Tag Archives: 2010

One Man, Two Battles: Vietnam and Dental Health

As a dentist, ADA first brings to mind American Dental Association, but American Disabilities Act is yet another agency for this acronym. It’s responsible for handicapped parking places, wheelchair ramps and many implemented standards to assist handicapped people in living life without having to face more barriers than their handicap already has given them.

Recently, a wheelchair-bound patient entered my office, and based upon the ADA, he had ample room to maneuver his wheelchair in our treatment room, perform a transfer procedure into our dental chair and receive his normal dental cleaning and exam. Our patient history revealed no significant medical findings, no allergies, but did not reveal the most significant aspect of this man’s life. This came later in conversation during a dental consult.

John Higginbotham, at age 19, was drafted into the Vietnam War in October 1968. He was instructed in military procedure, informed of Viet Cong, the North Vietnamese Army and handed an M-16 automatic rifle. By comparison, my daughter recently headed to college at about the same age and I’m worried about whether she will have the insight to wash her cloths and eat properly.

Base Helicopters

John Higginbotham, an Army soldier, was stationed in Pleiku (“playcoo”) Vietnam located in the Central Highlands, a cold mountainous region near the Ho Chi Minh Trail (a supply line between north and south Vietnam). Plieku was the location for Camp Holloway, a helicopter base that flew search and destroy missions and provided air support for ground troops. John’s job was to protect this helicopter base against invading enemy patrols. His bravery was displayed volunteering for dangerous nighttime “roving missions”, that entailed engaging the enemy when radar intercepts of enemy activity were reported. Faced with ambushes, booby traps such as landmines and other explosive devises, John and other infantry soldiers headed out to engage the Vietcong on February 19, 1969, when suddenly John’s body was launched into the air by the explosion of a mortar round ten feet away and a large piece of shrapnel that entered into his back. The damage was instant at the lower part of his spine causing broken vertebrae and loss of the use of his legs. The same helicopters he served to protect now provided the rescue mission for him to be airlifted to the closest hospital for immediate surgery. After 16 months of treatment, despite several medical doctor’s opinions that he would never walk again, was the astounding image of John walking out of Martin Army Hospital on June 26, 1970 with two canes, all thanks to the “magical” skills of his neurosurgeon.

Regaining his life and the use of his legs, John ultimately found a job as a Nuclear Plant Mechanic at Georgia Power in 1976 that lasted him for thirty years until June 2004 when he was forced to go on long-term disability and once again say goodbye to the use of his legs.

John has won many battles, and beat the odds when they were against him. John, however, had another ongoing battle between him and his teeth. Exposed to Agent Orange (a herbicide), especially while crawling on his belly in the jungle, John along with many other Vietnam vets, have experienced unusual dental problems including loss of teeth.

John entered into our dental office displaying tremendous courage because of psychological obstacles created by numerous bad dental experiences in the past. Entitled to the benefits of the Veterans Administration (or “VA”), which provides patient care and federal benefits to veterans, there was no reason John should not have gotten his dental problems taken care of over the past thirty years. His missing teeth, poor chewing and general discomfort instilled his desire for better teeth.

A comprehensive exam created the dental goal of several bridges and coordinated partial dentures to replace his missing teeth. This plan would eliminate poor chewing and alleviate his pain. Through the efforts of dentist and staff working diligently with the VA, we ultimately received clearance for John to enact his treatment plan. John is a man without use of his legs, confined to the total use of a wheelchair, often experiences shooting pains down into his legs and lives with the memories of war. Despite these adversities, John has a great outlook on life, and has recently found great happiness with the “new mouth that I’ve always dreamed of”. His dental health care was pain-free, which was a primary objective for John. His dental outcome achieved all his wishes of having his missing teeth replaced. He was very pleased he finally had overcome the huge hurdle of receiving dental care that he had battled for decades. His dental care restored not only his teeth, but also his confidence in himself. I salute John as an outstanding person and a man that fought for the freedom of this country.

The Mathematical Formula for Successful Patient Care

Patient Care! It’s what every doctor strives to achieve. It’s what every patient desires. Staff in every hospital, clinic and private office all want to provide the best patient care possible. This is the beginning notion for all these individuals. Then, reality gets in the way, and patient care is delivered at a level lower than anyone would like to admit. Patient care could boil down to the old phrase: “Happiness is when Reality meets or exceeds Expectations”. I do not believe patient’s expectations are too high. I do believe reality does fall short of what it should be. So, how do we improve Patient Care so that everyone, patients and health care staff, feels good about the process and the end result? If we don’t ask the question, we will not have an answer.  How do we make patients feel special and not “like a number”?

Twenty years of doing dentistry has taught me that there are certain fundamental elements that make patients feel good about their dental visit, and I refer to them as

“The Big 10 Elements of Patient Satisfaction”:

  1. Patient understanding of their dental treatment (communication during exam)
  2. Patient awareness of the cost for dental treatment in advance
  3. Promptness of patient being seated on time for their appointment
  4. Dental appointment performed in predicted amount of time
  5. Patient comfort during their treatment
  6. Appointment confirmation call in advance of dental appointment
  7. Follow-up call by staff or doctor to check on patient after dental care
  8. Patient acknowledgement upon entering reception area
  9. Listening to patient needs carefully to help patient in any way possible
  10. Proper filing of insurance and billing.

Any one of these areas are potential “hot spots” for patients. Even if an office delivers most of these elements does not mean the patient is satisfied. An anxious patient that feels any pain during an appointment may never return to that office or have the courage to receive dental care for years. A patient that is a stickler about time and waits in the reception area for 20 minutes may get up and leave and never return. Thus, it is important for the care-provider to achieve all aspects of “The Big 10” for every patient to achieve an “A+” result. Any less than all of these elements and the outcome could fall to a “C” or lower.

Why do dental offices fall short of delivering all of “The Big 10” elements of patient care?   There are countless reasons. Several examples are as follows: (a) your appointment is running 20- 30 minutes late because the two or three patients prior to your appointment were late getting to the office or perhaps the dental procedure on a patient before you ends up more complex than anticipated and delays the schedule; (b) your treatment becomes more complex than originally planned, requires more treatment, and costs more than anticipated. Let’s stay with just these two examples. Anything that is carefully planned out can change. Notably, this will affect our premise that Happiness is when Reality meets expectations. So, what can the dental office and staff do to maximize the patient’s satisfaction relative to changes like these? If there is a delay in the schedule, it is ideal for the dental office to contact you and let you know the office is running behind, which “resets” your expectations and allows you a buffer to relax about striving to be on time (only later to find out there is a wait). The dentist and assisting staff should be aware of your time constraints and any commitments after your dental appointment to adjust care to fit your schedule. If treatment changes in the dental chair, it is always polite and respectful to stop the procedure and make you aware of this fact and have a front office person inform you of any changes in cost and get your approval before continuing on with treatment. These examples clearly reflect fundamental respect for the patient and good communication. These are key elements to achieve patient satisfaction.

Mathematically, there are three elements that broadly provide the basis for successful dental patient care – Office Environment, Dental Staff and Dental Care. Any one of these three elements can be rated by the patient to be: “positive”, “negative” or “neutral”. If a dental office environment is warm and friendly it would receive a “positive” rating. If the Dental Staff calls before your appointment with an upbeat personal message and the dental assistant gets you a blanket because your cold and the doctor takes time to explain the necessary details that make you confident about that days treatment, they would receive a “positive” rating. If the treatment goes smoothly and the anesthesia and subsequent treatment is comfortable, the best to hope for here would be “neutral”. After all, patients typically don’t really find dental treatment positive; we just don’t want them to find treatment negative.   The mathematics of dental care following this summary would be “positive”, “positive”, “neutral” and the overall rating would be “positive”. The mathematical formula for patient satisfaction is a gross weighted average and is based upon “The Big 10” individual elements of patient satisfaction previously discussed. If the entire dental care team shares an understanding of how important these factors are and how to implement them on a patient to patient basis day after day, then the patient wins by being satisfied and leaves the dental office with a positive outlook regarding their dental experience.

“My Fillings Don’t Last Forever? Oh My Gosh!”

“Thank you” Lori Moller who inspired this article during a recent visit to our office. Lori provided her unbiased opinion stating she believed her dental fillings lasted a lifetime. This is such a big misconception in dentistry. Lori granted an in-depth telephone interview to provide further insights as to why she felt her fillings would last throughout her entire life.

QUIZ:

  1. Fillings last a lifetime; true or false?
  2. How long do dental fillings last?
  3. All fillings last about the same time; true or false?
  4. People’s mouths don’t influence how long fillings last; true or false?
  5. All dentists achieve the same quality fillings; true or false?
  6. Old fillings have to fracture before they need replacing: true or false?
  7. Fillings don’t get decay around them; true or false?

(Answers: found throughout the article.)

Most people are not very enlightened about their dental fillings, and have the same notion Lori did. Most of us receive fillings when we’re children and dentists seldom volunteer an explanation of how long these fillings should last. A comedian once joked asking Jimmy Carter what he thought about pregnant Scandinavian Nuns, to which he replied, I don’t think about pregnant Scandinavian Nuns. The same aspect applies to dental fillings. We just don’t think about fillings. Consequently, we grow up without any facts or expectations regarding our fillings, we do not discuss this in school, nor socially, so until a dentist examines our fillings and surprisingly tells us they need to be replaced, we assume they last indefinitely.

During routine discussions with patients on a daily basis, it is clearly evident a large majority of patients believe dental fillings placed during childhood last for the remainder of their lives. When you consider our mouths are constantly moist, 98.6 degrees and full of millions of bacteria, it is as the Listerine commercial used to say, “a battle ground”.

In fact, there are more than 100 species of bacteria, hundreds of species of fungi, protozoa, and viruses that reside in our mouths. Further, microbiologists estimate there are an additional 500 living, breathing organisms inhabiting our mouths. Our mouths contain more bacteria than the entire world’s population, while our bodies house approximately one trillion bacteria.   Bacteria get into our teeth because of many imperfections — the grooves in the top of our teeth — despite the defense of our saliva, immune system, brushing and fluoride. A cavity follows. Decay must be removed and is accomplished by drilling and creating what is termed a “cavity prep”.   The cavity prep is now filled, traditionally by “amalgam” (silver filling) or more recently by “composite” (white fillings), to create a new surface that is impervious to future decay, but realistically not forever. So, how long do fillings last?

Think about car tires and answer the question, how long do tires last? The answer depends on many factors including the quality of the tires, how much you drive in a year, how heavy the vehicle, how many people typically ride in the vehicle, conservative or aggressive driving habits, damaging the tires, whether the tires are properly aligned, and even the geographical climate of where you drive the vehicle.

Dental fillings are also affected by many variables. These include thermal changes that affect the tooth and filling differently, the size of the filling, how big the filling is relative to the tooth, type of food and liquid the person ingests (i.e. sodas, chewing ice or hard candy), heavy biting force, acid reflux, grinding of teeth at night, clenching teeth during the day, taking medications, aggressive strains of bacteria, and strength of person’s immune system.  Fillings, similar to the tire analogy, can last for only a few years or for decades depending on the abuse they must withstand.

For example, a large man with strong jaw muscles, that clenches in the day and grinds at night, with acid reflux that is exacerbated by a poor diet of acid-rich foods, sodas and many medications cannot expect fillings, especially large fillings, to last anywhere near the norm of 10-15 years.

Fillings more obviously require replacement when a filling breaks fillingsout of the tooth or the tooth breaks around the filling leaving a gap and exposing “dentin”, which is the layer of soft tooth structure beneath the enamel very vulnerable to bacteria.   Fillings less obviously require replacement as they chronically disintegrate from years of physical deterioration at the junction of the filling and tooth, allowing bacteria to penetrate down the sides of the fillinginto the tooth, causing “recurring decay”. Bacteria once inside the tooth cause decay by producing acid that destroys tooth structure. Another common cause of recurring decay is an old philosophy of placing a small filling in the middle of a tooth surface with many grooves that were not all included in the cavity prep (known today as “extension for prevention”), nor were the grooves sealed, and resulting in these grooves eventually experiencing recurrent decay. Thus fillings or teeth do not have to break in order to replace a filling.

In SUMMARY, fillings don’t last a lifetime. Fillings last 10-15 years based upon historical average. The best time to replace fillings is once they demonstrate “marginal” breakdown (gaps between the filling and tooth) so that recurrent decay is kept at a minimum.

It is important to realize all dental treatment and fillings are performed to eliminate bacteria and prevent the future access of bacteria. Therefore, the dentist should work with microscopic glasses to magnify the tooth and let him see details associated with placing the filling into the tooth and polishing the filling so well that bacteria cannot get under it.

Dental fillings will typically be placed during childhood and replaced three times in a person’s life. Fillings initially placed during ages 6-13 will be replaced in a person’s 30-40’s, again in a person’s 50-60’s, and again in a person’s 70-80’s. Dental fillings are amazing.   Rejoice in the fact that dental fillings in today’s technology are white and very natural looking, very different from the unattractive result of a mouth full of silver fillings that was experienced years ago. Realize that decay happens, and fillings need to be replaced multiple times in your life. This will avoid the surprise felt by Lori and many other patients.

How Does Dental Anesthesia Work?

Anesthesia is an amazing phenomenon for dentistry and medicine that allows us to perform miraculous procedures that would otherwise be impossible to accomplish. Can you imagine going to have any major surgery or dental procedure without anesthesia? The concept of anesthesia invokes the simple principle of separating an area of the body from the brain so it does not interpret pain. How does anesthesia work or more specifically for this article, how does dental anesthesia work?

According to Stanley Malamed, author of The Handbook of Local Anesthesia, several things happen at a cellular level when anesthesia is placed into an area of the mouth. Nerves normally transmit information from countless areas in the mouth to our brains like a telephone wire. This transmission of information, including pain, causes the action of sodium ions to move within the nerve fibers and results in the nerve sending the pain message to our brain for a reaction from our body. The more pain involved, the more cellular activity that occurs and the “louder” the transmission to our brain. Dental anesthesia works by binding to the nerve with a stronger affinity than natural elements in the area, specifically blocking sodium activity so there is no transmission of any nerve signals, (including pain), which permits several hours of working time to complete dental treatment.

The most commonly used local dental anesthetic is Lidocaine (also called Xylocaine or Lignocaine), an amide-type anesthetic, popular because amide anesthetics rarely cause allergies. Replaced by the amide anesthetics in the 1940s, a still commonly reAnesthesia Picture Showing Nervesferred to anesthetic is Novocaine, seldom used today because of allergic reactions. Other local anaesthetics in current use include Septocaine, Marcaine (a long-acting anesthetic), and Mepivacaine. Most dental anesthetics come in two forms: with and without epinephrine. Epinepherine is added to dental anesthetic to make it last longer and is most commonly used in Lidocaine anesthesia. This agent can occasionally mimic adrenaline reactions for patients (especially women) by causing slight increase in heart rate and although this is normal and safe, it can be disturbing. Pregnant women and patients with high blood pressure receive epinephrine-free anesthesia.

Dental anesthesia is best delivered by use of recent technology known as “computer anesthesia”, which is a very comfortable and consistent way of “numbing” a patient.

Upper teeth are easily “numbed” by infiltration injections where the anesthesia is delivered above each tooth individually. It is easy and predictable. The most common technique for “numbing” the lower teeth and jaw is called an inferior alveolar nerve injection anesthesia or a block. This “numbs” half of the lower jaw and lower teeth to the midline of the lower lip, and can often involve half of the tongue. The tongue gets numb because of a nerve branch called the lingual nerve. Block injections sometimes require booster injections because the nerve position can vary slightly from person to person and often requires targeting different areas to achieve numbness. If the dentist only wishes to numb the lower middle or front teeth, they can numb adjacent to the teeth just as explained for the top teeth. This works because of a nerve called the mental nerve, which supplies nerves to the lower premolars (middle teeth) and lower front teeth. The facial nerve lies some distance from the inferior alveolar nerve, but in rare cases anesthetic can diffuse far enough to temporarily anesthetize a small area of the face as well.

Another anesthetic includes Nitrous Oxide (N2O), also known as “laughing gas”. This is a great adjunct to dental care for relaxing patients, especially those that experience dental anxiety. This is inhaled and easily crosses the alveoli of the lung and is dissolved into the passing blood, where it travels to the brain, leaving a dissociated and euphoric feeling for most patients. It does not put patients to sleep, like general anesthesia. Further, a patient can drive themselves to and from a dental appointment safely without because the effects of Nitrous Oxide are quickly reversed at the end of the dental appointment. Nitrous Oxide does not cause any numbing of the teeth and patients still require normal dental anesthesia during use of Nitrous Oxide.

The network of nerves in the oral cavity is relatively complex, but consistent, with only slight variation of the inferior alveolar nerve as described above. Knowledge of dental nerve anatomy is important to understand the best avenues for numbing teeth easily and effectively. This permits the routine administration of dental anesthesia, which is predictable and comfortable for patients so that dental treatment can be performed.

Our Little Dental Secret

When Mary bit down on her breakfast creation of an egg muffin with crisp bacon, she suddenly felt her partial denture shift in her mouth and a sharp pain in one of her teeth. “I knew it was just a matter of time before the tooth broke,” she thought.   Mary informed her husband that one of the few remaining upper teeth that held in her upper plate had cracked. Unbeknownst to him, Mary had been enduring pain in that tooth for several months. Mary along with others who grew up in the aftermath of the Great Depression, tolerated many problems, including dental-related problems.

Mary’s husband made a dental appointment that same day so his wife could have her tooth and denture problem resolved.

Mary looked in the mirror as she prepared to leave for the appointment and felt hypocritical as she reflected on many things she had spent time and money on in her life that offered temporary or unnoticeable results. I only have one set of teeth though. Her many trips to the hair stylist, the years of purchasing expensive make up, money spent on one diet program after another, her membership to the gym, her designer clothes — all designed to improve her physical appearance and health. She had not maintained a balance with her dental health,

Mary had gained valuable insight about her long overdue need for dental care. She may have been in her 70s, but she valued keeping her teeth. Her dental health had suffered, and her ability to eat without discomfort was now a primary focus and would remain so the rest of her life.

“I lost so many teeth and wear this old ill-fitting upper plate because I have forsaken my teeth and dental health all my life and always waited until problems escalated to a dental emergency,” she told her husband. “You would think at my age, I’d be smart enough to have figured this out long ago.”

Her dental visit was surprisingly pleasant and peaceful for her. Mary had determined even before walking in my office that she was committed to her oral health and wished to restore her mouth to a healthy condition and be able to chew comfortably. Mary was diagnosed with several areas of gum disease, root decay, tooth decay around old fillings, broken teeth and a very poor fitting denture. Gum disease in the elderly is common because of decreased immune system response, limited dexterity for brushing and flossing and infrequent visits to the dentist. Root decay is one of the most debilitating dental problems faced by the elderly simply because naturally occurring gum recession in later years exposes the roots of teeth to bacteria and can cause terrible tooth decay. Mary’s tooth broke off at the gum line and required extraction because her denture fit so poorly it generated heavy uneven stresses on her teeth when she ate.

Mary’s focus on dental care did not end with herself. Her husband had neglected his dental care just like Mary, but worse. As a heart patient who uses oxygen and has a long list of medications, his need for proper oral health was obvious even to his wife. He agreed to a dental exam, which revealed very debilitated dental health.

Geriatric patients need to value their dental health and realize infection spreads from teeth and gums into the body, sending bacteria through the heart and other organs. The level of an infection in the mouth is often considerably worse than an infected cut on your arm that would require immediate medical attention. We tolerate infection in both our teeth and gums quite well. Out of sight and out of mind leads to neglected dental problems. “Our Little Dental Secret” is that we can have missing or broken teeth, gum disease, abscessed teeth that typically don’t hurt, poor function, and ill-fitting dentures (often not worn any more) all hidden behind the curtain of our lips, and no one knows. The problems only escalate and become worse over time and more expensive to treat. The best time for dental care and a good examination is today. Don’t put off your dental care because it will only be worse tomorrow.

Dr. Scott Harden is a dentist at Fountain View Family Dentistry and has served the Towne Lake area for more than 21 years. He is a Dental Advisor for two nationally renowned dental research companies. You can reach him at (770) 926-0000 or visit FountainViewSmiles.com.O

Dental Article For Children

July 2010

I am so glad you are reading this article about dental care for kids. It’s written for children and I’ll let you in on a secret. You’re very lucky because a trip to the dental office is really great fun! There are video games, massage chairs, big pictures taken of your teeth so you can understand what the dentist is talking about and there are even cartoons on the TV in the room where they clean your teeth. Of course, the real reasons you go to the dentist are to have your teeth cleaned by a dental hygienist and have them checked by a dentist for cavities and other concerns. Years ago dental offices smelled funny and were very boring, but now dental offices are awesome, so remember how lucky you are.

A dental cleaning involves polishing your teeth to remove plaque off all sides of your teeth. “Plaque” is a white film that covers your teeth and eats holes in your teeth known as “cavities” or “decay”. Think of plaque like little ants (called “bacteria”) that get on your teeth and work hard to eat your tooth.cavities

The cavities can form on the top of your teeth where you chew your food or in between your teeth and usually make your teeth turn brown or black in color. The “dental hygienist” is like a nurse and uses a professional toothbrush to polish your teeth so all the plaque is removed and makes your teeth look whiter and gives you a nicer smile.

The dentist can take pictures of your teeth with a camera (as shown above) and they also can take “x-rays” of your teeth, which are a special kind picture that can show whether plaque have made holes in between your teeth (as shown below).

cavities xrayThe area between your teeth is hard to reach with a toothbrush and this is why cavities often form in between your teeth. Brushing your teeth with a toothbrush and a small amount of toothpaste gets most of the surfaces of your teeth clean. To get your teeth fully clean, you must use “floss”, a string that goes in between your teeth to remove the plaque and stop cavities from forming in between your teeth. The dental hygienist will help you learn how to properly use floss every day to fully clean your teeth.

Plaque (the little ants) covers your teeth more when you drink soda, eat a lot of chips and especially when you do not clean your teeth well with toothbrush and floss. Remember, dirty teeth cause cavities or holes in your teeth. If your tooth get a cavity, then the dentist will need to clean out the cavities with a special tool called a “handpiece” and fill the hole with a special material called a “filling”.   This makes your tooth healthy again and makes the cavity or hole go away.

Make sure you brush and floss your teeth at least two times every day in the morning after breakfast and at night before you go to bed. During the summer brush and floss your teeth after you eat lunch to keep your teeth extra clean.