Bite Point

First Two Days, First Two Trays

When it comes to Invisalign, the method of orthodontically moving teeth with clear Aligner trays, I've always told patients that the discomfort is with the first two trays, and during the first two days of wearing each.

Thank heavens I was right!

You see, now I'm the patient and am wearing Aligners and have found that to be true.  Nothing affirms medical opinions so much as when we get to experience the treatment ourselves, right?

Actually it's a bit complicated in my case.  Like some of our patients, I was genetically missing two teeth- in my case, upper middle teeth, "2nd premolars" to be precise.  I was able to maintain my primary or baby teeth until recently.  They were finally getting weak though, and especially before their deterioration compromised the surrounding permanent teeth, I elected to have them extracted and, after healing, to have implant replacement.  No way would I have bridges because my adjacent teeth are untouched by cavities or fillings and to cut them down goes against my tooth-conserving philosophy.  (See "Watch out, Washout!")

So, only a week ago the remarkable Tom Kohler, DDS, periodontist and long-time friend, performed the extractions and- get this- raised my sinuses about 8 or 9 mm per side- they had migrated or expanded down over these baby teeth.  Such an astonishing experience- I could never use the word "pain" to describe the post-operative course, only "ache".  "Mild ache" captures the feeling, I'd say.

It made sense to utilize the space that is temporarily opened up to assist in straightening my teeth.  Invisalign (www.align.com) is very good at certain tooth movements, less so at others.  For my situation and that of many of our patients, it excels and is efficient and relatively fast.

You see, there are muscle forces on our teeth as we speak and eat.  Over time, in most people, the forces of the cheek muscles inward are greater than those of the tongue pushing outward.  This pushes the arch of teeth inward and causes crowding.  Couple that with the inexorable forward drifting of teeth that is built in by evolution to make up for wearing our teeth throughout life, and crowding gets slowly worse as we age.

(There are exceptions.  Trumpeter Dizzy Gillespie comes to mind.  Oh what I would have given to examine his teeth...  But I was too young!  Then there are probably going to be effects of piercings on the dynamics of the oral musculature; we'll see as the years go by and the number of oral piercings goes up.  Finally there is the special case of politicians- they enjoy hearing themselves talk so much that we sometimes see a gradual steady expansion of the jaws due to all that tongue wagging...  Some authors even feel that the constant force of the wind expands their teeth...  And by the way, there are no measureable differences between the parties.)

Anyway back to the clear plastic Aligners that I'm wearing.  Each is worn for two weeks.  The majority of tooth movement occurs in the first two days; the rest of the time is mainly the cellular response in the bone catching up, and giving this process time to occur is extremely important.  Hence, the first two days are a bit tough on us.  Once a patient passes the first two trays or so, things have "got rolling" and the ligaments around the teeth are getting flexible and adapted to the forces that are moving the teeth.  Hence, the first two trays are a bit tough on us as well.

In a marvelous coincidence, the plastic material of the Aligners or trays is most active for two days; after that it deforms a bit more permanently and the actual capacity for moving the teeth slown down.  This times perfectly with our human bone biology.

Neat, huh?

 

X-Rays

Folks naturally have concerns about the X-rays that we take in dentistry, and what is our radiation exposure as patients.  Here are some points to consider about the safety of dental radiographs, especially our modern digital ones:

First, the X-ray beams are collimated (directed, contained) by lead in the tubes on our machines.

 

Then we always have our patients put on those lead aprons which protect our bodies so well that even sensitive equipment cannot measure any radiation getting through the lead.  They're heavy, but effective!  Actually some patients ask for the lead apron when we treat them, even when no X-rays are required.  It seems that there's a comfort value, something akin to crawling under your covers and escaping the world at large...

With our modern digital radiography the exposure is lessened compared to analog films. Then, with a Panoramic film, there's a phosphor plate next to the film that acts as an amplifier, further reducing the exposure.

We also have to do risk assessment in a totally rational way, without preconceived notions-

Ever fly across country or overseas?  Besides those questionable scanners that the TSA is starting to force on travelers in airports, flying delivers a significant whole-body radiation exposure due to the simple fact that modern jet airliners fly in the stratosphere, well above the protective effects of most of the Earth's atmosphere:

http://www.hps.org/publicinformation/ate/q444.html

or

http://www.airspacemag.com/need-to-know/NEED-radiation.html

This radiation exposure is a whole lot worse than dental radiographs because of many factors, but the main one is that it's whole-body. Ugh!

Plus, we take our films at long intervals, a Panoramic or full set every 5 years, bitewings every year. The diagnostic value is intense- in fact we aren't legally allowed to treat people without them being taken at some reasonable interval, because working without that critical diagnostic information would be so far below the standard of care.

"Risk assessment" is actually always difficult, because we all have so many biases. We have to train ourselves to look at things clearly.  For instance:

I, for one, ride my bike to work (9 miles, more when I meander home) once a week or so in the nicer weather and yet will not go near a roller coaster, sushi or any automobile or house from which I can hear Mariah Carey on the sound system. And what happens? Last year I got hit by a car while cycling. (Actually the police report clearly states that I hit the car, which was embarassing and not favorable from an insurance standpoint. But it WAS raining!)

I therefore engage in a fairly risky behavior and shun others that are statistically far safer, simply because I feel that I have control over the situation. And look what happens!

Dental X-rays help us to diagnose periodontal (gum) disease, endodontic (root canal) infections, and hidden cavities that we cannot easily see even with our vision augmented by magnifiers.  All of these conditions are best treated as early as possible.  The danger to our health is minimized, and in the case of oral infections this is a real threat.  New studies show over and over again that the bacteria themselves and the inflammation that they result in are an important causative factor in heart disease and stroke.  Cavities, when they get deep, lead to infections in the mouth, mostly through the root canal systems of our teeth.  Yes, early treatment is better in every way.  Even from a cost standpoint- early treatment is less expensive treatment.

So, when looking at the issue through the lens of risk assessment, doses of diagnostic X-rays that are kept to the minimum that technology allows and that provide valuable information about our health are acceptable and are worth the exposure.

Let's look at just a few examples of serious diagnoses made possible by X-rays.

Here is a "silent" root canal infection- there's no pain at all, yet the large dark halo around the root of the middle tooth in the film is our first sign of infection:

 

We evaluate these "radiographic findings" and confirm our suspicions by examining our patients directly- I'm always mindful of my professors' admonitions to "treat people, not X-rays", but these films are an essential piece of the diagnostic puzzle.  These kinds of infections have many potential effects on our overall health as well, especially on our cardiovascular system.

Periodontal or gum disease is usually one of those conditions without painful symptoms; other examples are high blood pressure and glaucoma.  Until the later stages when something bad happens, there's no pain.  One of our patients once famously said, "Give me novocaine, I'm philosophically opposed to pain", which I thought was a beautiful way to phrase it, but still the presence of pain is one of our body's most effective warning signs.  When it's absent we can get into major trouble and not even know it.  This X-ray shows angular bone loss of the middle tooth in the film.  That V-shaped contour is not good, not good at all:

 

Periodontal disease is even more of a cardiovascular threat than are root canal infections.

Perhaps the most common diagnosis we make with X-rays is that of cavities between the teeth.  This X-ray actually shows a special case; I use it as an example because it's easy to see the random dark shape inder the filling (lighter) on the third tooth from the left:

 

We might feel that cavity with an instrument if the soft area of tooth was large enough, but we'd never see it- it's under the gums.  Plus, the whole point is that we want to catch these things before they get to any significant size.

Speaking of size, this is an artist's conception view from a hypothetical planet circling around the double star Beta Lyrae- a truly magnificent source of X-rays and many other kinds of radiation.  From a safe distance, it must be astonishingly beautiful...

 

One Week's Worth

One 20 oz Coke or Pepsi has 69 grams of sugar and 250 calories.  As far as actual pure, refined sugar goes, this is all you should have in an entire week.

Another way of looking at this is that 250 calories is 1/8 of an entire day's 2000 calorie limit and 1/10 of a 2500 calorie daily limit. You often see 2000-2500 or so cited as some kind of reasonable average for non-athletes.

Then there's Insulin Shock and Awe- if we hit our pancreas with 69 grams of sugar in the span of 30 minutes and don't immediately enter the Iditarod race, we inexorably edge ourselves closer to Type II diabetes.  Which is a national epidemic.  Some folks who study these things estimate that one out of three Americans will be a Type II diabetic in coming years.

Then of course there are cavities.  The longer I'm in practice, the more I believe that, in America at least, more than half the reason for cavities is from liquid sugar sources. 

My medical advice is to avoid "regular" soda entirely, or to consume the most minimal amounts on occasion. 

(Doesn't the driver of this truck that we frequently see making deliveries understand the risks inherent in parking this product so close to a dentist's office?)

In any event, this is pretty interesting:

http://www.naturalnews.com/003228_Coca-Cola_soft_drinks.html

as is this:

http://www.msnbc.msn.com/id/36675390/ns/health-heart_health/

Also, so many news headlines contain phrases like "Soft Drink Consumption May Contribute to Childhood Obesity" and I have to wonder at that word "May".  "Does" is the truth of it.

We simply don't need an entire week's worth of sugar in an hour- at any age.

Carts

From "The Long Tail", by Chris Anderson:

"The first supermarket was a King Kullen store that opened in Queens, New York, on August 4, 1930, in the depths of the Great Depression."

And:

"Key to the early success of the supermarket was the shopping cart (first introduced in 1937), the automobile, free parking lots, and mechanical refrigerators in the home and store."

Do you see what he just said? There were seven years between the invention of the supermarket and the invention of the shopping cart.

 

To make food shopping an excellent experience you need the store and the cart.  Many other things too, but the gestalt includes a well-stocked, staffed and maintained store and carts.  Otherwise they're punishing their best customers, the ones who buy the most.  Anyone can pick up a brisket and carry it home, in fact my New Yorker mother-in-law once famously called a car service to deliver one before a family gathering when she didn't have time to go to the store, there were too many preparations going on.

(To this day I still have a mental image right out of a Woody Allen movie of a big piece of meat wrapped in paper, happily sitting on the back seat of a 1987 Ford Crown Victoria as it gets whisked along Queens Boulevard in high style...)

I love history and I love to learn from history and my goal for our dental practice is to never have a patient experience where something important is missing.  Something as important as the shopping cart...

(Please tell me directly if such a thing ever happens at [email protected])

www.smilephiladelphian.com