Bite Point

Why Microscopes in Dentistry?

I was recently asked why I have four Microscopes; specifically, why did I purchase one extremely expensive Operating Microscope for each doctor and hygienist in the practice? I answered:

There are lately many dozens of new dental technologies, all of them bringing great benefits to specific areas of dental treatment outcomes. One technology, though, bestows astonishing benefits on ALL forms of dental treatment: the Surgical Operating Microscope. Our practice is one of the few in the world to have Microscopes in every treatment room, used by every primary caregiver in our practice. This remarkable tool gives us unparalleled views of the mouth and teeth. We can diagnose better because we can see better. And as to treatment? Microscope dentistry is defect-free dentistry. It's a spectacular change.

 

Only One Correct Diagnosis

I recently met a new patient, a remarkable and engaging young woman with complex medical issues. She falls under the rubric 'disabled' from a physical definition standpoint, but there's absolutely nothing disabled about her splendid expression of the human spirit. In my brief experience of her so far, I've noted that she accomplishes and creates more in a day, in the face of endless challenges large and small, than many of us accomplish in weeks.

One striking thing that comes out in our conversations is how many of her young friends haven't been to the dentist in awhile, and how often this reluctance is because of concerns about cost. Hearing this always sends a sort of shock through my finely attuned dentist's body. Because, you see, most dental problems don't ever get better on their own.

In point of fact, they always get worse.

By 'most' I include cavities and all the complications that go with them, like root canal treatments and even extractions, should the decay get deep enough. I include gum disease, certainly. Even crowded and misaligned teeth--they get more jumbled up over the years. The most severe concern of all is of course the specter of oral cancer. It's one of those cancers where you actually have a pretty good chance of a cure--IF it's caught early.

Many oral diseases are actually silent for long periods. Early cavities, much of gum disease, oral cancer--all painless and sneaky for quite some time. The opposite problem of course is pain. Patients can face physical pain and they also can face esthetic pain; the pain or social embarrassment that results when front teeth go bad.

Mulling on all those concerns, I really want to meet the folks, especially the young folks, who are fearful of cost. Because whatever the cost of dental treatment might be just now, it's going to cost more the more time goes by. On account of the worsening ...

Why am I so keen to meet them?

One of our greatest dental educators, Dr. Morton Amsterdam, famously asserted, "There may be many ways to treat a case, but there is only one correct diagnosis."

I live by that.

Only once we have a diagnosis can we start to talk treatment. Yes, what it takes to treat oral health problems may be expensive at times. Once we have our diagnosis, though, we can suggest options. Once a patient understands and wants a certain kind of dentistry, the question that remains is simply, "Is this the kind of dentistry you would like to have done, if you could fit it into your budget?" And then it's purely a matter of fitting it into one's budget.

Everyone has a budget, even those who don't budget (verb).

At that point, having our diagnosis, we'll talk, we'll strategize, we'll solve problems with you and most of all, we'll listen. But first, you have to come in. First, we both have to obtain a diagnosis.

Cost? Fear? Fear of cost? Meh. The vital thing to consider is this:

There's nothing to fear about making a dental appointment so long as you know you're going to be listened to.

Dangers of Corporate Dentistry

Corporate dentistry places the goal of maximizing profit far above all other goals, including that of solving oral health problems for patients. This has real-world effects on the health of those patients.

It essentially works like this--

Corporate dentistry entices patients with low fees for any given procedure. Then, they over-diagnose and over-treat. Patients actually end up paying more. In money--and in health.

Examples:

-The corporate dental definition of the dental pulp is "a small piece of oral tissue that can be readily turned into cash." Endodontics is performed with the thinnest of rationales, or often with no rationale at all, in the name of production quotas. In contrast, a *bespoke* dentist strives to keep the dental pulp alive, in cases where there is no infection or intractable pain.

-Corporate dentistry fabricates periodontal probing depths in order to perform scaling and root planing on all new patients, many of whom do not need it (and will be harmed by it). Over time, this of course makes it more difficult to have treatment discussions with patients who actually have periodontal disease, as the profession's credibility is harmed.

-Teeth that could be restored with direct restorations of moderate size are crowned instead. Crowns are extraordinarily useful when indicated to save a tooth and keep in in function. I wonder, though, how many tons of human tooth enamel are sacrificed in the U.S. each year by corporate dentistry, not because the teeth in question were severely compromised--but because the fee for a crown is eight to ten times higher than the fee for a direct restoration.

Corporate dentistry also treats doctors, hygienists, assistants and business staff as interchangeable, temporary and disposable. Production quotas are the driving metric.

A truly *bespoke* dentist, in contrast, considers this metric to be the most important: "How much difference did I, and my staff, make for this patient who stands before me?"

Marijuana, Corporations and Politicians

As I write this post, it is the one-year anniversary since sales of marijuana for recreational use began in Washington state.

In this very first year, $70 million in tax revenue has been generated statewide from marijuana sales.

Marijuana dispensaries in Washington State have enjoyed gross receipts of well over $260 million.

Again--one state, first year. The projections run towards half a billion in tax revenues by 2019.

http://dor.wa.gov/Content/FindTaxesAndRates/marijuana/Default.aspx

http://www.businessinsider.com/recreational-marijuana-washington-state-tax-revenue-2015-7

Well--

Politicians have noticed. And that means they're all in on this one. Conservatives, Liberals, doesn't matter--tax money is the prime aphrodisiac of a politician. So get ready for changes in law and policy that facilitate (and even encourage) the sales of marijuana. There's no consideration, no moral stand that trumps tax revenue and campaign money in a politician's deviant mind.

Corporations have noticed too. Corporations are legal instruments designed to maximize profit for their shareholders. This is a fine thing in many ways, as corporations and governments are the only instruments devised by mankind (so far) that can amass enough financial and human capital to make many of the great things in our world come to be. So many complex things, like life-saving drugs, and automobiles, and this computer I work on, and skyscrapers, and sending a man to the moon. (And, of course, the indispensable Tang.)

But "maximize profit for shareholders" is often followed by "at all costs," and so we face a bitter legacy of broken laws and lies. We face unchecked pollution, and overuse of prescription drugs for profit, and preventable consumer deaths, and workers harmed in unsafe workplaces, and so on and so on. Whatever it takes to maximize profit (and keep the CEO in power), that's what will get done.

And so do you think corporations are going to stand idly by and let marijuana dispensaries remain a cottage industry?

Certainly not. The drooling hounds of unfettered capitalism are already well on the Scent of Weed.

It's only a matter of time until there's a mass-production machine for marijuana.

It's only a matter of time until there's a mass-marketing machine for marijuana.

It's only a matter of time until there's a mass-distribution machine for marijuana.

It's only a matter of time until we witness the industrialization of Getting High.

It's only a matter of time until corporations market and sell marijuana with the same implacable force and zeal as they do soda, potato chips and kid's breakfast cereal. (Imagine the myriad merchandise tie-ins and product placements in movies and TV shows.) And until politicians rake in the resultant taxes and campaign funds, and relentlessly vote for any bill that increases those revenues, regardless of the effects on our American society at large.

And then what? What will America look like when all that happens?

Thorough Cement Removal

The cement isn't all gone until you use an ultrasonic on the crown margins.

 

Cement all gone:

 

 

Cement unfortunately not all gone:

 

 

*

 

Temporary crowns, permanent crowns;

Temporary cements, permanent cements;

Doesn't matter.

There's still cement left until you cavitron it. Go ahead, try it and see.

Cavity Prevention

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.

http://www.basicbites.com/

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.

http://www.synedent.com/

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.

I'm sold.

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.

United Concordia is Stealing from Dental Patients in Pennsylvania

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

 

2/15/15

 

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.

 

Sincerely,

 

Rick Wilson, D.M.D.

 

Fluoride Varnish

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.

-Eating disorders.

-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.

Area-Ruled Teeth!

These periodontally involved teeth:

Are faster than these periodontally involved teeth:

Because they're area-ruled!

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

 

 

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.

All Microscope Dentistry

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.

2.2x--

3.2x--

5.1x--

8.0x--

12.8x--

19.2x--

That is my friend Jaimin's lab work on an extracted tooth--before she started attending dental school. Such potential!