No Big Deal...Just a Breathing Crisis.

Hanging out at the house last night, basking in the glow of the tree and feeling logy after the third full day of digesting mass quantities. And there's egg nog and candy in every corner of the house in case my blood sugar drops below 200.  The kids are thrilled to be a part of it all, squirreling away candies and sneaking away to the play room. My 6-year old son is still buried in Lego kits, and my 2-year-old daughter is starting her journey as a performer, with a cute little drum set and a microphone sounding off at all hours.

It's a good thing she didn't get too far from Candy Mountain last night. Because she ended up lodging a Werther's in her airway.  She was sitting on my grandmother's lap when my step dad threw an index finger in her direction, and furiously wagged it.  "She's...she can't..."

I rolled my head in her direction, eyes at half-mast. Through my haze, I saw her reach for her throat. When my eyes locked on her face, turning from red to a dusky color. The hallmarks of choking were playing out exactly as they have been published. A tidal wave of adrenaline rushed through me, and I levitated out of the sofa. My instincts and first aid training took over.

In 2008, the American Heart Association published a survey about nationwide CPR training. Although 89% of respondents were willing to assist or step in to provide CPR  for a victim, only 21% felt confident enough to perform it. Only 15% said they could utilize an AED in an emergency. The report added that most people were afraid they would screw something up, and/or suffer legal consequences.

I admit I was shocked, frozen, and completely surprised that my daughter would be the first victim that I saved from a choking emergency. I was scared that my training or my memory of the first aid algorithms would be accurate and effective enough to save her.  I am trained in advanced cardiac life support, and my team undergoes routine training multiple times a year for CPR, AED, and first aid. But I was flat-out freaked I would fail. All of these thoughts went through my mind in a fraction of a second as I grabbed her and began the pediatric airway routines.

The outcome was positive. I had to beat up on her a bit, and had to institute a diaphragm maneuver. But the caramel popped out of her airway like a cork out of a bottle. Nothing but a scare for her, and she went to bed like an angel.

In reality, your family or friends will likely be the victims you have to save. And having the practice to save them is what it comes down to. Various sources place the length of time for brain death from lack of oxygen  between 2 and 6 minutes. And that doesn't count the spectrum of brain damage during the time the brain has been deprived.

Being familiar with medical emergencies is easy to read about online; there are countless pages and sites. But rehearsing scenarios for heart attack, stroke, choking, and other common first aid situations is essential if anyone is to respond quickly enough to help a victim avoid brain damage, physical disability, or even death. Rehearsing at least once a quarter at home with your family or at work with your colleagues could mean the difference for those in trouble.

Please Get Educated about the 2010 Healthcare Act

A decent summary of the Affordable Healthcare Act (ACA) as it impacts dental patient care was released recently.

The ACA has inadvertently developed many complicated twists and turns for patients and providers on the long road to a successful, comprehensive care horizon.

My thoughts:

1) Dentistry isn't about to get cheaper or easier to access with the advent of the ACA activity.

2) Maintain great communication with your employers and human resources representatives. Do your best to communicate the continued need for dental insurance policies.

3) Consider a health savings account or a flexible spending account and talk with your employer or HR about matching or funding those accounts for dental care. These types of accounts allow flexibility in how and where you get care. They can also help you and your family break through dental insurance limitations for where, when, and how you get care.

4) Educate yourself on how you can keep your children healthy under the ACA provisions. Odds are there is a state-funded program for kids in need, wherever you may live.

5) The ACA will create better access to medical insurance for our country's patients. Keep in mind surgical care in a dental office (tooth extractions, periodontal surgery, grafting, dental implants) and treatment for sleep apnea in a dental office can be submitted to medical insurance.

Reduce your Medical Costs By Seeing Me

The oral-systemic link between dental disease and other medical disorders was further solidified this year in health science research. In March, dental researchers convened in Tampa to share findings. The paper can be found here.  It was found that diabetics who sought dental care for periodontal disease reduced their overall number of hospital or medical visits, thus reducing their overall healthcare spending.

Periodontal disease and diabetes are inextricably linked. The nature of the inflammatory pathways in gum is to disrupt the body's ability to manage the processes of glucose control, insulin and glucagon production, and metabolism of sugars.  Chronic inflammation from any infection also inhibits the ability for a body to heal or perform optimally in countless ways.

With the constantly evolving demands of patient access to care, the model of caring for your mouth to care for your body really means more. There's only so many medical facilities to supply the ever-expanding demand for a clinic when patients need it.  So if seeing a dentist can reduce medical visits, it ultimately creates a win-win-win: Win 1: patients can be healthier. Win 2: doctors and hospitals can reduce their labor and equipment costs. Win 3: medical insurers could potentially reduce policy premiums as healthcare utilization is reduced, and policy holders benefit.

SO, I say call our office and get an appointment reserved today!

Building Momentum

I took care of a patient a few months ago who was sweating bullets in my conference room when she saw me for the first time. She couldn't imaging treatment without being "put under."  Now, I don't put anybody to sleep in my clinic, because I simply don't want to assume responsibility for their breathing. But I provided moderate sedation for her, and I have seen her twice for surgeries to replace a tooth with an implant.  Last week, she asked me if I would discuss how to improve her facial esthetics with Botox and Juvederm. WITHOUT sedation.

I thought her progress was interesting, because I have seen a similar pattern in fearful patients. I truly believe that past experiences of traumatic dentistry never fade; those events are hard-wired into the patients' processes of fear and/or anxiety, kind of like a deeply rutted road that is traveled thousands of times. But when I can create a visit that is free of the triggers for that psychological cascade of behaviors, I could swear that a new pathway is created for patients to travel that has a totally different context for them as they sit in my office for consecutive visits.

It's pretty fascinating and rewarding to talk with this patient about how I am going to stick her with a needle, and she is significantly more relaxed. And I proceeded to inject her without anesthesia!!!! Yes, I engineered some trust between us. But that is quite a positive trend she has displayed.  I anticipate she will see me for dental care in the future without the need for sedation, because I see that evolution in other patients too. I like not having to sedate patients. And I like it even more when I know that they can build momentum in a positive way to eliminate that need for sedation care.

Lord Of The Veneers

This gentleman has been wanting a new smile for hundreds of years. He was referred by our patient, Sam, after coming home from a long stint in the mountains.


Thanks to Scott Clampett.

An Aspirin A Day

My dad is a gasteroenterologist. And I know this might be shocking: we talk medicine a lot in our family. He passed this op-ed piece along to me this morning. It summarizes the past , present, and future uses of aspirin to improve our health, and maybe--just maybe--improve our nation's economy.

I hapen to like this article, not only because it introduces a potentially beneficial strategy for reducing the amount of healthcare utilization across the country, but also because it is just good science. People live healthier lives with fewer medical compromises or events over their lifetimes when using aspirin.
 
I have to admit I am surprised by the studies that illustrate the anti-cancer effects of aspirin. I know aspirin can suppress some of the biophysical processes of cancer cells, but the summary depicted a much greater benefit than I thought. 

Anecdotally, I see about 50% of my patients using daily aspirin. My patients ask if it is good to stop using aspirin before they come for an appointment. As a general rule, I do not want my patients to stop using aspiring before they come to see me.  The risks of NOT using aspirin are higher for them than the risks of continuing to take it. .I do not have any trouble with my patients bleeding during procedure. It's true that all aspirin users have a lesser ability to clot when bleeding.  But we routinely use lasers and other equipment to prevent bleeding. 

Canine Eminence

I'm not a dog guy. I mean, I like dogs. I had dogs in my family as I was growing up, and my grandfather used to raise several different pure breeds. I don't own a dog these days. But seeing this example of behavioral therapy in the dental office with a loving, peaceful golden retriever may be enough for me to get back in the canine saddle.

I started drilling down in to a history of therapy dogs and dentistry.  I found a lot of commentary, but no particular white paper or American Dental Association policy on use of therapy dogs in dentistry. It appears that quite a few people or clinicians are against the thought of dogs in the treatment rooms because it's a messy, germy business. But I think we have to understand the purpose of therapy animals before we can really write off their use in dental visits.

Therapy dogs are used specifically to aid their owners or patients in managing their emotional or behavioral challenges. While it is true that the animals need to be accredited and specifically trained for medical use, there has been no published mandate about stringent gowning or disease precautions in the dental operating theater. Human contact is required for therapy dogs to fulfill their purpose.

In dentistry, it has been estimated that 30% of all patients have disabling anxiety, preventing them from seeking proper dental care. Sedation and general anesthesia has been successful options for those patients. But for numerous reasons, sedation procedures may not be appropriate. I interview and sedate a lot of dental patients, and some people simply can't have the medications

I think it's a great idea. It stands to reason that if a therapy dog with its excellent temperament could consistently not lick my patients on their mouths, and I didn't fulfill the urge to scratch it behind the ears every 2 minutes, that we could have a pretty great situation for anxious patients.


Thanks to Scott Clampett for the aforementioned link.

Vitamin D: A Tool Against Decay?

Vitamin D is a building block of teeth. A recent study that summarizes 60 years of clinical results suggests that increased levels of Vitamin D may reduce the prevalence of tooth decay in children.

Vitamin D is generated in response to exposure to sun or high-intensity artificial lighting. It is routinely taken as a food supplement.

My thoughts: If the studies are accurate, and the biochemistry of vitamin D and tooth formation is accurate, then it may be beneficial for kids to be outside wtih judicious amounts of sunlight exposure. I see light-based vitamin D therapy as win-win for kids: it reinforces the idea of 60 minutes of exercise outdoors a day, which is an anti-obesity behavior; and it reduces decay risks.

Regardless, have your kids attend regular dental visits to screen them for decay as well as establish a "dental home" for them to reinforce excellent dental care behaviors for a lifetime. Call us today to schedule your children!

Improve Our Care, Not Our Workforce

Danny Warner, DDS, is the new president of the Washington State Dental Association.  He recently released an op-ed piece in the Seattle Times. It discusses how dentists, lawmakers, and the public should be thoughtful and cautious about creating a new dental therapist role in Washington.  We have some effective programs in place for helping our state's most at-risk patients--those being children--with dental disease. And if the current population of dental patients worked more consistently to prevent their dental troubles (see my post), this topic of adding dental therapists to the workforce would likely be swept off the lawmakers' tables. I wrote about this issue a few months ago.  I feel the position Dr. Warner takes is sound and reasonable.

Apnea and Obesity

It is estimated that 1 in 5 people (both adults and children) in the US have some form of sleep disrodered breathing. One of the major contributing factors is obesity. Obesity creates redundant neck and midsection fat deposits and can constrict the airway.  The interesting data is that obstructive apnea has risen across the nation over the past several decades along with obesity. The following images track the trend in national obesity.

Sleep Apnea--A Pictorial

Short-Term Orthodontics Is A Great Alternative to Veneers and Crowns.

Here's a recent case.This gentleman wanted to eliminate the spacing and flaring, as well as the chipping in his smile.Veneering teeth was not an option because of the large space, as well as the flaring of the adjacent teeth. It would have required aggressive tooth reduction and probably some root canal therapy. In my opinion, that's not conservative dentistry for the smile. I advised against that. He decided to pursue short term-orthodontics with us.

 

Braces were completed in about 6 months. After they were removed, he whitened his teeth before we repaired his upper front tooth.

Call us for a free consultation to show you how we can improve your smile without veneering or crowns.

Getting Stuck With The Check

1/1/2013. That's a big day for me as a solo dentist working in America.

You see, I'm a guy who works hard to offer great dentistry. But the costs of dentistry have always been difficult for me to swallow. So I made a decision a few years back to do my best to keep costs as low as possible for patients while keeping the dental office lights on. A couple of examples here: I offer more affordable specialty care than most of my colleagues. And I have signed a contract with the most popular dental insurance provider in our area as an effort to help my patients keep costs down when they need my help.

But 1/1/2013 will usher in another phase of the Healthcare Affordability Act--an excise tax on medical manufacturers.  Any costs for this excise tax are going to get passed down the chain to healthcare providers. I'm not exactly sure how my costs are going to increase to buy supplies and equipment, but they are going to go up anywhere from 2% to maybe even 7% depending on the manufacturer. I attached post from a colleague of mine, Dr. Alan Hudley, and I think he puts it pretty well. I feel handcuffed because I am trying to maintain a lower level of cost for patients, but it comes at a pretty big hit to me. The insurance companies won't increase patient reimbursement.

I don't know exactly how it will affect me or my patients, but I think it would be a good idea to consider the following:

1) Do you like the service I am delivering?
2) Can you manage an increase in your healthcare costs?
3) Would you feel good about seeing me for dental and specialty care if I was not a contracted provider with Washington Dental Service?
4) If you have the ability to fund a flexible spending account (FSA), it will likely help you offset the rising costs of healthcare, not only for dentistry, but other medical care as well. More information is available about  FSAs here.

I would love to hear your comments, either at the blog, or send me an email to chris@cascadiadentistry.com.

Treating Sleep Apnea Without CPAP or Oral Appliances?

My practice of sleep disordered breathing therapy continues. I will be bolstering my continuing education in sleep medicine and sleep dentistry. My focus in the near future will be to learn how epigenetic orthodontics and medical management of allergies can help solve airway obstruction.

Epigenetic orthodontics is a philosophy of managing the right size and shape of the cranial, facial, and dental structures. This can be done with removable and fixed orthodontic appliances. People who have breathing disorders, either allergic or physiologic, deserve to be examined for deficiencies in the size and shape of the various structures associated with an open, patent airway. Some patients cannot tolerate CPAP or oral appliance therapy for sleep disordered breathing or apnea. Epigenetic orthodontics is another possibility for creating a better airway.

An allergist, orthodontist, dentist, and/or an ENT specialist are great resources. Consulting wtih them helps discover issues and organize a plan to address allergies and growth and development of a healthy airway to prevent breathing disorders for a lifetime. I realized that I can help supervise patients' care and direct them to the proper doctors when I recognize signs and symptoms of breathing disorders.

Managing allergies and food/environmental irritants is more personal now for me than ever. Our daughter has had various protein intolerances since she was little (see previous post), and our son has had some evolving trouble over the past 2 years with clearing his throat, poor sleep, congestion. So our investigation is now ramping up to identify the causes of his troubles. The process of managing allergies is complex, but I feel that there are certain trends that I have recognized with respect to kids' allergy onset, allergic events, and ongoing mitigation of their allergies. I'll share my recent experiences.

Allergies may come and go. Kids are very resilient and can function remarkably well while enduring allergy events. But it is their underlying growth and development that is changed in the face of allergic events. As parents, we have control over what we provide for our kid's nutrition, and the right nutrition plan is a powerful and successful tool in preventing or reducing allergic responses.

Environmental allergies are tough to prevent outside the home, but inside the home resonable changes can be made to reduce allergic response.

The mechanics of allergic events are centered around inflammation. Ears, noses, and throats are susceptible to changes in growth and development as allergies persist. In my kids, we have witnessed changes in their ability to breathe. This leads to problems with sleep quality, loss of concentration or focus, hyperactivity, moodiness, anxiety, depression.

We chose to test my son for allergies, permitted a CT scan of his airway, and initiated a baseline sleep study, all in our interest of better understanding of his allergy mechanics. We now know he has an upper airway obstruction that can help explain his poor sleep quality. He will have his adenoids removed soon.  We will remain vigilant about how and what he eats, and the cleanliness of our home for dust, pollen and other airborne allergens.

Surgery and Bisphosphonate Use--An Update

Years ago, we in the oral surgery and dental professions were very worried about Fosamax and the related drugs patients used for osteoporosis/osteopenia therapy. We were concerned that there would be a significantly high risk of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients who used bisphosphonates for the management of osteoporosis or osteopenia.

Studies were conducted over the past several years that shows those who take intravenous bisphosphonates are more likely to have a risk of BRONJ (0.8%-20%) than those who take oral bisphosphonates (around 0.1%). Studies continue to be presented showing the reduced incidence of BRONJ. Regardless of the improving outlook for those patients, there are some dental guidelines that patients need to follow:

1) maintain regular dental examinations/checkups, preferably 2-3x year to prevent any dental infection from evolving into a need for oral surgery.
2) regular daily self-care is essential, including use of an electric toothbrush, oral antimicrobial rinse, and interdental cleaning devices (floss, waterpik, etc)
3) Non-surgical dental solutions are always preferred when managing patients with a history of bisphosphonate use.
4) Denture wearers who use bisphosphonates are at risk for soft tissue perforations or tears that can lead to BRONJ. Regular oral exams and assessment of the dentures are best.

Patients who undergo bisphosphonate therapy may need surgical treatment. There is a specific protocol that we provide for patients who require oral surgery to reduce the risk of BRONJ.

Call our office and let us help you reduce your risk for BRONJ.

Let Us Help You Understand Your Risk For Sleep Disordered Breathing

Sleep apnea is more common today than ever. Just look at how national news covers this disease. But a better way of defining this problem is sleep-disordered breathing (SDB). SDB is connected to a higher risk of depression, loss of concentration, hyperactivity, heart disease, heart attack, stroke, dementia, as well as a number of dental problems.Children and adults are candidates for this problem. In previous posts, I have shared what signs you or your partner should look for when you suspect a sleep breathing disorder for you or your family.

If you are worried about you, your partner, or your family having SDB, we can help. We can screen you for signs and symptoms of the disease in our office.

Some people question a dental office as the best place for a screening. But Dentists may likely be the best providers to screen patients for SDB based on their understanding of the head, and neck, the many anatomic signs they can diagnose in SDB patients. Dentists also have the luxury of seeing patients more often over time than their physician counterparts, and that is a helpful element when being able to track changes in patients' health as it relates to SDB.

Based on your initial consultation, we can offer an at-home overnight oximetry and motion sensor test to monitor your breathing and motion while sleeping. We will analyze the data from your at-home test and determine if you are at high risk for sleep disordered breathing.Call us today for a free consultation to discuss your sleep breathing concerns.

Movember at Cascadia for Prostate Awareness

Join Dr. Chris and Cascadia Dentistry in our fund raising effort to support men’s health. 

Stop in for a cup of coffee or cocoa and watch the ‘stache grow!

Contribute online at:     http://us.movember.com/mospace/3229945

OVERVIEW OF MOVEMBER

During November each year, Movember is responsible for the sprouting of moustaches on thousands of men’s faces, in the US and around the world. With their Mo's, these men raise vital awareness and funds for men's health issues, specifically prostate and testicular cancer initiatives.

The Movember Effect: Awareness & Education, Survivorship, Research
The funds raised in the US support prostate cancer and testicular cancer initiatives. The funds raised are directed to programs run directly by Movember and our men’s health partners, the Prostate Cancer Foundation and LIVESTRONG Foundation.