Do Gadgets Make Good Dentists?

A prospective patient came by one day to interview me. She was looking for a new dentist for her family. She and her husband were intelligent people and owned two successful businesses. This woman was doing her best to select a good dentist for her family- or so she thought.

The questions she asked centered on what expensive gadgets I had bought for my office. Did I have digital x-rays? Did I have a laser? How about one of those expensive CAD-CAM machines that makes crowns while patients wait?

Sorry to say, I am a conservative business owner who is leery of incurring debt to buy expensive and unproven equipment.  I must have disappointed this woman, as she did not return. Doubtless she found a dentist with most of the expensive gadgets she thought were standard for good dental treatment.

It is unfortunate, but a lot of people think many expensive gadgets = quality dental care. This is in no small part due to manufacturers’ propaganda. In the high-overhead professions of both medicine and dentistry, it is a hard sell to get docs to buy expensive new equipment. Nobody wants to be an early adopter who spends $50,000 on an invention that doesn’t live up to its expectation.

So the trend is to first advertise any new expensive technology directly to patient populations. Without a professional background and access to scientific journals, it is easy for the average patient to be convinced that some new gadget is the greatest thing since sliced bread.

The next step is for manufacturers to post an online list of dentists who bought their product, so patients can view and patronize these practitioners. In this way, manufacturers seek to reward dentists who make a large purchase of their new equipment.

Am I against new technology? Absolutely not. My problem is that much of it does not work out to be practical or economical. Someone has to pay for this expensive stuff. Invariably it is the patients via higher fees. It is instructive to look through the “For Sale- Used” ads in my dental journals and see what is available. Invariably I encounter expensive items that were highly touted three to four years prior, but did not end up being a worthwhile investment. These gadgets sell used for pennies on the dollar.

Would digital x-rays save my patients radiation over my top-notch film and equipment? Not much, if any. Intraoral digital x-ray sensors are uncomfortable in the mouth and cannot be sterilized. The chief convenience is immediate reading by the dentist.

How about spending thousands of dollars for software to trace and measure parameters of skull x-rays for orthodontics? It would save me time, but considering the fact I analyze about eight such x-rays a year, would it make sense? Hand tracing and measurement take me a little time, but the result is just as good.

Would investing over $100,000 in a CAD-CAM machine to make crowns in the office do better than my lab technicians? Not from the examples I have seen. And the crowns still have to be custom-stained to look authentic. But again, it is convenient for the dentist not to have to schedule a second patient appointment for cementation.

Would a $40,000 laser work magic on my patient’s gums? Well, it is not true that patients don’t need anesthetic injections before using lasers. These machines cut very slowly, and stink when they do. The only convincing use I have seen for lasers is to cut gums around implants, where my electrosugery unit cannot be used.  In dentistry at least, lasers seem like expensive toys.

By now I am sure you get the picture. With high enough patient volume, there are a few technologies that sometime make sense for a practice. These are few and far between. For every technology that proves itself in medical or dental practice, there might be nine that disappear because they do not live up to expectations.

In dental and medical practice, if you don’t get diagnosis and treatment planning right, no technological marvel in the world will make up for it. Technology is no substitute for experience in surgery. The main effect of technology is to increase doctor productivity. In general, the number of high-tech gadgets in an office is not a good indicator of quality of treatment you will receive.

New help for Snoring

Many of us have significant others in our life that snore. Many these people also have mild sleep apnea. At the minimum, they make life difficult for others in the household. At the worst, they may be adding an additional risk for heart disease.

Many people cannot tolerate the CPAP machine. It may be overkill for mild sleep apnea anyway. For these people, a simple oral device that advances the lower jaw to clear the airway might be just the thing.

It takes a sturdy appliance to hold a patient’s jaw forward all night long. In our experience, the Thornton Adjustable Positioner (TAP) appliance is the best of the bunch. Not only is it sturdy, but its adjustment features allow each patient to find the perfect advancement position for comfort and effectiveness.

I used this device to reduce my own snoring for several years before orthodontics. Once my braces were off, I procrastinated about having a new one constructed, until my wife complained enough.  Finally I had the current improved version of the TAP constructed, which is much more comfortable. My wife reports my snoring is down significantly.

These things are not cheap. All totaled, they cost $1200. If you have had a sleep study, there is a chance that you may get your medical insurance to cover a portion of the cost.

Not everyone is a candidate for an intraoral sleep appliance. Almost all natural teeth must be present to anchor a device like the TAP. It is not possible to wear when undergoing orthodontics.  For those who can wear them, however, oral appliances may offer relief to the snorer and loved ones who try to sleep in the same house!

When should my child have braces?

 I am often asked this simple question by parents. And I have a simple, but not very satisfying, answer- it depends!

There are a few problems that I would correct even in a 5- or 6- year old.  These are “crossbites”, where either the upper front or back teeth are locked inside the lower teeth.  If left uncorrected, cross bites will soon make the child’s jaw grow abnormally crooked or long. Often such abnormal growth may be remedied only by extensive surgery later in adulthood!

Dr Kim Henry orthodontics

This child of 8 has her upper incisors locked behind her lower incisors in crossbite. If untreated, this will become a very complicated surgical-orthodontic case.

Another important interceptive strategy in children this young is to stop thumb or lip sucking habits, or modify the way the tongue moves during swallowing.  Teeth can be moved into very unnatural positions by unusual tongue, lip, or finger habits.  If not corrected early before orthodontics, tooth movement will not be stable.

Many things we do at an early age can minimize or even prevent your child’s need for braces. The most important is keeping baby teeth in the mouth until they are ready to come out. Pulling back baby teeth early has severe consequences. It is guaranteed to cause the need for complicated orthodontics later!

The earliest age we usually treat children orthodontically is age 7 to 9.  This is called “Phase I treatment.”  We can make most of the corrections in difficult cases here, leaving only a little to do when all the permanent teeth come in at age 12 to 13. There are many advantages to Phase I treatment. The most important are that children this age cooperate better, orthodontic corrections are easier and more stable, and we can more often avoid extractions of permanent teeth. The most common Phase I treatment we do is expansion of the growing arches, to make sufficient room for eruption of the permanent teeth.

This child had a narrow palate, making it impossible to erupt the permanent canine teeth.  A “Hyrax” ex-pander was placed in the roof of her mouth.  Over the course of several days the device was expanded, until there was enough room to bring the impacted teeth into the arch.

This child had a narrow palate, making it impossible to erupt the permanent canine teeth. A “Hyrax” ex-pander was placed in the roof of her mouth. Over the course of several days the device was expanded, until there was enough room to bring the impacted teeth into the arch.

Usually too many teeth are erupting at age 10 and 11 to do fixed braces. All we can do is place space maintainers to preserve every bit of space as the last baby teeth are lost. This age may still be a critical time for treatment, as far as growth alteration is concerned. Some girls are nearly finished with bone growth at the end of their 11th year.

Age 12 and above, when all permanent teeth are in the mouth, has been the traditional time of most orthodontics. Most Phase I cases need final correction at this age. However, even this is variable.  I do not know why, but many children are getting all the permanent teeth in the mouth earlier.  I am now able to put complete braces on some 11 year- olds and finish the treatment by age 12.

A critical event occurs at age 18. Two bones in the roof of the mouth fuse together, and no longer can be expanded easily. It is at this point that orthodontics can really be slow going!

One of the many advantages to your child’s treatment in this practice is my many years of experience doing orthodontics, beginning in 1987. At each dental checkup, we monitor your child’s growth and tooth eruption. In fact, I spend more time doing this than checking for cavities! We will alert you to critical times for possible orthodontic intervention, so your financial outlays and time in braces can be minimized.

Kim Henry, D.M.D.

 

 

The Great Silver Filling flim-flam ~ or~ Straight talk about a good Filling Material

“Aren’t those silver fillings you put in people’s mouths poisonous?” Patients ask me questions like this weekly.  They think they might be victims of an unsafe filling material, but they are instead victims of self-serving fear mongers. There is so much misinformation about health issues in the news media, it is no wonder many patients are confused.  It seems like the purpose of reporters is to scare us to death with sensationalism, rather than to inform us.

Silver amalgam fillings were placed by the Chinese as early as 1400AD, and in Western countries since the early 1800s.  This material has saved countless of millions of teeth from extraction.  Silver amalgam is economical, easy to place, and durable.  Current formulations are about 59% of a mixture of silver, copper, and tin, and 42% mercury.

“Mercury!  Isn’t mercury a poison?”  This is always patients’ next question.

Yes, if you ingest elemental mercury or sufficient amounts of methyl mercury, it is.  Many common everyday items contain amounts of dangerous elements, bound together in stable molecules.  Elemental chlorine gas is lethal if inhaled.  Bound together with sodium, it is the table salt you ingest in food every day.

It is true, silver amalgam contains mercury, but it is bound together in a stable alloy that poses no health risk.  Silver fillings have been the subject of countless scientific investigations. Although it is true that trace amounts of mercury are released in heavy chewing, the amounts are inconsequential and have not been found to pose a health hazard.  Eating fish, especially tuna, releases more mercury in your body than do silver fillings.

The most elemental mercury is released from silver fillings during their placement and during their removal from teeth.  Now think about this: my assistant and I remove old silver fillings and place new ones in teeth during much of our workday.  If silver fillings are so dangerous, don’t you think dentists and their assistants would be the people who were very ill?

Now why on earth would people try to scare you into thinking fillings in your mouth are poisoning you?  There are two reasons- publicity and money.  Please examine people’s motives before you believe what they say.

If one researcher concluded that drinking tap water was a dangerous health risk, it might make headlines on the news. If ten researchers concluded that drinking tap water was safe, do you think you would hear about it?  No- It wouldn’t be news, because it would not be contrary to what anyone believes.  It wouldn’t scare anyone, nor generate any publicity!  For a researcher, claiming silver fillings cause a variety of serious illnesses is a sure way to be an instant celebrity. It also gains publicity for his university employer, which increases the researcher’s chance of promotion.

Likewise, if a dentist tells you that your silver fillings are safe and should stay in your mouth, he will earn no money from you.  However, if a dentist acts unethically and claims your silver fillings are toxic hazards and should be replaced, he stands to make money from replacing them with more expensive types of fillings.  Think about it!  Where is the motivation?

silver dental fillingsTwo beautiful new and polished silver amalgam fillings, alongside an older amalgam on the left.  Amalgams like these may easily last 20 years, and often 40 years in the mouth.

Now that we have gone over all the reasons why amalgams are safe, why should you consider using them in your mouth, instead of types of fillings?

  1. Amalgams are cost-effective.  They have the lowest cost per year of useful life of any filling material.
  2. They are easy for the dentist to place, even when there is moisture.
  3. It is relatively easy to get a good contact between a silver filling and an adjacent tooth. Inadequate contacts can cause food impaction and gum disease.
  4. Post-op sensitivity is usually minimal and short-lived.
  5. Silver fillings actually seal better with increased time.
  6. They are more decay-resistant than resin-based or resin-cemented fillings.
  7. Silver fillings can be repaired or added to.
  8. The amalgam material is not so hard that it wears the opposing natural teeth.

Silver amalgam fillings remain the most durable filling material for back teeth after gold.  Gold fillings are wonderful, but are more complicated to do, and cost several times as much as silver amalgams. Science has made great improvements in white resin fillings, but such fillings still do not last nearly so long in back teeth.  It is not rare for silver fillings to last 30 years, and it is possible for them to last 60.  There is no reason why you should have silver fillings replaced for health reasons.

Dr. Kim Henry

May 3, 2002

 

 

 

 

Why remove my wisdom teeth? They’re not bothering me!

It’s a fair objection.  If a body part is not symptomatic, why remove it?  After all, I would have objected if a surgeon had wanted to take remove my appendix prophylactically, before I developed appendicitis.  Why should wisdom teeth be any different?  Why should third molars (wisdom teeth) be removed before symptoms occur?

It is because in most cases, the damage from wisdom teeth occurs gradually, with no symptoms until very late.  But it nearly always occurs- either damage from gum disease, bone cysts or from cavities on the back of 2nd molars.

The gums around the wisdom teeth are usually not the type most resistant to gum disease.  Added to this is the fact that the wisdom teeth usually erupt in the corner of the jaw, allowing gums to partially cover them.  These two factors predisposes patients to have gum disease around wisdom teeth.

Now we would not worry if wisdom teeth lost bone and ligament support around them until they got loose and fell out.  The problem is that if wisdom teeth are left in, periodontal destruction almost always occurs between the wisdom teeth and 2nd molars in front of them.  When the wisdom teeth are finally lost, the second molars are often weakened due to ligament and bone loss.  Often, when patients maintain their wisdom teeth over many years, they end up losing both the wisdom teeth AND the 2nd molars due to gum disease.

Wisdom teeth often jeopardize 2nd molars in another way.  Often food gets trapped between wisdom teeth and 2nd molars and cause decay. My patient histories are replete with many cases like this:

 wisdom teeth dental decay

This patient developed decay on the back of his 2nd molar (black spot on the right of the middle  tooth) because of his wisdom tooth (on the right.) By the time he realized it, the decay had infected the nerve. This meant a root canal, buildup filling, and crown were necessary on the  2nd molar in order to save it.

Most patients have trouble cleaning between the rest of their teeth with floss.  How much more difficult it is to clean around wisdom teeth! Honestly, I have met few patients who can do it well.

Should unerupted wisdom teeth also be removed?

A third, rarer reason to remove wisdom teeth is to prevent cysts and tumors in the bone.  Around each unerupted wisdom tooth is a sac of cells which formed the tooth, call the dental follicle.  Especially in the lower jaw, these cells sometimes expand, forming a tumor which can destroy a big part of the lower jaw.

The presence of an impacted wisdom tooth may also weaken the jaw structurally.  Sometimes I have seen accident victims in which the jaw broke at the location of an impacted wisdom tooth.  Had the space been filled with sturdy bone, the jaw fracture might not have happened.

Just because a wisdom tooth is unerupted, does not mean it will stay that way. Wisdom teeth can sometimes erupt and cause inconvenient problems later in life- even if a patient has complete dentures!

Are there any situations where you might leave wisdom teeth in the mouth?

Yes, there are a few.

When patients have four premolars removed for orthodontics, all molars are positioned farther forward in the mouth. Occasionally, there is enough room for the third molars to erupt and be maintained in good health.

Another instance is when 1st or 2nd molars are lost.  Occasionally, the wisdom teeth may be moved by orthodontics to be good substitutes for the lost teeth.  But it is a very difficult movement, except in young patients.

When patients lose their first and second molars, wisdom teeth can be used to anchor a removable partial denture, especially on the lower arch. Wisdom teeth are often not shaped very well for this use, but it can be better than resting the partial denture on gums alone.

In elderly individuals, especially those on drugs to prevent osteoporosis, I might leave wisdom teeth alone, whether unerupted or not.  Sometimes the surgical risk outweighs the benefits of extraction in older patients.

If they are so useless, why do humans still have 3rd molars?

The trend has been toward shorter jaws in mankind.  The higher apes have plenty of room for 3rd molars, and some even have 4th molars as well.  Through the years, man’s jaws have become shorter, but the size of his teeth has stayed the same.  The result is not enough room for the wisdom teeth, which are the last to erupt in the mouth.

 Kim Henry, D.M.D.

 July 25, 2007

What Causes Cavities?

When I ask patients with cavity problems to guess the origin of their problem, I occasionally get answers like these:

“It was some medicine I took as a child.”

 “My teeth were fine until I had my children.  They sucked all the calcium out of my teeth when I was pregnant. Then my teeth got weak and decayed.”

 “My parents had dentures.  I guess I inherited bad teeth.”

 “It must be from not brushing my teeth right.”

 Let us look together and see how decay really gets started, then go on to investigate how we may prevent it!

What is decay?

Teeth are made of minerals, and are the hardest organs of the body- much harder than bone!  Decay is a process whereby the hard enamel outside of a tooth is dissolved by acid.  Once decay gets through the enamel, the same acid dissolution progresses very quickly in the inner dentin of the tooth. If the patient does not get the cavity filled, decay invade the tooth root (containing nerves) and a toothache results.

So where does this acid come from?

It can come from a couple of sources.  The most common is from bacteria living inside our mouths.  Many of these sugars utilize for energy, and produce lactic acid as a by-product. It is primarily this acid which acts to dissolve teeth.  Bacteria can turn dietary sugars into lactic acid in only 20 minutes. Unless the mouth is rinsed or cleaned, this acid hangs around to dissolve teeth for a whole hour!  So you can see that a child who ingests candy most of the day will have an acid mouth all day, an inevitably have move than a few cavities!  An adult who sips sweetened coffee most of the workday will likely suffer from the same fate.

But adults frequently get acid more directly- by drinking soda pop!  Few people realize what strong acids carbonated beverages really are!  Carbonated drinks are such potent acids that they can dissolve teeth directly whether the soda is “diet” or has sugar in it.  I would estimate that 75% of adult decay I see is the direct result of excessive soda drinking.  And as if that were not enough, too many sodas can contribute to stomach ulcers and even osteoporosis.

dental tooth decay Excessive daily soda pop intake caused characteristic tooth decay around gums.

Other sources of acid we sometimes encounter:

Chronic vomiting, as seen in bulimia and some other disorders, can erode teeth and also cause cavities.

We have noted lately many cases of gastric reflux, where small quantities of stomach acid enter the mouth.  This causes rampant destruction in your mouth, and should be controlled by prescriptions or surgery!

Don’t some medical conditions expedite decay?

Yes. Although not directly a cause of decay, any condition which dries the mouth can make your teeth more susceptible to it. Examples are doses of radiation to the head, using certain antidepressants, and antihistamines. We find that people that are mouth breathers are prone to more decay than those who can breathe normally through their nose.

Fluoride- our two-edged sword in fighting decay:

Even should physicians be unable to treat the above medical conditions, we still are able to stop decay- provided we have patient cooperation and fluoride.

Fluoride actually works two ways.  It has a toxic effect on decay causing bacteria. It also hardens tooth enamel and makes it more resistant to acid attack.  Interestingly, fluoride strengthens bone in the same way it strengthens teeth.  Physicians sometimes use fluoride supplement to treat osteoporosis.

For adults with decay problems, we often prescribe a fluoride gel to brush on the teeth at night just before bed, and a fluoride mouth rinse in the morning.  For really tough cases, including patients who have uncontrolled gastric reflux, we make custom trays to wear with fluoride at night.  With this heavy-duty preventive treatment, few patients get cavities!

Kim Henry, D.M.D.

 

 

“But I thought my cleanings were covered at 100%!”

That¹s what patients call to tell us when they get a bill for the balance on their periodic examination and cleaning appointments. Some are quite mad, and accuse us of ripping them off. They remind us that the insurance card in their hands plainly states “100% coverage for preventive treatment.”

What is going on? To understand, one has to grasp how the shell game of dental “insurance” has evolved over the years.

In the first generation of dental benefit plans, reimbursements were based on something called “UCR” fees. UCR stands for usual, customary, and reasonable. Fees were based on a percentile of real fee surveys within zip codes. They had a real resemblance to fees charged by dentists in the community. Sure, some insurance companies gamed the system by not updating their UCR fees with any regularity. But by and large, when insurers promised patients “100 coverage for preventive treatment,” the claim was generally correct.

In the second generation of dental benefit plans, called PPOs, fees were still based on some sort of UCR ideal. These plans were concocted to save employers money. They promised to deliver patients to dentists who participated (by signing slanted contracts) with plenty of patients, provided the dentists billed 20 to 30% less for procedures. Often this was the dentists¹ whole profit margin, so most resorted to procedure upcoding and other antics to make up the difference. The dental insurance companies really did not care. The important point of these plans was that they penalized patients for choosing their own dentists. A cleaning covered at 100% at a “participating” dentist would be covered at only 70-80% by a freedom-of-choice dentist.

In the latest generation of dental benefit plans, employers have flexed their muscle with dental insurers. Many now only pay companies a per-claim fee for administration, typically $5 or less. Employers now designate any “allowable” fee they wish, based solely on a cost target for their company. In these plans, any fee whatsoever can be designated for any procedure. For example, an employer can set $25 as an “allowable” fee for a dental cleaning, even though no dentists in the US may charge so little. The fee is merely a fairy-tale price concocted on the whim of the employer.

Meanwhile, the card given the employee still says “100% coverage.” But sadly, when employees use the benefits, they may discover the plan only covers $25 of a $90 cleaning. Few employees truly understand what is happening, and their anger is deflected onto the dentist. Instead, they should blame the employer, who is playing a deceptive shell game with its workers.

The whole driver of these shenanigans is the desire by employers to save benefit dollars. We can certainly empathize with that goal in this difficult economy for business. However, we think honesty with employees is a better path than deception. The honest thing to do would be to cut the benefit maximum, or lower percentage reimbursement for dental services. Unfortunately, that makes it a lot more obvious to employee-patients that benefits are being cut. Thus, the deception of employer-proscribed low “allowable” fees goes on.

We remind our patients once again that dental “insurance” is an inefficient contrivance born in an era of high marginal tax rates. The crucial test of your dental plan is whether it pays out more in benefits each year than the premiums you pay for it. With employers cutting benefit plan subsidies and at the same time lowering “allowed fees,” fewer and fewer dental plans are worthwhile. It seems remarkable, but if an employee is covered by a FLEX benefit or 125S Cafeteria plan, it is usually more economical to drop the dental benefit plan. Paying for dental expenses by a FLEX or Cafeteria plan is more efficient, and gives you complete freedom of choice in choosing dentists!

by Kim Henry, D.M.D.