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. 

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.

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. 

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.

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.