Bite Point

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. 

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.