydrate frequency, and use some fluoride product; toothpaste is fine.
My letter to the insurance commissioner of Pennsylvania, still in draft form I may edit further:
Teresa D. Miller Insurance Commissioner of Pennsylvania Pennsylvania Insurance Department 1326 Strawberry Square Harrisburg, PA 17120
Dear Ms. Miller:
Thank you in advance for your attention to a vital matter that affects the oral health of the citizens of Pennsylvania.
In the past two years, the United Concordia insurance company has embarked upon a program of consistent, spurious, groundless denials of both claims, and pre-determinations of benefits for, the treatment of periodontal (gum) disease.
In particular, they are denying payments on the grounds that there is no bone loss on dental radiographs. Yet in dentistry we have decades of scientific research that shows that: (1) Periodontal disease is primarily diagnosed by clinical measurements. Dental radiographs provide further, supplemental information to the treating doctor, but are not the primary means of diagnosis. (2) Periodontal disease is best treated early, before radiographic bone loss ever occurs. Early treatment is far less costly treatment as well.
In a recent email, attached, James B. Bramson, D.D.S., Chief Dental Officer of United Concordia Companies, Inc., specifically asserts, " Pocket depths are an important indicator of disease but do not necessarily indicate the presence of bone loss. Therefore, pocket depths alone are not an indicator of the need for PSRP." The abbreviation "PSRP" stands for the primary form of non-surgical treatment for periodontal disease, the treatment for which United Concordia is so consistently denying payment. They deny this treatment on the basis of not seeing bone loss on radiographs that we dentists present to them.
This assertion of Bramson's is utterly and entirely false in the light of all our dental science; in fact, it is an outright lie.
He is also placing the cart before the horse, as bone loss is a result of periodontal disease, and it increases with time and disease activity. Our goal in dentistry is to diagnose and treat periodontal disease before significant bone loss occurs. We do not wait until bone loss occurs, and allow the disease to become severe, and then embark on a course of treatment.
If I rephrase Bramson's statement to make it apply to another disease, you will see its absurdity. "Heart attacks and strokes are an important indicator of disease but do not necessarily indicate the presence of atherosclerotic arterial disease. Therefore, heart attacks and strokes alone are not an indicator of the need for angioplasty and stents."
Does that make any sense to you at all?
On behalf of the dental profession in Pennsylvania, I ask you to investigate and bring corrective action against United Concordia for this flagrant violation of the fiduciary responsibility and trust that they owe to their subscribers--Pennsylvania companies and the employees they enroll--who have paid so very much in premiums for scientifically justified services that are being stolen away from them.
Gatorade is a for-profit company, and since it is in their best interest to do so, Gatorade strives to bury any and all information that would lead people to realize that it has a high potential to cause tooth decay. But it's sweetened with a sucrose-dextrose mix, and at times in its past, has been sweetened with that ubiquitous dreaded nemesis of human health in North America, high fructose corn syrup.
Either way, that's sugar, Sugah.
Just be careful with it. Frequency matters. It's ok to drink Gatorade once in awhile during or after an intense sport or exercise session--but if you sip at it all throughout the game, time and time again, you are going to get cavities. Just like with soft drinks. These liquids are tooth-killers.
And speaking of profits ...
Let us all take a moment after Super Bowl XLIX to thank the IRS, in its great wisdom, for maintaining the NFL as a 501(c) 6 non-profit tax-exempt entity since 1944. (Not the teams, but the NFL itself).
I'm sure that's just as appropriate today as it was in those dark wartime days of 1944.
I adapted this from an internal document crafted by our own Dr. Derek Conover, so this is a guest post of sorts. He reminds us of the efficacy of fluoride in preventing cavities--vitally important in our sugar-laden culture.
Flouride is one of the most important public health interventions of the 20th century. Simply put, fluoride strengthens teeth and makes them more resistant to decay.
Fluoride is the single most important tool we have to combat the most common dental disease: dental caries (tooth decay).
Factors that increase caries risk include but are not limited to:
-Frequent ingestion of refined sugars. This means in solid or liquid form. Sugar-containing beverages are extraordinarily common in our society. The Big Four are Coca Cola, Pepsi, Mountain Dew and Gatorade. More on sugar frequency issues here: http://www.smilephiladelphian.com/clock/Caries.php
-Poor oral hygiene.
-Irregular dental care.
-Active cavities in the previous 12 months.
-Extensive pre-existing dental restorations.
-Defective dental restorations.
-Active orthodontic treatment.
-Developmental or acquired enamel defects.
-Chemo or head & neck radiation therapy.
-Drug or alcohol abuse.
-Xerostomia (Dry Mouth). Dry mouth can result from medications, the aging process or other factors.
We use a fluoride varnish that is painted onto the teeth after a cleaning. The varnish sets in the presence of saliva and delivers fluoride directly onto the tooth for several hours. The beneficial enamel-strengthening effects last for months.
We have recently lowered our fee for this service to $35 in order to make fluoride treatments affordable for the most people possible. We'll be offering this important and beneficial service to our patients at their routine hygiene visits.
But seriously, folks ... In this era of ultrasonic instrumentation for periodontal treatment, no one should have their teeth scaled this much in the pursuit of periodontal health. We can maintain tooth dimension and contour and achieve periodontal lhealth at the same time.
We are now an all Microscope office, with Dr. Shu-Zhen Kuang, Dr. Derek Conover and myself, Dr. Rick Wilson, doing our dentistry through these magnificent instruments,--and two more on order for our hygienists, Maryanne and Melissa.
The light and magnification is so spectacular, that treating patients in a Microscope is an entirely different level of dentistry than anything that came before. It's Dentistry V2.0, is what it is.
Just to give you some tiny inkling of the idea of how much more precisely we can treat you, have a look at one of my student friend's work at six successive increases in magnification.
That is my friend Jaimin's lab work on an extracted tooth--before she started attending dental school. Such potential!
Time to return to technical subjects! Been philosophizing a lot.
Pulps of teeth calcify. Meaning the cells in the living tissue inside our teeth lay down more hard tooth structure, and so they get smaller. This happens throughout life as part of the aging process. My dental school X-rays, for example, which I still have in the office somewhere, show larger pulp spaces than my X-rays do now. Simply because I'm older.
And pulps really get smaller when teeth are challenged by decay or fracture.
Still, they calcify from the crown down. Meaning that if we need to perform root canal treatment, finding the tops of the canals may be difficult, but once we find 'em, they're going to get larger the further we go in to clean them of infection.
Here's a view from above (in the Microscope) during root canal treatment:
This is what I call "the smiling monkey" view, with two canals filled and one cleaned but not yet filled. Imagine if these were just tiny, tiny crevices with just a slight darker color to indicate where they are. That's often the challenge we face initially, as we start root canal treatment.
But as I said, if we can find 'em we can clean 'em. Usually. Every once in awhile, we pass into a canal and get blocked part way in. Like this:
The light lines are Resilon, the material that fills and seals the part of the root canal system that I cleaned. You can see that I didn't get to the end of the root. I couldn't. I felt like all my instruments were hitting a solid wall of granite at a certain point in the root canal system. Nothing I did would pass through it. Now... Note the dark halo in the X-ray that surrounds the tip of the root. This indicates less bone density, which indicates where the worst of the infection is.
Not getting to it is a bad thing.
And yet. I've been around the block a few times by now. I know the value of patience.
After a month and a half or so, we brought our patient back for an additional treatment. I've found that if we "go back in" after some time has passed, the blockage is usually astonishingly easy to bypass.
And so it was:
This endodontic treatment ended up being the most predictable and seamless procedure I did that entire week.
Why are these "blocked" root canals easier to treat on a second try? I've never heard a detailed, scientifically sound explanation. Perhaps we dentists have blocked such canals ourselves, with dentin chips that we create in our instrumentation. This is a known issue; instrumentation debris forms a sort of microscopic mud or plaster that can fill a canal and impede our instruments. But in this case, I remember hitting the wall with the very first pass of my tiniest instrument, so I have my doubts about debris being the reason. Still, perhaps it was.
In any case, a second attempt at treatment (at no additional fee, we're still trying to get an acceptable result for our patient!) is almost always successful at getting past blockages in root canals. Never give up endodontic treatment without a good fight!