Bite Point

Using the Number e to predict COVID19 Progression

The number e is one of the most powerful, profound, mysterious, mystical things I've ever encountered. I mean in all of life. Let's use its power to explore the growth rate of the COVID-19 epidemic in the U.S.

From my very favorite explanation of e:
https://betterexplained.com/articles/an-intuitive-guide-to-exponential-functions-e/

"e is the base rate of growth shared by all continually growing processes. e lets you take a simple growth rate (where all change happens at the end of the year) and find the impact of compound, continuous growth, where every nanosecond (or faster) you are growing just a little bit."

"e shows up whenever systems grow exponentially and continuously: population, radioactive decay, interest calculations, and more. Even jagged systems that don’t grow smoothly can be approximated by e."

Let's get right to COVID-19 now. For those with interest in math, explore that chap's  delightful and intuitive exploration of e and its magical properties.

Starting on March 18th, I've taken the total number of cases of COVID-19 infection in the U.S. and divided by the previous day's total. Here are the results:
1.46    March 18th
1.50
1.40
1.25    
1.39
1.30
1.25    
1.24
1.23
1.21
1.18
1.15
1.13, on March 30th
1.14, on March 31st

Now let's convert those numbers to percentage growth:
46 % (on March 18)
50 %
40 %
25 %
39 %
30 %
25 %
24%
23 %
21 %
18 %
15 %
13 % (on March 30)
14 % (on March 31)

Now, e merges rate and time. That's one of its amazing powers.
The exponent to which we raise e signifies the rate of change and then the time passed.

We humans tend to think in terms of how we measure time. Hours, days, weeks, months, years. Let's see what the spread of COVID-19 would look like if we forecast several of those growth rates over one month--30 days of epidemic progression at the daily growth percentage that occurred on any of those days.

The formula is this: e^{x
x will be, in each case, the percent growth for the day times 30 days. We will start with one patient.
Thus, in these projections, we will see how many patients would be infected with COVID-19 one month after just one patient started off infected, at the growth rate for that day. Rounded to nearest whole number.}

^{13% growth}    e^{.13 x 30    49-fold number of cases at 30 days.}

^{18% growth}     e^{.18 x 30    221-fold number of cases at 30 days.}

^{25% growth}   e^{.25 x 30    1,808-fold number of cases at 30 days.}

^{40% growth}   e^{.40 x 30    162,755-fold number of cases at 30 days.}

^{If we were fortunate enough to slow this pandemic to 2% growth per day this month:}

^{2% growth}   e^{.02 x 30    1.8-fold number of cases at 30 days. How different than the others!}

^{We see how wildly different the month-end projections are given the different growth rates. Early in an epidemic, the growth rate is generally faster than later because at the beginning, the virus spreads far more rapidly than it could later. Put simply, that's because the virus is in a "target-rich environment." Nearly everyone is un-infected at the start and no one yet knows the dangers, or has changed their behaviors from normal.}

^{Now let's use e to come up with a useful projection. We start with today's known U.S. COVID-19 infections. (Many more of us likely have asymptomatic cases).}

^{On March 31, as I write this, there are 180,000+ known COVID-19 cases in the U.S.}

^{Starting with that, at the recent daily growth rate of 2%, by April 30 we end up with:
327,981 cases.}

^{At a 4% daily growth rate, by April 30 we end up with:
597,621 cases.}

^{At a 13% daily growth rate we recently experienced, by April 30 we end up with:
8,820,000 cases.}

^{At a 25% daily growth rate we recently experienced, by April 30 we end up with:
325,440,000 cases. Nearly all Americans.}

^{In real life, exponential virus infection curves steepen and they flatten. They usually flatten as the epidemic progresses because the number of un-infected "targets" decreases. Host behavior may change as well.}

^{Still. We now see, through the splendid magic and power of e, the importance of hand washing and social distancing. 327,981 cases by April 30 versus 325,440,000 cases by April 30. That's a 1,000-fold difference.}

Using the Natural Logarithm to Forecast COVID19 Progression

In our last post, we explored how to predict the COVID-19 epidemic progression with the irrational, transcendental and may I say supernatural number e.

e is the base rate of growth shared by all continuously growing processes. e merges growth rate and time. If we know the growth rate of a process and we wish to know how it will grow in a certain specific period of time, e computes the answer.

What if we want to know the time? What if we have a certain amount in growth in mind, and we want to know how long it will take to reach that growth?

Ah, the answer is as beautiful as e itself. e has an opposite, a mirror. This is the natural logarithm, ln.

In other words,
e^x lets us plug in time and get growth.
ln(x) lets us plug in growth and get the time it would take.

Let us move right into COVID-19 epidemic forecasting examples. As we saw in my last post, over the course of March 2020, the epidemic grew at different rates in the U.S., depending on the day. I will present these rates to you and ask the two questions:

(1) How long would it take, at the given rate, for the number of infected patients to double?
(2) How long would it take, at the given rate, for the number of infected patients to increase ten times?

We will answer these two questions for each rate with the natural log.

Here are the epidemic growth rates we've noted in March, minus the early outliers, and the time calculations.
On March 31 there were 180,000 U.S. COVID-19 cases. For each rate, we will ask, how long will it take to reach 360,000 cases, and how long will it take to reach 1,800,000 cases, assuming that growth rate continued?

2% Growth Rate per Day

2x, to 360,000 cases:
ln(2) = 0.69 ...
0.69/.02 = 34 days
10x, to 1,800,000 cases:
ln(10) = 2.30 ...
2.30/.02 = 115 days

4% Growth Rate per Day

2x, to 360,000 cases:
ln(2) = 0.69 ...
0.69/.04 = 17 days
10x, to 1,800,000 cases:
ln(10) = 2.30 ...
2.30/.04 = 57 days

8% Growth Rate per Day

2x, to 360,000 cases:
ln(2) = 0.69 ...
0.69/.08 = 9 days
10x, to 1,800,000 cases:
ln(10) = 2.30 ...
2.30/.08 = 29 days

20% Growth Rate per Day

2x, to 360,000 cases:
ln(2) = 0.69 ...
0.69/.20 = 3.5 days
10x, to 1,800,000 cases:
ln(10) = 2.30 ...
2.30/.20 = 11.5 days

22% Growth Rate per Day

2x, to 360,000 cases:
ln(2) = 0.69 ...
0.69/.22 = 3 days
10x, to 1,800,000 cases:
ln(10) = 2.30 ...
2.30/.22 = 10 days

And so. We end up with case-doubling times that range from 17 days down all the way to just 3 days, depending upon human behavior.
And we end up with ten-fold case increase times that range from 57 days down all the way to just 10 days, depending upon human behavior.

I find it chilling that the March 30--March 31 interval returned us to a 22% growth rate of new COVID-19 infections. We need to (if we even can) return that to 2% and less, as these ln forecasts show.

Wash Hands, Social Distancing. They matter even more than you think.

 

Dental "Insurance" is Just a Coupon (the short version)

Here is the short version of my last post.

In 1967, when dental insurance first ramped up in America, employers commonly purchased plans with $1,000 yearly maximums.

Today, in our experience in Philadelphia, some 95% of PPO plans from United Concordia, Delta Dental, Aetna, Guardian, Cigna and MetLife are purchased with $1,000 for their yearly maximums.

$1,000 in 1967 is the purchasing equivalent to $7,700 in 2019.

Implications:

(1) For 2020, you would need an $8,000 maximum to enjoy the same dental financial benefits that your 1967-era predecessor did.

(2) Your 2020 $1,000-a-year dental insurance plan has decreased in relative value to less than $130-a-year, if you compare purchasing power to what it was for your 1967-era predecessor.

(3) Your payroll deductions are generally much larger than your 1967 predecessor faced. In fact, in those days, there often were no payroll deductions for dental insurance; it was an actual benefit. Something extra.
While there are regional differences, today, Americans who have dental insurance pay an average of around $360 a year for the privilege. Most payroll deductions range between $15 and $50 a month.

In one sense, thus, a modern employee who has dental insurance pays $360 per year to gain $130 per year in inflation-adjusted value, as compared to the tangible value their 1967-era predecessor received. For free. With myriad restrictions and plan limitations and "sorry, not-covered's."

Does this, perhaps, make you angry?

Modern era dental insurance is not insurance at all. It's a yearly coupon, albeit a thousand-dollar one.

Dental "Insurance" is Actually a Yearly Coupon

It is high time to have a detailed discussion about dental insurance. What it is, and what it is not.

In part this is to help patients who have dental insurance utilize it properly, to their best advantage. And in part, this discussion is meant to help the approximately 50% of Americans who do not have dental insurance, to unlearn the destructive (and fatalistic) belief that, "I don't have dental insurance, so I can't go to the dentist."

The key reason that all-too-common thought is so damaging is that no dental problem ever gets better on its own. Cavities, tooth infections, gum disease, tooth crowding and misalignment and even oral cancer are all disease processes that only and always worsen with time, and never heal without professional intervention.

The fact is, and I shall prove it, is that folks who do not have dental insurance can seek dental care affordably through other means, which we will review in a bit.

The first thing to understand about dental insurance is that it is not insurance at all, but rather, it's a yearly coupon. A thousand-dollar coupon, to be sure, but still a coupon.

Now why do I say such an outrageous thing? Two words:

Inflation Calculator.

In 1967, when dental insurance first started in America, employers commonly purchased plans with $1,000 yearly maximums. The striking thing is, this number is still remarkably common today. In our experience in Philadelphia, some 95% of PPO plans from United Concordia, Delta Dental, Aetna, Guardian, Cigna and MetLife are set at $1,000 for their yearly maximums.

$1,000 in 1967 is the purchasing equivalent to $7,700 in 2019.

This is such an astonishing thing to realize that we must look at it from a number of different points of view, in order to even fully understand it:

(1) Your 2019 $1,000-a-year dental insurance plan has decreased in value to $130-a-year, if you compare purchasing power to what it was for a 1967-era patient.

(2) To have the same useful insurance product that a 1967-era dental patient enjoyed, you'd have to have nearly eight times that yearly maximum now. Or in raw dollars, add $6,700 to your present coverage maximum of $1,000.

(3) Dental crowns are a major procedure in dentistry, and thus a useful example to demonstrate principles. Crowns are often covered at 50% (when the various restrictions are navigated and a dental insurance company approves one). Meaning, the insurance company pays 50%, and the patient pays 50%. Plus a deductible. Oh yes, there's always a deductible too!

So. In 2019, $1,000 in yearly coverage (your big yearly coupon) usually allows a patient to have one crown done, with 50% coverage, and then preventive recall visits and X-rays and so on. At that point, coverage is all used up. If you need root canal treatment first (which is often covered at 80%), and then a crown, you will "max." This is the slang for reaching and then exceeding your yearly maximum and running out of benefits.

But the question presents itself: how many crowns could you do, on $1,000 in a year, if it was 1967 and you had terrible problems with cavities and broken, unsightly teeth? That was the heyday of Coca Cola and Pepsi, after all. Sugar water was destroying American teeth (and pancreases) even more than it does today.

Well, the answer may surprise you. Between reverse-inflation of dental costs and that 50% crown-coverage deal, on $1,000 you could have fifteen crowns done in 1967, in most private practice fee structures back in those halcyon days.

That's more than an entire arch of human teeth, if we leave out wisdom teeth. In 1967, your company's dental insurance was really insurance, because you could do a full mouth reconstruction, one arch in late fall and the other the next spring, and have all the cost offset by 50%.

Now in 2019, it's one crown and done. Or, as the armchair philosopher once opined, "What used to was, now it ain't."

We also have the issue of payroll deductions to deal with. Some employers provide dental insurance as part of their "package," and there is no overt cost to the employee. Many more employers, however, post payroll deductions for dental insurance premiums. Thus, the hapless modern employee gets 1/8th the value of their 1967 counterpart, and pays a lot more for the privilege as well.

Apparently on average, Americans pay about $360 a year, or between $15 and $50 a month, for dental insurance. There are large regional variations. We need to ask, is $360 per year worth it, when you're purchasing the equivalent of $130 when compared to your 1967 predecessor?

Please draw your own conclusions from all this. It's a lot to take in and process. As a practicing dentist, please allow me to share with you my two key conclusions:

For people with dental insurance, the product is, truly, a yearly coupon, if a rather large one, with various restrictions, and is not insurance at all.

For people who do not have dental insurance, the not-having is not a true barrier to care. Especially early care, before things get disastrous and really expensive to treat fully.

Many, many dentists around the United States have crafted in-house Programs which are not dental insurance, but rather, a means of making dental care more affordable and engaging.

It is generally best for dentists not to talk fees in public, but we need a basis for comparison here, and my own Program numbers are in public on our website, so here goes.

Our yearly enrollment for an individual is currently $332. This gives you two recall visits and professional examinations per year, as well as all X-rays, taken for any purpose. These professional services would normally total $459; or $519 every five years for most patients, when a full set of X-rays is due. Our Program also reduces the fee for all other professional services by 20%, with the exception of dental implants which are reduced for Program members by 10%. (Dental implant case lab bills often exceed the total GDP of some of the world's smaller nations.)

With such Programs, there are no monthly premiums or payroll deductions. For $332 you gain a cost savings over regular professional fees of $127 or $187, depending on what X-rays are taken.

And that's an example based purely on preventive services. Let's see what happens when a person has an ideal treatment plan involving six crowns, and decides to follow through on it. Let's further assume that the doctor does not participate in the dental insurance (but still bills to it), and that their fee is $1,300 for each crown. (I'm using this as a regional average sort of number, not my own.)

Dental Insurance Cost Analysis:
$1,300 x 6 = $7,800 total fee
Dental insurance pays the $1,000 maximum and that's it.
Patient pays that year, if they adhere to preventive care as well:
$6,800 plus $459 (just using our preventive fees for convenience) plus $360 in payroll deductions plus the inevitable $50 deductible = $7,669.

Our In-House Program Cost Analysis:
$1,300 x 6 = $7,800 total fee
$7,800 - 20% = $6,240 adjusted fee.

You may say "Count the $332 as well!" I disagree philosophically, but if we must, ok then, the number becomes $6,572.

And either way, my Program wins.

This hypothetical patient saves $1,097. To evaluate it another way, with our Program this patient pays 85% of what they would with dental insurance.

With increasing scale of treatment, it is worth noting, our Program performs better and better compared to dental insurance.

And that's the final point to consider. I always thought that insurance, of any kind, was meant to protect us from the financial effects of catastrophes. A complex and expensive surgery. An auto accident in which a vehicle is totaled. A hurricane that destroys entire houses, neighborhoods. The big stuff.

Isn't it odd how dental "insurance" works in the exact opposite way? The more severe a patient's dental disease, the less relative help it offers.

*

Next time, we'll have a look at the endless restrictions placed upon what dental insurance can actually be used for, as well as have a go at how corporate dentistry in the U.S. distorts the dental insurance system to everyone's detriment.

 

Californium

Warning: anything and everything made up of any combination of the any of the following elements is known to the State of California to cause cancer:

H - Hydrogen
He - Helium
Li - Lithium
Be - Beryllium
B - Boron
C - Carbon
N - Nitrogen
O - Oxygen
F - Fluorine
Ne - Neon
Na - Sodium
Mg - Magnesium
Al - Aluminum, Aluminium
Si - Silicon
P - Phosphorus
S - Sulfur
Cl - Chlorine
Ar - Argon
K - Potassium
Ca - Calcium
Sc - Scandium
Ti - Titanium
V - Vanadium
Cr - Chromium
Mn - Manganese
Fe - Iron
Co - Cobalt
Ni - Nickel
Cu - Copper
Zn - Zinc
Ga - Gallium
Ge - Germanium
As - Arsenic
Se - Selenium
Br - Bromine
Kr - Krypton
Rb - Rubidium
Sr - Strontium
Y - Yttrium
Zr - Zirconium
Nb - Niobium
Mo - Molybdenum
Tc - Technetium
Ru - Ruthenium
Rh - Rhodium
Pd - Palladium
Ag - Silver
Cd - Cadmium
In - Indium
Sn - Tin
Sb - Antimony
Te - Tellurium
I - Iodine
Xe - Xenon
Cs - Cesium
Ba - Barium
La - Lanthanum
Ce - Cerium
Pr - Praseodymium
Nd - Neodymium
Pm - Promethium
Sm - Samarium
Eu - Europium
Gd - Gadolinium
Tb - Terbium
Dy - Dysprosium
Ho - Holmium
Er - Erbium
Tm - Thulium
Yb - Ytterbium
Lu - Lutetium
Hf - Hafnium
Ta - Tantalum
W - Tungsten
Re - Rhenium
Os - Osmium
Ir - Iridium
Pt - Platinum
Au - Gold
Hg - Mercury
Tl - Thallium
Pb - Lead
Bi - Bismuth
Po - Polonium
At - Astatine
Rn - Radon
Fr - Francium
Ra - Radium
Ac - Actinium
Th - Thorium
Pa - Protactinium
U - Uranium
Np - Neptunium
Pu - Plutonium
Am - Americium
Cm - Curium
Bk - Berkelium
Cf - Californium
Es - Einsteinium
Fm - Fermium
Md - Mendelevium
No - Nobelium
Lr - Lawrencium
Rf - Rutherfordium
Db - Dubnium
Sg - Seaborgium
Bh - Bohrium
Hs - Hassium
Mt - Meitnerium
Ds - Darmstadtium
Rg - Roentgenium
Cn - Copernicium
Nh - Nihonium
Fl - Flerovium
Mc - Moscovium
Lv - Livermorium
Ts - Tennessine
Og - Oganesson

What’s that?
Oh, yes.
Even Californium.

138 Years of Caries Knowledge

"The researches of the late Professor W.D.Miller, published about 1880, finally gave to the world the true explanation of the process of tooth decay."

"Briefly stated, Miller, as the result of a long and exhaustive experimental study of the subject, found that the destruction of the hard structures of the tooth by dental caries was accomplished by the agency of a certain class of microorganisms which had the characteristic function of fermenting certain of the sugars and converting these sugars into lactic acid, which acid in its turn attacked the solid tooth structure wherever it came into contact with it, dissolving out its mineral matter which caused the structure to disintegrate, forming a cavity which gradually enlarged until it eventually included the entire crown; indeed, if unchecked, the whole tooth may in this manner become disintegrated and lost."

--Edward Cameron Kirk, DDS, UPenn Dean from 1895-1917, writing (with rather less periods than we would use today) in Alfred Fones' remarkable text Mouth Hygiene. This is my original 1916 edition.

Dr. Kirk goes on to say,

"Dental caries is a characteristic disease with a well-marked and definite group of symptoms and within certain limits it has a known causation, which is the localized destruction of the hard tissues of the tooth by the solvent action of lactic acid generated at the point of decay by the agency of bacteria acting upon carbohydrate foodstuff."

*

And so. Although Dr. Kirk and others had a little further to go in terms of understanding the dynamics of the frequency of refined sugars consumption, we had the answer to the total prevention of dental caries ***138*** years ago, with Dr. Miller's astonishing insightful research.

Why did, and does, caries remain such a widespread public health problem?

For one, the sugar lobby in the U.S. is extraordinarily powerful. Labeling foods and drinks for their cariogenicity potential will likely NEVER happen in the U.S. Which is a shame, because it really needn't decrease sales of high cariogenic foodstuffs. I positively love chocolate, more than I can put into words. I only eat it around meals, though, and usually only once a day. I dig raisins, sugary little beasties that stick in tooth grooves for hours, on cereal in the morning. But that's the only time I eat them, and I brush afterwards. Frequency matters with sugars, even natural ones. We can still safely enjoy cariogenic foods and drinks--just not via grazing.

The other reason that dental caries is still so widespread is that the industrialists who run things discovered long ago that foods high in sugar, fat and salt sell very well in the U.S. Across our nation, healthy foods are expensive and unhealthy foods are cheap--as well as designed to be maximally addictive via the enticements (powerful ones, that speak directly to our species' lean evolutionary past) of sugar, fat and salt. This makes me angry. You can't tell me that it costs more to ship a head of lettuce from California to Philadelphia than it does to make a pack of Twinkies, with all the processing and ink and packaging that a pack of Twinkies entails. And yet routinely, the vegetables cost more than the high-carb snack foods.

It's maddening.

Most maddening of all, though, is the inherent and rather unfair paradox that has been built into our foods, beverages and oral health care patterns in recent decades.

What I have noticed--and perhaps you have too--is that well-educated patients with a sound economic life often have few caries. (Most of the new patients we see between ages 21-40 have good educations, great jobs and no caries. Minimal existing restorations as well.) In contrast, less educated patients with less economic means, in my experience and perhaps in yours, tend to have more caries. Industrialists are more than happy to market and sell unhealthy foods to the most susceptible segments of our society. Hence the inherent unfairness--

Today, those who can least afford to treat dental caries generally have the most dental caries.

This is a markedly different situation than the one that existed from at least the 1920s to the 1980s, in which captains of industry, wealthy businesspeople and Hollywood celebrities often had mutilated dentitions. Nowadays, I doubt there's even one CEO of a Fortune 500 company who has posterior bite collapse due to the effects of severe dental caries. Or from periodontal disease, for that matter.

In my view, this epidemiological challenge--not the latest, greatest, costly means of restoring multiple implants, nor the finer nuances of "digital workflow"-- is the key challenge in American dentistry today.

And so a pair of vital questions arise.

How do we practice prevention in the face of what the industrialists of the food and beverage businesses are doing?

And how do we reach those many potential patients, those often at-risk patients who believe--mistakenly--that they cannot afford us, and therefore do not seek care?

Vincenzo Luccardi Statue of Saint Appolonia

Recently, my partner Dr. Kuang and I attended a highly innovative lecture on periodontal treatment at Penn School of Dental Medicine. While there, we encountered this superb statue of Saint Appolonia. The sculptor was Vincenzo Luccardi. His dates were 1811-1876.

Saint Appolonia was an early Christian from Alexandria, Egypt. She was martyred for her faith in A.D. 249. Her assailants attempted to force her to recant her faith and utter a blasphemy. When she refused, by repeated blows they broke all her teeth. The mob then built a fire and threatened to burn her to death unless she recanted. According to the historian Dionysius, Saint Appolonia reacted by leaping into the fire herself, rather than being tortured further and allowing her will to be broken.

To this day, in the Roman Catholic and Eastern Orthdox churches, Saint Appolonia is popularly regarded as the patroness of dentistry and those suffering from toothache or other dental problems.

Interestingly, Saint Appolonia has most often been depicted as a woman in the prime of her youth, yet historrical sources indicate that she was in her sixties or seventies at the time of her passing.

When I saw this splendid work last night, I stood there in awe at its incredible technical execution. Senore Luccardi is, perhaps, under-rated.

This work by Luccardi is meaningful to me because of the way it symbolizes my profession’s highest purpose, which is to relieve and even to prevent human suffering. Further, Saint Appolonia reminds me–on an almost personal level, as if she is speaking directly to me across the span of ages–of mankind’s frequent cruelty towards itself, and of how supremely important it is to strive all throughout our too-brief lives to prevent such cruelty, wherever and whenever we can.

Saint Appolonia may have died one thousand seven hundred and sixty-nine years ago, but she continues to have great meaning and relevance to this twenty-first century dentist.

Industrialization

Sometimes I get to thinking that the entire history of industrialization is (1) saved us by and large from dying young of trauma and infection and then (2) made us ill with everything else.

And then of course (3) sold us endless expensive drugs to fix (2).

Please Be Aware: Werther's Original Contain Sugar!

We have now seen our third patient in the past few months who has wrecked their dentition with one overwhelming specific cause--overuse of Werther's Original Hard Candies. Thus, I wish to post a warning about this product.

And that warning is: Werther's Original Hard Candies contain sugar! Lots of it. This would seem self-evident, but each patient was totally surprised by the fact, and their surprise may spring from Werther's marketing. "The Classic Candy made with Real Butter and Fresh Cream" is a fine tagline, but we never see the word "sugar," the main ingredient, in there at all.

While it's easy to find Werther's ingredients online, there's a sort of burying of this information in all their marketing messages. And of course nowhere is there any warning like, "This product contains straight sugar; overuse of sugar-containing food products leads to tooth decay."

But that's the truth. Of any food, liquid or solid, that contains refined carbohydrates.

Here are the ingredients in a Werther's Original Hard Candy:

Ingredients: Sugar, Glucose Syrup (from Wheat or Corn), Cream, Condensed Whey, Butter, Cane Sugar Syrup, Salt, Soy Lecithin Emulsifier, Artificial Flavor.

Translation: Sugar, sugar, milky sugar, more milky sugar, butter, sugar, salt, chemicals, chemicals and sugar.

I mean, damn. It's like the beloved old Monty Python Spam skit, only with sugar.

https://www.youtube.com/watch?v=anwy2MPT5RE

Please, please, folks, if you enjoy Werther's, or Life Savers, or hard candies of any kind, watch the frequency! Have them once a day. Each and every time you put a miniature hockey puck made of sugar into your mouth, you're bathing your teeth in sugars and acids for the entire time the thing takes to dissolve, plus about half an hour afterwards. Thus, the nightmare scenario for your teeth is to pop another one in every hour or so. Or right before you fall asleep. Your teeth never get a chance to recover from the acids. They WILL rot out of your head. It's only a matter of time.

This may sound like an odd warning to many, but each of these patients said the exact same thing once we identified that hard candies were the cause of the destruction in their mouths:

"Oh! I carry a bag of them around with me everywhere."

Words to send a shiver down every dentist's spine.

In the photos, the red arrows point to the serious cavities (darker areas on the images) that were caused, so far as I can tell, by interviewing each patient in detail about their diet, mainly by the overuse of one product--in these cases, Werther's Original Hard Candies.

Please, folks. Use any and all hard sugar candies sparingly and infrequently. Certainly never more than twice a day outside of mealtimes. And when it comes to cough drops--only use them while you actually suffer from a cough, not after it has passed.

Commodity Versus Bespoke in Dentistry Revisited

In an online public place, a prospective patient who never actually met us in person railed at us for being expensive. This particular raillery was in response to a phone conversation only, no other interaction. The person's main point was in regards to dental implant crowns, and the crux of it was stated:

"Other Dentists START at $499!"

I've re-posted my response here, as this assertion is a superb springboard for a discussion of what I've come to think of as the spectrum that runs from "commodity" to "bespoke."

Here 'tis:

*****

With every consumer decision we make, we ask the question: "Do I want a commodity or do I want something bespoke?"

If a person wants a $499 crown, made at a foreign lab with unspecified materials, from an impression made with alginate not a precision material, then that is a decision to purchase a commodity. We all do this in many areas of our commercial lives (who would purchase bespoke paper towels??). There are risks, however, when making health care decisions that are skewed towards the commodity side of things. With dental crowns? Recurrent cavities, porcelain fractures and increased risk of root canal complications are all possible sequelae of poor fit and fabrication.

Our fees are what they are because we made a decision long ago to diagnose with great care, provide the finest treatment, and, along the way--listen! In a world of Big Data and corporate seeking after profit at any cost, the act of actually listening to a patient has become almost an act of reverence.

It does cost more to diagnose and treat our patients with high technology (like our Operating Microscopes through which we do our treatment, and our use of the finest dental adhesive materials made, and the excellent dental laboratory we work with). Listening to patients is technically 'free' but I suppose there is a cost somewhere because there are only so many hours in a day, and we constantly have to decide where to direct our time. But what could be more important than listening? Even arriving at the correct diagnosis depends on that.

So, xxxxx, if ever you are unhappy with a lowest-bid, commoditized dental treatment decision, I hope you will return to us or seek care at one of our many conscientious dental colleagues who see the word "finest" as one of the most important words in the English language.