Learning Center: Blog

A recent interaction with a patient this week reminded me of another interaction with a female patient a couple years ago. For privacy sake I’ll refer to her as Jane.

Jane, a presentable, well-kept 38 year old woman sat down in the dental chair and simply wanted a cleaning. Of course, as every new patient knows, if Jane was to become a comprehensive patient, she would need a full mouth series of radiographs and a complete exam before I could determine what type of cleaning she would need. As it turns out, her oral hygiene was very good. She didn’t have any cavities and only had a few fillings on her lower right back teeth.  Jane also showed subtle signs of recession localized only on the right side of her mouth. This finding prompted me to dig deeper. I remembered from her health questionnaire that Jane marked “yes” when asked if she suffered from headaches/migraines.  In fact, Jane also took some heavy duty meds to prevent these migraines from starting in the first place.

“Can you remember when you first started getting migraines?” I asked her.

“When I started collage, I guess the stress and pressure set it off.” Jane said

“And can you remember when you got these fillings?” I continued.

“Jeez, I don’t remember….I was pretty young…I guess the end of High School?” She replied. “My parents wanted me to see a dentist before I went away to college.”

Eager to test the theory forming in my head, I reached for the articulating paper (blue and red marking paper). I asked Jane to bite on the paper on both the right and left sides. I also checked how she grinded her teeth, side to side and front and back. With these simple tests I told Jane that her bite was visibly off and this likely was the cause of her recession and possibly her headaches. I asked if I could make a small adjustment with the drill and Jane agreed.  It took about 5 minutes to adjust her bite and polish her teeth.

Jane thanked me and checked out at the front.

After two weeks, Jane called the office complaining about the bill she received.

“Why was I charged for something called ‘bite equilibration’? I just wanted a cleaning. I agreed to the exam and x-rays because you said you needed it before you could clean my teeth.”  Jane declared.

“The bite equilibration was when I adjusted your bite.” I told her.

“Why was it so expensive? You barely did anything! You were in my mouth for less than 5 minutes. I shouldn’t have to pay for that. I didn’t even ask you to do it. I just wanted a cleaning!” She demanded.

I had to correct her. “I’m sorry, Jane, but what took me only 5 minutes to do in your mouth actually took me 7 years to know how and what to do. Let me ask you though; have you had many migraines since your visit?”

“No, but sometimes I don’t get them for a couple weeks.” She replied.

“OK, I’ll tell you what”, I said. “Pay me what you think is fair.”

I hung up the phone and returned to my work. Approximately 3 weeks later Jane’s bill arrived and was paid in full.  She later told me that she had never had a migraine headache again and was able to stop taking the strong medication she previously needed.*

*Migraines can develop from many reasons and can also have unknown causes. This story does not mean that everyone who suffers from migraines needs dental work.

I am very proud and honored to have had this article written about me and my passion for both dentistry and fine art. Please click here for the full article.

Why do I need a “Deep Cleaning”?

By: Alon Dori, DDS

I can’t tell you how many people come up to me exasperated, saying “My dentist says I need a deep cleaning…Do you think I need a deep cleaning!?” This, of course is a loaded question because I need a lot more information to diagnose. My quick response usually is, “Not from where I’m standing.” My long response usually goes like this…

A “Deep Cleaning” or more appropriately – Scaling and Root Planning is an involved periodontal (gums) procedure which involves removing plaque and calculus (hardened plaque) from the DEEP pockets between the teeth and gums and then smoothing the surface of the roots. Please note that I emphasized the word deep. A deep pocket is anything that is 5mm or more (4mm in select cases). So, the first question a patient needs to know is – Do they have deep pockets? If the answer is “No”, well…then a DEEP cleaning is not indicated.

I am disheartened that many dentists incorrectly diagnose a deep cleaning just because there is a lot of debris. Large amounts of calculus in the absence of deep pockets requires a cleaning, but scaling and root planning is rarely the appropriate treatment.*

A “deep cleaning” is expensive. It requires a good amount of time, dexterity and often times numbing the mouth; unlike regular cleanings. With the right instruments and gentle hands, removing debris from the teeth above the gums is generally painless. Discomfort usually comes from removing debris from below the gums which are already inflamed, swollen and tender.

So why do some dentists treatment plan a deep cleaning when there are no deep pockets, but there is a lot of calculus? It’s simple, they want to be compensated for their time and use of materials.  We want the same in our office, but we need to be fair. If an involved cleaning is in order in the absence of deep pockets, we will generally perform a bulk debridement procedure followed by a fine scaling (prophy). This way the patient gets the proper treatment without breaking the bank.

*Calculus below the gums that can be detected on an x-ray is very tough to remove, even though the pockets are shallow. These cases may require anesthesia for patient comfort and localized deep cleaning.

It never fails, I hear it all the time, “I don’t want x-rays, I just want a cleaning” and “Dr. OZ says dental x-rays cause thyroid cancer.” Comments such as these are commonplace in the field of dentistry.  However, no matter how many times I explain the value of dental x-rays coupled with the ultra low dose of radiation, many patients remain skeptical.  So, in an attempt to clear the air, I will try to break it down into understandable terms.

We live in a radioactive world and radiation is part of our natural environment.  Simply put, we are all exposed to radiation on a daily basis.  This radiation (specifically, ionizing radiation) can be measured in several different ways, but for the purpose of this discussion I will focus on the smaller unit called millirem (mrem).

The average exposure dose of radiation per person from all sources is about 360 mrems per year. However, it is not uncommon for someone to receive more or less than this average in a given year (largely due to medical procedures one may undergo such as CT scans).  For those who work with and around radioactive material, International Standards allow exposure to as much as 5,000 mrems per year and still consider this dose as “safe”.

The following are common sources of radiation EVERYONE receives:

• Cosmic (from outer space) Radiation at sea level = 28 mrem/year  (more if you live in an area with higher elevation like Denver, CO)
• Terrestrial (from the ground) Radiation = 30 mrem/year
• From Food and Water = 40 mrem/year
• From Air = 228 mrem/year

Dental X-rays (Radiographs)

• Full mouth series (need at first visit and every 5 years) = 54 mrem
• 4 Bitewings (need every 1 or 2 years) = 12 mrem

Other Man-made Sources of Radiation for Comparison

• From living with another person = 1 mrem/year
• From living in a stone, brick or concrete building = 7 mrem/year
• Flying from LA to NY = 2.5 mrem 
• Smoking a half pack of cigarettes every day = 18 mrem/year
• Mammogram = 42 mrem
• Hip x-ray = 70 mrem
• CT scan of chest = 700 mrem
• CT scan of heart = 2000 mrem

Conclusion: 
Ionizing radiation in large doses can cause damage to the human body. However, the very small and localized amount used in dentistry far outweigh the risks.  Dental x-rays diagnose a wide range of problems, including but not limited to: dental caries (cavities) that cannot be seen clinically (by looking in the mouth), periodontal disease (bone loss), excess cement left behind after cementing a crown (which can lead to gum disease), abscesses /cysts, infections in the bone, impacted teeth, fractured teeth, cancer, genetic disorders, and much more.

Finding a dental problem early can save your tooth. It will also save you time, money, and overall health.
So the next time you go to your dentist and he/she says it’s time for x-rays, feel free to ask why. Any good dentist will take the time to explain why x-rays are indicated.

American Nuclear Society:  http://www.new.ans.org/pi/resources/dosechart/
Martin S. Spiller, D.M.D: http://www.doctorspiller.com/Dental%20_X-Rays.htm
Idaho State University: http://www.physics.isu.edu/radinf/risk.htm
United States Nuclear Regulatory commission: http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/bio-effects-radiation.html

What is Plaque, really?

By Alon Dori

Here’s the scientific answer:  Dental plaque is a soft deposit that accumulates on the teeth. Plaque can be defined as a complex microbial community, with greater than 10¹⁰ bacteria per milligram. It has been estimated that as many as 400 distinct bacterial species may be found in plaque. In addition to the bacterial cells, plaque contains a small number of epithelial cells, leukocytes, and macrophages. The cells are contained within an extracellular matrix, which is formed from bacterial products and saliva. The extracellular matrix contains protein, polysaccharide and lipids.

Here’s what it means in English: Dental plaque is basically comprised of three things: Food, Saliva and Bacteria…lot’s of bacteria (10¹⁰ = Ten Trillion per milligram!!). After we brush our teeth, the microscopic bacteria that did not get washed away begin to re-colonize our mouth almost immediately.  Foods that are rich in sugars (not just the sweet stuff) like carbohydrates are fuel for many species of oral bacteria and help the germs to reproduce and grow. That’s why we brush our teeth; to keep the amount of germs in our mouth under control.

How can we get rid of the bacteria once and for all, you ask? This has two answers: 1) You can’t!, 2) Some bacteria is good.  Let’s start with answer #1. Bacteria is everywhere. It can be found on every surface on Earth, you included. It has been around for billions of years and has evolved as the dominant organism on Earth as it has survived for so long and continues to survive. Generally, we think of bacteria as being bad because they cause disease and even death in other living things. But, this is not always true, which brings me to answer #2. Bacteria compete with each other for valuable real-estate. It’s kinda like the saying; “Better the devil you know than the devil you don’t”. The main bacteria that live in our mouth are Streptococcus sanguis, Streptococcus mutans, and Actinomyces viscosu. If they disappear (as a result of antibiotic drugs) other organisms like fungus can fill in the void and cause big problems like Thrush.

So, what’s the take home message? Our mouth is the perfect home for bacteria; it’s always warm, moist and food is delivered at least three times a day (exactly like a Petri dish, image 1 and 2). The main purpose of brushing (and flossing) is to keep the amount of bacteria in your mouth low. If you can scrape the plaque off your teeth with your fingernail, you are way past due for a good brushing.

Image 1: Plaque developing on teeth                           Image 2: Same bacteria developing in a Petri dish

Referrences:

1) Susan Kinder Haake, Microbiology of Dental Plaque, Dental Plaque: Structural, Microbiological and Developmental Characteristics. http://www.dent.ucla.edu/pic/members/microbio/mdphome.html

2) Carranza, Newman, Clinical Periodontology, 8th edition, Etiology of Periodontal Disease, page 83-206.

3) Martin S. Spiller, http://doctorspiller.com/Periodontal_Disease/Gum_Disease.htm

A few months back I had a 17 year old boy in the dental chair. He came in with his mother and was crying.  He was gaunt, pale and in obvious pain. I really felt bad for him. The young man was suffering from a toothache. Actually, he was suffering from several toothaches. When I interviewed him, I learned that he had been “dealing” with this pain on and off for a year. Finally, his mother couldn’t stand the whining and finally “forced” him to come to the dentist.

I examined him and his x-rays and easily diagnosed multiple abscesses (infections) and several severely decayed teeth which reached the pulp (nerves).  It was amazing to me that this patient had been able to suffer through all these infections until now. Luckily for him, it was 2011 and not 1911, all but one tooth was savable and had a good prognosis. And if we acted fast, he could be pain free and back on his feet in no time….but of course, that is not how this story ends.

With considerable effort the office prepared a very conservative treatment plan outlining the cost associated with saving the young man’s teeth.  In almost one fluid motion, the mother looked at the estimate and tossed it back declaring, “we can’t afford that…how much to pull the bad teeth?”.  As a father of 2 boys, I was caught off guard and was at a loss for words.  With all the chairside manner I could muster, I replied, “Pull all the bad teeth!?…that’s….6,7,8…9 teeth! Most of them are molars. He is going to have a hard time eating”. “Well,” she replied matter of factly, “we just can’t afford that much right now. He’ll just have to deal with it.”

I was saddened to hear of their financial difficulties and considered proposing a financial arrangement because lacking teeth this early in life was going to be a life changing event for the young man. Just as I was about to speak, a cell phone rang. It wasn’t the ring tone, “Don’t stop believin’” so I knew it wasn’t mine. By the second ring, the boy sitting in my chair reached into his pocket and pulled out his iPhone4 and turned the ringer off. “Who was that?” asked the mother. “Dylan”. “You better tell him you’re not going to be able to go snowboarding with him this weekend, if they pull your teeth,” she threatened and reached into her purse, “That reminds me…”. Out of her bag came another iPhone4 and she quickly began texting someone as I sat there taking it all in.

This patient interaction got me thinking. I too have an iPhone4.  It cost me about $200 for the phone and $120 a month for the service.  It’s not cheap (about $1,400 a year) but I rely on it quite a bit for communication and entertainment.  But then again, I rely entirely on my teeth for the same things and more.  In fact, my healthy teeth (and gums) give me considerably more pleasure than my iPhone4.  I can eat and taste everything and anything.  I can smile with confidence and speak clearly. I can even whistle.  Simple as these things are, they make our lives easier and enjoyable. We all take them for granted until we can’t do them.

To sum up, people are always happy to pay for things they enjoy, like videos, apps and the ability to talk to a friend whenever they feel like it.  Equally, people dislike paying for things they don’t enjoy, like x-rays, cleanings and dental work. This is because they don’t derive pleasure from the dental treatment itself.  However, it’s not actually the treatment that they are paying for, it’s what the treatment affords them.  A confident smile, the ability to eat wonderful foods, and peace of mind that they are doing their best to stay healthy and strong.

As for the 17 year old boy…he went though with the extractions and is now wearing two temporary partial dentures.  He is infection free but very dissatisfied with his false teeth.  He complains that he can’t eat the foods he once enjoyed and wishes he saved his teeth. It breaks my heart.