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. 

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.

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.

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!

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. 

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.

Anxious Patients Who Self-Sedate!?!?!

The following is definitely a scenario that many dentists experience: An anxious patient takes a prescribed sedative medication to "settle down" prior to coming to a dental visit. The dentist has not been previously informed about this decision. The patient has decided that "there is enough" medication to effectively relax to begin treatment. Some dentists would treat this patient with no additional attention paid to the sedative medication, and the visit would appear to be successful with no difficulties of any kind.

Even though the above scenario may be commonplace, there is a significant amount of risk that is created for the patient, the doctor, and the team. There are a number of medical, ethical and legal issues with this situation.

1)  Even if a physician or dentist has prescribed a sedative medication for anxiety control, and the patient had self-administered the recommended dose, it is always implied that the drug can impair ability to drive or operate machinery. It is no different than being under the influence of alcohol. The drugs should not be used unless the patient has consulted with the doctor about the safest, most effective dose to reduce anxiety and complete the treatment successfully. The patient needs an advocate and/or escort present. The safety of the patient is at risk. The safety of the public at large is at risk if the patient was to drive away from that appointment under the influence.

2) Sedative medications can impair the ability to make sound decisions. If treatment had to change, or an unforeseen event demanded a change in treatment, it would be difficult for the patient under the influence of the medication to offer clear-minded consent to change their treatment. The best ethical and legal choice is to have the patient's advocate (who had been designated prior to sedation) make the choice in the best interest of the patient.

3) Without proper and continual monitoring, there is no way that the dentist or any healthcare provider can assess the real-time safety and physical status of any patient under the influence of sedation medication. The medical implications are too numerous to get into. Let's just briefly summarize the potential consequences: Injury, disability, or death are possible outcomes without proper attention to sedated patients.

4) Consultation and planning prior to treatment is essential in order to safely administer the least amount of medication to produce the best sedation effect for the anxious patient, while successfully and comfortably completing their treatment. This falls under the ethical category of non-maleficence: do no harm.

5) It takes time, effort, and expense for a healthcare team to manage a sedated patient to ensure their safety and success with any treatment while under the influence of sedation medication. So you should be aware: whenever our team treats you, and you have self-administered medications or substances to eliminate dental anxiety, you can expect us to deliver the safest and most successful outcome for you. But it will come at a nominal price to ensure that happens.

Th New Paradigm for Periodontal Disease Control, Part 3

Dentistry has found ways to manage these infections beyond cleaning up the biofilms in the past 10 years. Routinely altering the patient's susceptibility (shifting it towards being more resistant to disease) helps them keep their teeth longer.

Shifting a patient's inflammatory response can be done with unique medications (Periostat, Oracea). These medications suppress an enzyme that is critical in creating inflammation.

Probiotics like Evora Plus have been engineered to displace the bad bugs in the biofilms with a specific group of bacterial species. Just as we see Activia yogurt commercials showing how we can add good bugs to our gut, we now see how oral probiotics shift the prevalence of oral bacteria that promote periodontal disease. 

Achieving excellent diabetic control is another way to improve a patient's threshold for infection.

Autoimmune disorders, such as diabetes, are complex and numerous. Rheumatoid arthritis, lupus, HIV--just to name a few--are all diseases that, when well-controlled, influence the outcome of teeth in periodontal disease patients.

Smoking cessation, stress reduction, creating healthy work environments, behavioral therapy, proper diet and managing alcohol intake, consistent exercise--all of these are lifestyle changes that make a difference.

Most people don't realize that periodontal disease is a bug problem AND a bite problem. Balancing a bite with orthodontics, wearing bite guards, and anchoring or stabilizing teeth are dental solutions to treating periodontal disease. And the last resort, of course, is to remove teeth that have contributed to the constant pileup of biofilms.

The New Paradigm In Periodontal Disease Control, Part 2

Last entry discussed how biofilm is constantly occurring and attacking at-risk patients. So this entry will focus on how a patient has to be susceptible to inflammatory problems like periodontitis. There are genetic, dental, and medical reasons that influence how a patient contracts the disease.
  
Biofilms affect all of us, but they affect each of us differently. In fact, about two-thirds of patients who have periodontal disease only contract a mild form of it. The other third have serious and complex infections. There are things in people's lives that tip the scales in the direction of severe disease. Patients' genetics, lifestyle, and medical health influence their thresholds for infection and damage. The big categories are:

1) Genes for highly sensitive inflammatory response, or a family history of the disease.
2) Medical conditions that alter the immune response or inflammatory response.
3) Smoking habit.
4) Chronic stress in any form.
5) Bite problems, including clenching, grinding, or unbalanced bites.

Even if we remove biofilm when patients have infections, they may still get recurrent infections because of the above factors. Since biofilms never take a day off, patients with one or more of these above risk factors need to constantly manage their disease issues with their dentists and specialists. Shifting the patients' responses to inflammation means getting rid of biofilm regularly, but also treating  the risk factors. Until the those are managed the right way, the periodontal disease will hang around, and the chances of losing teeth go up.

Diabetes, heart disease, chronic inflammatory lung diseases, apnea, autoimmune disorders, obesity --these are all disorders that raise the level of body-wide inflammation and reduce the body's ability to heal.And periodontitis works to complicate these diseases too.

Smoking introduces toxins that depress the immune system's ability to fight infection, and also stimulates the release of a number of inflammatory proteins in the body.

Chronic stress, be it physical or psychological, will alter the body's threshold to infection. Chronic pain induces the same inflammatory proteins as smoking in some cases. Depression has been shown to alter physical health and immune response.

The New Paradigm in Periodontal Disease Control, Part 1

I woke up this morning thinking about one patient who saw me several months ago for non-surgical treatment of his periodontal disease. He had been surprised about how it did not take multiple visits, nor did it require the scraping of hand instruments to treat his infection.  And it makes sense that he would question our standards and practices; he had a history of treatment for the disease, as well as a decent clinical concept of how to treat it. His wife was a hygienist who dedicated her life to treating periodontal disease based on the most ideal knowledge base, instruments, and protocols available at that time in her career. He questioned the value of the treatment based on the shorter treatment times and lack of "hand scraping."

I realized there was a lot of things that have changed about how we recognize, treat, and manage periodontal disease that I may not have expressed to him. So I decided to drill down into the deep pile of knowledge we have accumulated over the past 10 years of clinical and scientific research. I want to do a better job of explaining the two different paradigms of treatment for periodontal disease. I want to help my patient as well as our readers understand there was a previously practiced "old-school" paradigm and a solidly established "new-school" paradigm that drives how we treat our patients today.

The new paradigm is focused on how practitioners manage the infection threshold for patients susceptible to periodontitis. Long ago, it was thought that periodontal disease was a bacterial disease; although some patients had more severe disease, and some patients less, bacteria was primarily responsible for tooth loss associated with the disease. But today, we realize three important concepts hold true for periodontal patients: 1) biofilm (the bacterial sludge) has to find a home around and between teeth, 2) the patient has to be susceptible to inflammatory disease like periodontitis(genetically and medically driven reasons for that), and 3) routinely altering the patient's susceptibility (shifting it towards being more resistant to disease) helps them keep their teeth longer. This newer model of management uses progressive technology to better mange the disease. Management is also more medically driven than it is dentally driven; heavy tartar or lots of bugs are not the sole focus for eliminating disease. That means we take a different approach to measuring, analyzing, and directing other treatments for the disease then we ever did before.

So biofilm piles up around and in between teeth like a bad TV rerun. It's episodic. And there's some nasty strains of bugs in there. Certain strains of the bugs are more aggressive and more resistant to treatment. So if doctors or hygienists try to simply hand scrape the bugs off the teeth, they just smear it around if it's not present in hard tartar. The bugs have also evolved ways to reside in the soft tissues. The new paradigm involves sonic or mechanical instruments to not only remove the biofilm from the teeth, but also irrigate or flush the biofilm from the holes in which they live. And research shows it eliminates the bugs. And sonic instruments can remove some inflamed soft tissue with less trauma than hand scraping. Lasers are also more effective: vaporizing biofilm and soft tissue where the bugs live has shown dramatic results in disinfection and healing of tissues. And research studies have shown how mechanical instrumentation is as good or better than hand instrumentation.We've traded muscles for technology: we have more effective and more efficient tools to treat the disease.We have seen patient outcomes with the new paradigm of  that are as good or better than the old-school equipment and practices.

In my next blog, I'll discuss how controlling biofilms requires attention to follow-up visits and assessing the medical profile of every patient.

We have information available about periodontal disease on our website. Call us to set up a consultation about your health today.

Midlevel Dental Providers--Equal In Skill and Training To Dentists?

PBS' Frontline series has been a great example of quality in television journalism.  I heard about the episode that was released about 2 months ago that focused on the challenges of the dental care system in America. So I went online to review it. And I drew some conclusions and formed some opinions. I also have some solid advice I'd like to offer to our readers.


Our country has a crisis on our hands. Patients can't get access to dental care as readily as they can for medical care. But from a wellness standpoint, I feel that there are a lot of patients who could manage their diet, lifestyle choices, and their own preventive dental care in much better ways. But the issue I agree with in the Frontline piece--the problem of uniting patients with affordable healthcare--is growing.

Beyond lifestyle changes, another factor in creating the growing problem is that the historically more accessible medical insurance model for care--which is also failing--is not applied in dentistry.  You say, "hey, wait--there's dental insurance, and it's like medical insurance!"  WRONG.  There are a significantly lesser number of insurance providers and subscribers for dental insurance to create an environment for dental care that would even come close to rivaling access to medicine. Let's not forget that this is correlated with the embarrassingly low level of reimbursement and insulting iron curtain of restrictions and limitations evolved by dental insurance policies. This is not a figurative statement I'm about to make, it's a fact: dental insurance reimbursement levels are stalled at levels seen in the 1960's and '70's.

An economic downturn and high level of unemployment has created a ripple effect that I am able to gauge with just my pool of patients. I would consider my community to be an average suburban/rural community--lots of families, lots of commuting employees to distant offices/work locations, a wide variety of age groups and career types. I witnessed about 20% of the patient pool disappear from my work schedule in 2008-2009 at Cascadia Dentistry.  And upon further research, I noticed that across the nation that was generally the trend. Unemployment increases led to less cash flow for dental care for a lot of patients. The fallout from the unemployment and economic downturns are still occurring in my practice and abroad.

Another truth about dental care: there are a lot of people who are more susceptible to the perils of dental disease that really need more help than they can provide themselves. Said another way: no matter how much preventive care and attention is paid to managing their lifestyle, high-risk dental patients will always exist. And if more of those high-risk patients are unemployed?  The dental health epidemic starts to snowball even further.

I started to envision a hypothesis where all dental patients that 100% access to care would be able to have the properly planned and executed dental care, given the dental professionals are all made equal.  BUt as the Frontline piece illuminated, that hypothesis is a fantasy.  This industry has a lot of variability in the style of how healthcare is delivered, and also in how business models dictate the performance of dental care providers.

The business models profiled on Frontline seem to be god working models for dentistry to cut costs--in theory. I have some doubts about the business model of corporate dentistry. Corporations and small businesses are alike in many ways. Both entities have operating costs and profit/loss goals. The main differences between them in my view are 1) the personal approach and continuity of the doctor-patient relationship (being able to see the same doctor consistently over time) and 2) the established set of rules for meeting profit/loss and productivity goals. Tying income to productivity (which means the amount or volume of dental procedures completed), can create the wrong emphasis in a dental practice. In my opinion, creating incentives for dental care providers to generate more productivity usually results in corruption of the doctor-patient relationship. Up-selling happens in dentistry to meet production goals if that is how the business model is managed, and I don't feel good about it. I feel the true mission of dentistry and dental businesses is to meet the goals of the patient first, and introduce those patients to opportunities to have treatment they didn't know were available to meet their goals.

So now we turn to a look at mid-level providers (MLPs). They are now being introduced in some areas of the country. They can improve access to dental care.  Lower costs are important to achieve, and a mid-level provider can help. Frontline interviewed an MLP as saying her training and skill for certain procedures was "exactly like...dentists."  That statement is questionable.  The consequence of MLPs, is that they are unable to work unsupervised; as it stands, our nation's MLPs require dentist supervision to plan and execute care. MLPs are also limited in their scope of care; they can't perform dentistry to the same level of excellence for all the needed procedures a patient may seek. And the level of training is limited to a few restorative procedures.  It is also uncertain what the continuing education expecttions or intent will be for MLPs.  But my biggest concern is that MLPs run the risk of caring for a patient that requires a change in treatment while in the midst of receiving care.  This could compromise the patient's treatment result. A dentist would ultimetely have to step in and complete the unfinished care, possibly not until a later date with the patient in limbo until that occurs. The expertise and vast knowledge of alternative remedies for any patient are at the fingertips of a well-trained dentist.

Also, the experience and ability for an MLP to perform the standard of care for patients is debatable. A lot of time and experience has been built by dentists to deliver the best care for their patients. Just because an MLP can fill a cavity, build a mouthguard or provide preventive care, doesn't mean they can execute an emergency root canal, manage complex infections, or solve ongoing challenges for high-risk dental decay patients in an efficient or effective way. Those few examples I listed require high-level medical and dental training that MLPs do not receive. In my opinion, the best use of MLPs is to work in tandem with a dentist, but the catch-22 is that it still bottlenecks the access to dentistry for a huge number of patients-in-need.

So what the Frontline episode showed me is that there are a number of great things happening to improve access to care, but we have a long way to go as a profession to make it work well.