Which Is It--Your Teeth, Your Jaw, Or Your Muscles?

Had a patient come in, complaining of some intense pain in her lower left back tooth that not even medication could help.  My instincts screamed "ROOT CANAL" for the hurting tooth, but I let my doctor brain put the brakes on that line of thinking and I thoughtfully worked through the examination.  In the end, there was no treatment recommended. WHAT?!?!? A dentist doesn't want to carve up a patient?

That scenario is more common than you think. I have treated head and neck pain for years, and I have learned about how pain can be referred from non-tooth sources. Problems with blood vessels, facial nerves, skin, and muscles can elicit tooth pain, and vice versa. These relationships are called bi-directional trigger points. 

Take the example of the primary muscles of chewing.  Not only do we use them to chew, we also use them to clench our teeth in times of stress. Wherever and whatever the nature of the stress (bruxism, apnea to name a couple), our muscles can become inflamed, and pass pain onto the nerve pathways of the teeth. The pictures below will show how upper teeth and lower teeth can be affected.

Conversely, I have anecdotal cases of patients with jaw or muscular or facial pain that is not felt in the teeth, but comes from abscessing, decayed, or inflamed teeth.

I have successfully used bite guards, night guards, Botox in the muscles, and sleep breathing appliances to deal with these aches and pains. 

Cascadia Hits The Zip Lines

I decided to get my crew out of the office and into the woods on nearby Camano Island for some good, old-fashioned thrill seeking. We headed over to NW Canopy Tours a couple of weeks ago to have some fun as friends as well as co-workers. My team deserves to have some rewards for putting in great efforts for our patients, and I am grateful.

Some pictures from our adventure are below!

I Can't Breathe, And My Teeth Are Shrinking!

Years ago, I could swear people were coming to me with signs of freshly ground tooth enamel or broken teeth and crowns. I could literally watch the teeth being carved down over the course of hygiene visits. So I would ask them if they were aware of a habit that would make that happen. "No," they would shrug. "I don't." The only thing I and my patients could agree on was that they didn't grind their teeth during the day.

I know tooth wear is not typical. In fact, our brains do not allow our teeth to touch, even when we eat. If they do touch, it's called parafunction, or an abnormal function. So I was puzzled for a long time. It's frustrating when you know there's a reason for an occurrence, but you can't identify it.

What I started to recognize around 2005 was that patients informed me more often about obstructed breathing in their medical histories. Then I started to make a tally of which of these patients had tooth damage  and which didn't. And then I compared them to the patients who were not claiming obstructed breathing disorders. I noticed that all patients I saw who had a sleep breathing disorder were manifesting tooth wear.  The literature showed that this was occurring in a cause-and-effect fashion: When your airway closes, your brain instructs your jaw to move to open your airway. Your teeth can be in the way, and over time, will suffer damage in attempts to remedy obstructed airflow.

We work closely with specialists to determine if you have a breathing disorder, and we treat sleep breathing disorders with oral appliance therapy. We just so happen to treat teeth as well. Call us to schedule an appointment today.

Pushing A Wheelchair With Our Feet

Heard a funny observation this morning on the way into work: you ever wonder why there are people who are bound to a wheelchair, yet they somehow find a way to push themselves across the street with their feet, all the while remaining seated in the chair?

Then I picked through the morning's literature review, and the disabled wheelchair riders may be similar to patients suffering a sleep breathing epidemic. The increase in middle-age and elderly population's use of medication "sleep aids," and the rising prevalence in sleep disordered breathing that goes undiagnosed. It is a silent epidemic on the rise, and those who suffer it may be able to navigate through their lives with no clear understanding of their breathing disability.

In recent studies, it was observed that over 90% of women and over 80% of men with moderate to severe obstructed breathing disorders were living undiagnosed prior to survey.

Middle age and elderly individuals have a greater prevalence of sleep breathing disorders, most of them being obstructive sleep breathing type. Many sufferers have other associated conditions that make their condition worse, like the rising prevalence of chronic allergic rhinitis and sinus congestion, and the rising incidence of obesity.

With that being said, I have witnessed a great number of patients in my practice that are candidates for a sleep breathing evaluation. And a majority of those patients I refer are confirmed with sleep breathing disorders by our specialists.

We routinely screen our patients for a risk of airway obstruction. Call us today for an appointment.

The Less I See You, The Better!

I think it's common knowledge that humans with teeth go to the dentists twice a year. But I hope to give you a better explanation for why it's a good thing.

Maintenance or hygiene visits are all about risk management. Most patients have a measurable amount of risk for tooth decay and periodontal disease. If you have had a history of tooth decay, for example, that's a standard that holds true in evidence-based literature: You are susceptible to decay, therefore, you should have an inspection done every 6 months.There's a lot of risk factors to consider. But your dentist can help you understand what those are.  Here at our office, we issue a risk management sheet explaining your factors for decay and how to treat those risks.

Periodontal disease is similar, but there are different factors to consider. If you are a smoker, a diabetic, or have a history of gum and bone damage from an infection, you should see the dentist at least twice a year. For some people, those factors don't exist. If you don't have any risk of decay, and you don't have a history of gum disease, you probably don't need to see me so much. That's why it's not necessary to see all patients twice a year.  Some patients only need to be seen once annually for examination. The cliche still holds true: Flossing Each Day Keeps the Doctor Away.

I'm Worried About Dentistry, So I Took A Pill!

Every now and then a patient will come in and explain they had to "take a pill" to be less anxious. I totally understand the rationale. Millions of people avoid coming to see guys like me, and have to take measures to relax. I'm a big fan of how effective that choice is for patients.

But self-medicating comes with significant risks. Take, for example the aforementioned patient. She drove herself to the visit while under the influence of the drug. I don't care if it's a time-release capsule or there is a late onset of effect from the drugs. That's a black-and-white no-no without a driver or an escort. It's a recipe for impaired judgement, a motor vehicle accident, or an accidental injury.

May people are surprised when I tell them it is a serious medical risk without close monitoring and controlled prescribing and dosing efforts. "But I feel perfect!"  some say. Most every common sedative will create respiratory depression, or mess with the brain's ability to regulate stable and consistent breathing. Then there's the physical changes to balance and communicating. The ability to reason starts to diminish. And most patients I see are using at least one other medication. Some patients metabolize or process the drugs differently; some get quick effects, some get little effect. That needs close management. There are countless drug interactions with sedatives. And those interactions need to be studied and managed for patients prior to taking the drugs.

So back to the question: why do patients self-medicate with sedatives instead of letting us administer them? It's mostly due to cost avoidance, in my experience. I get that. But I can't take on the liability of  patients using sedatives unless I can closely monitor administer, and control the drugs. And there's the point: risk management and monitoring patients while using sedatives will cost money. But ultimately the costs are lower given the numerous risks every patient faces.

We Have Evolved. It's Official!

Interesting article I read about the correlations between the introduction of  local anesthetic for dental treatment in kids and the reduction in 3rd molar formation and ocurrence. See below.

Spear article

Don't Run With Scissors, Don't Pour Gas On A Fire

My 3-year old daughter wanted to do some artwork last week. Upon the request to "go get some scissors," she ran to the office and ran back with the shears flailing in front of her face. Parenting Rule #856, Don't Run With Scissors, was then practiced for the umpteenth time.

There's plenty of new rules emerging in the dental world as we learn about the long-term effects of soda on teeth. My hygienist sent me a link about the wisdom of not drinking soda--'cause it's bad for your teeth--with a new twist. Not only does soda rot your teeth, it does it faster than we thought, and probably as well as meth and cocaine.

Methamphetamine and crack cocaine users suffer from dry mouth when using. Lethargy and thirst also increase, and users often turn to soda consumption to increase energy and satisfy the dry mouth. The triple whammy is that in addition to a dry mouth and acid erosion from soda, smoking the drugs will burn, erode, and decay teeth. It's like pouring gas on a fire.The photo below is pure meth mouth.

Non-drug users can suffer the same devastating results after long-term soda use. Caffeine will reduce the flow of protective saliva, and the pH of soda is so acidic, it will erode enamel quickly. This is a patient who has enjoyed Coke and Diet Coke for a decade.

 

 The good news is that soda erosion is manageable. Neutralizing the acidity of the soda immediately after drinking it will reduce the risk of this kind of decay. Chewing sugar-free gum, drinking water, or brushing your teeth are all effective choices. 

Putting A Spare on a Bad Axle?

If you haven't already given this idea some thought, wait no longer: I am a mechanic in some respects, and a doctor of the mouth in most. But Automovite specialists and I have something in common. We want to do the best job we can with any client, and minimize the liabilities for ourselves as well as the clients with any given job. We have challenges limping some clients along depending on  the severity or complexity of their problems.

One example of this occurred this morning. A patient called this morning complaining of continued pain with his severe periodontal disease after we began non-surgical treatment. He elected to retain a poor tooth instead of removing it, and now I'm guessing he is hurting because the continued infection has flared up. And he prefers to have me call his pharmacist to treat his pain and infection.  When I reviewed his case, I noted that the area where he was complaining has truly severe bone and tissue infection with little hope for medication to solve. In addition, he plans to transfer his care to another provider.

When your car has a problem, like a bad axle or suspension, it's tough to call the mechanic and have them send out a tow truck to put the spare tire on. Furthermore, your mechanic will have a tough time assessing the extent of the current damage without having your car up on the lift in the garage.

The same holds true for a change in conditions in the mouth. Even from week to week, periodontal disease and failing teeth are in flux. A prescription for pain control may be a poor choice for a number of reasons, both medical and dental. Some issues can't be resolved with prescriptions. Narcotic medication management is something we take seriously, and we do not provide narcotic medications without seeing patients directly. And from the medical-legal standpoint, making an assessment and treatment over the phone is risky for patients and providers.

Thanks for understanding we dentist types want the best for your your medical health, your teeth. And your cars.

CPR, First Aid Update For Our Office!

We regularly see patients with multiple medical conditions, multiple medications, or other therapies. We are seeing an increase in the age of our patients, as well as seeing a greater population of patients with obstructed breathing disorders and diabetes. Understanding the complexities of these types of patients requires ongoing training and practice. 

Thank you to Tara of Medic/First Aid, Inc. who led an intensive review of lifesaving and first aid emergencies. She tailored our recertification to the emergency protocols we encounter with our surgical, sedation, and general dental patients.

Dr. Rafoth is trained in advanced cardiac life support (ACLS). He is a Dental Organization for Conscious Sedation provider, mentor, and member. Our team is trained and up-to-date on the current techniques for conscious sedation care as well as CPR, AED, and first aid services.

Complicated Care Plans Require Flexibility in Treatment

Lately I have had several consultations regarding large-scale, complicated treatment plans to care for complex decay and periodontal disease. It's been pretty trying for me as I discuss the large costs of these treatments; my patients have developed these conditions over many, many years. To recommend the right kind of care for them, I have to walk a fine line between cost and care with them all. Most of the involved plans have a sticker price that is akin to a new car.

In order to make things affordable in dentistry, I have to find a way to create steps in care. I'm always using the simple (albeit sometimes oversimplified) analogy of building a house. At times I am proposing a remodel. Other times I am proposing a bulldozing and total rebuild. And when a house gets work done, it can happen in phases. No different in my line of work.

The reason it's important to share this?  Twofold. First, everything in dentistry is expensive. It's important for me to keep that in mind as I propose care plans, because it's a real world we live in with lots of expenses from all angles in our lives. If I can create a situation where patients can start a project, have stability in the interim, and finish it within a reasonable time frame while on a budget, then I feel good about that.

Secondly, dentistry done right is time-consuming. I actually feel steps HAVE to happen in many of these cases. "Teeth InAn Hour" is bandied about these days, and I don't think that fits the majority of patients; it's practically unfair to doctors and patients alike to push that same-day tooth replacement option.  Oral health doesn't blow up and fail in a day. So there's little chance that a quality result occurs in the same time frame.

Lastly, with financing, things can happen in steps with a flexible payment plan.

Give us a call to talk about your involved or complex care. I know we can find a way to make it happen in steps.

Battling The Banes Of Our Existence: Inflammation AND Big Pharma

Inflammation is pervasive in the human body.  It's likely that it is the primary cause for aging and our mortality. Hundreds of drugs have been brought to market to combat inflammatory diseases. It's likely thousands more will be introduced to treat inflammation at the genetic level, inhibit inflammatory enzymes and proteins; the list goes on.

One of the most influential drugs in the battle against periodontal disease is doxycycline. The popular brand name of this drug is called Periostat.  But it is available in generic formulations. It is an antibiotic by design. But instead of using heavy-duty doses to kill bacteria associated with periodontitis, the drug has been wielded by researchers and clinicians in small amounts to suppress the body's inflammatory process, which is actually a reaction to bacterial toxins.

When the inflammatory process begins in periodontal disease, it is not the bacteria that create tissue destruction. It is the body's reaction to the toxins that trigger enzymes and bone- and gum-killing proteins to surge. So the low-levels of doxycycline suppress the enzymes released during inflammation, and the tissues are not destroyed as readily over time. The concept is called host modulation therapy.

Patients occasionally pipe up with concerns that they will not use the drug because they fear it will promote a bacterial super-infection when using doxycycline.  But frankly, the doses are so small that they don't even kill bacteria, and do not promote the mutations responsible for bacteria to become more resistant to treatment. My opinion is that it should just be added to the water supply based on how effective it is for some patients with highly sensitive inflammatory reactions. It's one of the only good weapons I have seen sensitive patients use with success beyond good self-care to avoid surgical treatment and minimize the impact of periodontitis.

But there is now a greater challenge for patients to get access to this drug because of the decisions pharmaceutical companies and medical insurance companies are making. Not only are many drugs being taken off the shelf due to discontinuation of drug manufacturing, but insurers are also implementing increases in co-payments for patients who want to use drugs that are in short supply. So if you or others want to know the status of your drug of choice in the marketplace, go to the site managed by the American Society of Health Pharmacists.

New Beginnings

Old School is a favorite movie of mine.  For some reason, Will Ferrell's voice resounded in my head as I was getting my day started with a dental assistant for a working interview. To me, "new beginnings" mean that my team gets a chance to find a great asset to add to the mix. And the theme of new beginnings are also important when any of our team is welcoming a patient into the practice.

One of the major tenets of our mission is as follows:
                     
"Our patients are supported by a personable, approachable team concerned with building their trust and confidence.  We provide a relaxed, open forum where you can consider or express a new desire for dental care."

I have always been associated with activities an interests that include people having fun together; making and performing music, hosting uniquely themed parties, skiing with a group, mountaineering, playing Scrabble and other games around the table with my family. So naturally I want to get to know somebody before I launch into dental care. And that's what I decided my team should be great at. Inviting guests into our house means we hang their coat, give them a tour, and sit down for a bit to share about each other. Then we can take the steps to plan treatment people want to pursue. Until that relationship is made, we don't do dentistry. 

So call us! You can come in to meet us for a cup of coffee and a no-cost consultation, or book a visit for a cleaning and examination to get your dentistry done. 

Treat Blood Pressure By Treating Apnea

A patient walked in to see me last week, middle aged gentleman, energetic, talkative, friendly. Not the least bit stressed-out from all outward appearances. But his blood pressure was 210/130!  His readings came down modestly as we sat and talked.  But I booked him a visit at his primar care doctor's office before he left. Upon examination, I recognized he had lots of risky physical characteristics and a positive history for sleep breathing obstruction. I told him he could manage his blood pressure by managing his breathing.  His eyebrows went up.

It's true--blood pressures are reduced in patients treat their obstructive sleep apnea. The atricle I attached goes on to describe the study was performed with patients using oral appliance therapy.

I am a member of the AADSM--The American Academy of Dental Sleep Medicine.  Call today to begin your treatment.

Mid-Level Dental Providers--An Update

The idea of MLPs was introduced by advocacy groups to aid the most under-served portions of the population at large. MLPs have been suggested to work independently of dentists, possibly in their own clinics, and begin helping patients in geographic areas where providers are needed most. So with the unchanging tooth decay epidemic, the question  is: are MLPs valuable for Washington State's future? The answer:  not really. Over time we will likely see the value of MLPs diminish after they are introduced.  The answer lies in the eventual failure of the economics behind the model for MLPs.

The American Dental Association (ADA) released a recent report about mid-level dental providers. (MLPs) The upshot is MLPs can perform valuable skills to improve patients' dental health. However, there is no obvious economic value in having MLPs incorporated into the dental industry. The ADA report states that regardless of how may providers treat dental decay, the population at large will not see a reduction in dental decay.  Dental decay is an epidemic, and MLPs would not reduce the incidence of tooth decay.

If you recall, I have been against MLPs for a few reasons. MLPs could create catastrophic changes to our dental system for patients and dentists. The principles that I want you to consider were summed up nicely by an amazing colleague of mine, Dr. Christopher Jean, in a recent message:

"If independent mid-level providers have the capacity to operate a clinic independent of a dentist, the following will most likely occur:

1.  The (midlevel providers) will apply for and eventually receive acknowledgement from insurance companies to perform many of the same clinical functions as Dentists.  The reimbursement rate as set by the insurance companies will be the same.  In fact if mid-level providers can operate clinics, they can now hire dentists to perform ancillary procedures in much the same manner as denturists currently do.  Nothing will change, especially for the consumer.  The equipment costs will remain the same and the costs of day to day operations will still be the same.  Instead of a flood of midlevel providers going to areas to serve the poor, they will gravitate to where the money and jobs are.

2.  The wages for midlevel providers can initially be set (at a certain level), but with several years of experience, the market will eventually dictate what they can make and that is usually productivity based.  If a midlevel provider can produce what a dentist can produce, then they can make what a Dentist can make within a comparable scope of practice for how quickly they can turnover a chair...If hygienists can command (a higher wage) to go to an office for a day, but a midlevel provider can do so much more, it is doubtful that after several years the rate of pay for midlevel providers will be less than that of hygienists.  The demand for hygienists will go down and the cost of midlevels will eventually exceed (the hygiene wage).  The cost benefit ratio for becoming a therapist will exceed the motivation for becoming a hygienist.  The quality of applicants for hygiene programs which is very high will drop.  Therapists will have a broader focus of practice.  This can be beneficial in certain instances, but nobody is better at the focus of prevention and maintenance than hygienists.  There will be a drop off in quality of personal focus on this one key gate-keeping responsibility if there are fewer hygienists who practice as a proportion of the whole field.  Studies have never decried the importance of hygienists, just their average hourly wage within the state of Washington as an economic obstacle to affordable healthcare for the working poor and to medicaid patients.

3.  Public health clinics will restructure their personnel to take advantage of  midlevels.  Dentists will be more responsible for specialty procedures because there will be fewer of them.  Their practice risk and stress will increase.  Subsequently the retention rate will be more difficult and the turnover higher if salaries do not increase.  If private practices pay more for Therapists, public health will need to up their payroll ante as well.  The payroll savings will still be there but it won't be at (the same initial rate) after a few years.  The real effect won't trickle down to underserved areas because it would take several years to construct new clinics in underserved areas and by the time they are ready to run and people start to access care which may take a few more years, the wage cost savings may diminish significantly to have any concrete impact upon the patients they were intended to serve.

4.  The true beneficiary to the addition of a midlevel are corporations if they are heady enough to be opportunistic and take advantage of this.  They can offer a fixed salary, benefits plus productivity bonuses that public health and Mom and Pop private offices either can not or are not accustomed to providing.  Corporate chains already form a growing segment of the whole dental health field.  Although many are not as efficiently run office to office, they play an important part in the whole economic landscape of the field that their presence and impact cannot be dismissed.  They can draw upon that demographic that used to be the bread and butter of most dental practices.  Yes, I'm referring to the trade unions who have traditionally had the best insurance benefits, the members who actually needed the most amount of care and who had the most amount of flexible time to access the care.  If corporate offices strike a deal with unions that represent that majority demographic (for dentistry), it sets a precedent by lowering the value for services and treating the rendering of procedures as more of a product that is wholesale rather than treatment as part of a disease process.

And this is the whole point...we need to assess the impact of what this bill can really effect rather than what some advocacy groups hope it will effect.

The field is changing...the aspect of personalized care with a single doctor/ single hygienist model is becoming less of a standard.  The common idea of addressing a patients dental/medical needs and putting them on preventive maintenance is gradually being replaced by a greater profit driven second tier of money management which typically focuses more on productivity and return as opposed to the relationship based doctor patient approach.   Eventually the societal perception will slowly gravitate even more towards receiving dentistry as a product rather than a doctor-managed service. There is much more to being a good healthcare provider and a good doctor than just drilling, filling and cleaning.  Every procedure that is done and every word of advice that is communicated bears a relevance to the overall totality of a patients general health and where that patient is or is not headed as they age and pertains directly to their quality of life."



Dental Health Day is this week in our state's capital, Olympia, Washington. There is still a possibility that the health bill to allow MLPs in Washington, HB13, may move into the legislature for more activity. Please show your support to cancel this bill. The economics of MLPs are too complex and not beneficial to the dental industry at this time.