Dr. Ruhls Newsletter, September 2009

Previous Articles

Dental Clinic Press Release, Sept. 08 (pdf)

George Washington's Teeth
Periodontal Disease-Tongue Cancer Link
ADA Study Links Tooth Loss to Dementia
Ear Infections-Pacifier Link
A Piece of Technology Whose Time May Not Have Come
Revitalizing Old Crowns is Possible
Myths Versus Facts – “Implants Are To Expensive”
Myths Versus Facts-Implants Are Somewhat Experimental
OraVerse-Are You Interested?
Pucker Up...or Not
A Dental Dilemma
Independent Practice...a Good Idea?
A Good Chew!
Introducing “Logicon”
Dental Tourism

George Washington's Teeth

This past fall, my family visited Mount Vernon and enjoyed seeing the new visitor's center which contains an exhibit of what has been described as “The Most Famous Teeth in the World.” Although he never had wooden teeth, he did suffer from serious dental pain throughout his life.

Washington lost his first tooth at the age of 24 and it was literally downhill from there. There were no dental anesthetics, any extractions were done “cold turkey” or with the aid of hard liquor. Dental care was in its infancy. Fillings were rarely done and gold was the only restorative material. Plastics and ceramics were not available. The first impression material, Plaster of Paris, would not be invented for another 50 years.

Washington's favorite dentist was Dr. John Greenwood. Dentist's of those days did not graduated from a school, they learned by apprenticing themselves to another dentist. There was no licensing procedures and no examinations. When the student felt that he had learned enough, he set up practice. (I do mean “he”...the first female dentist was still over 100 years away.)

George Washington was a wealthy man, and he spent lavishly on his teeth. He would try this powder and that nostrum but he had a sweet tooth and it was all for naught. By the time that he became President, Washington had no teeth. Dr. Greenwood did his best and made his famous patient a state of the art denture...18th century style.

Dr Greenwood took thin sheets of lead that were flexible enough to be molded by hand to the jaws. Holes were drilled into the sheets and the teeth of an elk were wired into the denture with gold wire. The upper and lower dentures were held together with a hinge and small, powerful springs held the dentures open. Washington had to compress the dentures together to insert them into his mouth. The springs pushed the dentures into his jaws, holding them into place. To chew, he had to exert enough force to overcome the pressure of the springs before he could even chew. It's no wonder that he had a stiff, wooden look to his face.

One other thing that I have not researched but catches my interest. Washington was fond of his wine...Madeira being his favorite tipple. All wines are acidic and he was wearing dentures made with lead! The acid from the wine surely leached the lead out of the dentures. Is it possible that Washington suffered from lead poisoning? We will probably never know!

Periodontal Disease-Tongue Cancer Link

Scientists at the University of Buffalo's Roswell Park Cancer Institute have discovered that the severity of bone loss from periodontal disease appears to have a direct correlation to cancer of the tongue. A study was done comparing bone loss in adult males with tongue cancer with men who did not have cancer. After eliminating the potential effects of age, smoking status and the number of teeth, men with chronic gum disease were 5.2 times more likely to have cancer fir every millimeter of bone that they lost. The results further showed that other conditions of the teeth, including root canals, fillings, crowns and decays have NO significant effect on the incidence of tongue cancer.

Scientists hypothesize that the bacteria and viruses that live in the periodontal pockets could be toxic to the surrounding cells and produce changes that lead directly to oral cancer or could lead indirectly to cancer through causing chronic inflammation. Further research would be needed to confirm these findings but the message is clear. Overall health is affected by unchecked periodontal disease.

ADA Study Links Tooth Loss to Dementia

Tooth loss may predict the development of dementia late in life, according to research published in the October 2007 issue of the American Dental Association Journal. Researchers have long known that people with dementia are unlikely to have good oral hygiene and thus have poor oral health, but few studies have been done from the opposite direction.

Scientists at the University of Kansas studied a population of cloistered nuns over a number of years. This allowed for strict control of a number of factors not usually possible in other populations. Over the years of the study, those nuns with fewer teeth had an increased risk of developing dementia.

They noted that they could not determine whether the association is causal or casual but the statistical significance was very high.

Ear Infections-Pacifier Link

A recent study by the Academy of General Dentistry has linked the prolonged use of pacifiers to increased incidence of inner ear infections. Many parents run back and forth to their pediatrician's office battling recurring ear infections in their children. This has led to repeated use of antibiotics, placement of tubes in the ears and pain and suffering for children.

Otitis media, the scientific term for acute middle ear infections, often develops when viruses or bacteria from an infection of the nose and throat travel along the Eustachian, or auditory tube to the middle ear. It has been shown that continued sucking on a pacifier can cause the auditory tubes to become abnormally open, which allows secretion from the throat to seep into the middle ear. This can lead to inner ear infections.

It may be best to consider restricting the use of the pacifier to the baby's first 10 months. Pacifiers come into contact with many microbes and may also be a conduit for bacteria and viruses to enter the child's oral cavity.

If your child is constantly battling middle ear infections, discontinuing the use of the pacifier may be an alternative to surgery or antibiotics to stop this problem.

A Piece of Technology Whose Time May Not Have Come

The dental drill in many offices, including our own, are air turbines. The only moving parts are in the head of the drill. The handle is merely a covering over metal tubing that feeds air into the turbine and water to cool the drill. The drill never overheats and is safe. If the cutting load is too heavy, the drill simply stalls as the torque on the drill cannot overcome the load

A new technology that is becoming popular is the electric dental drill. The electric motor is small but extremely powerful. The drills are capable of providing enormous torque and cutting power. A cutting load that would simply stall an air turbine causes the electric turbine to simply work harder. This generates enormous heat as the motor labors. The problem is that, as dentists work, the handle of the drill often comes into prolonged contact with the lips or the cheek. There have been a number of incidents of patients suffering serious burns from the heat of the drills! As they are often anesthetized, patients are not aware that they are suffering injury until after their procedure is complete.

Revitalizing Old Crowns is Possible

After crowns are placed in the front teeth, a patient has a brand new smile that will last for many years. The problem is that the esthetic appearance of the crowns will not last forever. Wear and attrition will occur over the thousands of times that you will bite into your food and that you will brush your teeth. Porcelain on dental crowns is like porcelain on the family dishes, except that it takes a lot more abuse.

A portion of the esthetic appearance of the porcelain is the outer glaze of the porcelain. It is what gives the porcelain its attractive sheen and luster. When this glaze is gone, porcelain starts to appear dull and lifeless. Porcelain can also chip and crack. The crowns are still mechanically sound and this presents a dilemma. Do you live with the fractured or unaesthetic porcelain, or do you have the crowns replaced? This is a procedure that involves having anesthesia, cutting the old crowns away, taking impressions and making temporaries. New technology has, however, given us another option.

The breakthrough has come in the creation of new types of porcelain. Traditional dental porcelain is fabricated from a powder that the ceramist mixes with water and applies with an artist's brush layer upon layer and then fired in a special kiln. New types of porcelain can now be “pressed” where the material is subjected to pressurized conditions under a vacuum. The major advantage of this procedure is that the porcelain can be made as thin as a contact lens with great strength and wear resistance. This porcelain Lumineer is only one of several brands that can be bonded over existing porcelain on a damaged front crown to give new life and esthetics to the crown. Best of all, NO drilling is required!

Myths Versus Facts – “Implants Are To Expensive”

As we know, dental implants are most often not covered by insurance carriers. This, in no way, however, should dictate your choice of treatment. Obviously, our role is to provide our patients with treatment options and to emphasize those options that are in their best interests regardless of insurance coverage. When one looks at the cost of a single tooth implant versus a three tooth bridge, one can make the argument that implants are actually cheaper! We know that bridgework has an average lifespan of about 10 years. Insurance companies will actually pay to have bridgework replaced as frequently as every five years. Obviously, the patient has an out-of-pocket copay every time it occurs and, each time that a bridge is replaced, the likelihood that the teeth serving as the abutments will fail increases. It is our feeling that a properly cared for dental implant can last as long as a properly cared for natural tooth. It can never decay! The same cannot be said of bridgework.

Myths Versus Facts-Implants Are Somewhat Experimental

Implants are no longer experimental with over 40 years of data behind them, they are now considered to be the standard of care. A leading authority provides international statistics of 96% success rates for dental implants. These are better statistics than we see for retention of natural teeth! When faced with a tooth that might require crown lengthening and extensive restorative work with a questionable prognosis, a much more predicable alternative is often removal of that tooth and placement of a dental implant.

OraVerse-Are You Interested?

It was reported this May that the FDA has approved marketing phentolamine mesylate under the trade name OraVerse. I will be launched this October at the American Dental Associations annual meeting in San Antonio, Texas. OraVerse is being marketed as an antidote to local anesthesia. In double-blind studies, an injection of OraVerse following the completion of a dental procedure under anesthesia, resulted in an extremely rapid return to full function of all motor and sensory function. An average of over 80 minutes quicker recovery than with a placebo was reported.

So, would you be interested in this product? The manufacturer's marketing states “the primary benefits seen by dental professionals include reduced risk of injury during the period while patients are anesthetized and increased patient satisfaction.” I suppose that I would have to agree with that statement. Side effects have not been reported other than a bit of increased tenderness at the injection site. After all, you are injecting twice in the area...once to anesthetize and once to administer OraVerse. Although pricing has not been established, I expect that the cost of the product might be significant. What is your opinion? Would you like to see us offer this product? Would you be willing to pay extra for it? Please email us with your thoughts at drruhlom@sover.net

Pucker Up...or Not

Walk down the candy aisle at any convenience store and take a look at the extensive and colorful array of candy on the shelves. In contrast to the traditional confections of chocolate, caramel and nuts, there has been a distinct shift in preference of consumers towards the extreme or intense sour fruit flavors. Unfortunately, indulging your “sweet tooth” with these concoctions can lead to poor dental health!

Besides the usual heaping helping of decay producing high fructose corn syrup, these products are also charged with acids. To produce the sharp “Kick”, the candies often contain citric or malic acids. The more corrosive citric acid can produce an oral pH of less than 4. Tooth enamel begins to dissolve in pH's below 5.5.

In addition to a low pH level, the consistency of a candy also contributes to the erosive potential of a product. For instance, insoluble starchy candies, thick sticky gels and citric acid powders are harmful for other reasons. Sticky candies stay in the mouth for longer periods, giving them more time to work their damage. The powders are abrasive and inflict more damage on your teeth as they are chewed.

A Dental Dilemma

The role of government in our lives is, to say the least, ubiquitous. Whatever you may think of our government, one of its prime functions is to promote the general welfare. One facet is to insure that the healthcare system is available and properly regulated. They make sure practitioners are qualified, that they practice within the law and to the standards of care, that all populations are being served and that there are enough practitioners to serve the public properly. It is this last point that we will address.

We have a population of about 600,000 persons in Vermont. There are about 300 active dentists in the state. Of these, some are specialists such as oral surgeons and orthodontists. It comes down to there being about one general dentist for every 2,600 Vermonters. Now, of course, not every Vermonter even seeks dental care for a variety of reasons. However, not all dentists shown are full time practitioners, so it balances out. The scary statistic is that the average age of the dentists in the state of Vermont is about 54-55 years. The fact is that many dentists are getting closer to retirement age and there are few dentists that are moving to Vermont. This is for a variety of reasons, of which financial reasons probably top the list. Dentists graduate from their training with enormous debt. Then there are the huge costs of buying and equipping an office. This can leave the dentist with debt that can top $1,000,000!

Dentist must be able to generate an income that will allow them to service that debt and provide a living for their families. Dentists are simply not viewing Vermont as the place to do this. A very high percentage of Vermonters are low income...often their only means to afford care is Medicaid...which pays only $495 per year for services. More expensive services such as cosmetic veneers and implants are out of the reach of many Vermonters. Therefore, the average new dentist will often avoid Vermont. Practices for sale are not finding buyers and are sometimes simply being closed. More on the crisis in the next article entitled “Independent Practice...a Good Idea?

Independent Practice...a Good Idea?

A critical issue for healthcare, be it in medicine or dentistry, is access to care. As outlined in the previous article, there is a shortage of providers of dental services. The question that faces Vermont is how to deal with this issue. One solution is to provide alternative care. One suggestion is to permit independent practice for dental hygienists. This means that they would be allowed to practice on their own outside of the dental office setting. To a large degree, this has already occurred. Many hygienists practice in schools and clinics with only general supervision from the dentist.

I, personally, have no problems with the concept, but I do not believe that it will solve any issues of access. The supply of dental hygienists is very limited. The single hygiene school in Vermont graduates only 20 students each year!! Our office has been trying to hire a second hygienist for YEARS! Allowing them to practice independently isn't going to mean that they can see more patients. As for setting up their own office, the cost of doing so is so high that they could not make an income sufficient to service their debt by doing hygiene services. They would make a better wage in the dental office setting. In the years since Colorado enacted independent practice for hygienists, only seven hygienists currently maintain their own offices.

Another option that has been discussed is to take the hygienists or other individuals to a higher level...the Dental Care Assistant. The DCA receives intensive training to permit them to do fillings and extractions in addition to hygiene services. Very interesting but bad idea. If this was Alaska, where populations of people in the bush have no access to care at all, this might make a bit of sense. However, in Vermont, this is asking for trouble.

Even after many years of experience, I still get fooled. That simple extraction turns into a problem...the root fractures, the sinus is exposed, there is too much bleeding...what do you do? That filling is going along well and then a cusp fractures or the pulp is exposed...Who ya gonna call? The proper model is not to fragment the care system; the proper model is the current one with a doctor in the office and auxiliaries to help provide care to as many as possible.

A possible suggestion to ensure a supply of dentists is for the state to grow our own! By this, I mean that Vermont could follow the model of other states and contract with dental schools to hold seats for Vermonters. This would come with a lot of strings attached...a promise to practice in Vermont for many years for beginners!

A Good Chew!

Hankering for something sweet to enjoy as a treat? Well, I have a suggestion for our patients. My recommendation is Trident Xtra Care Gum. A sugar-free gum, it advertises itself as strengthening your teeth. In this case, the claim is really true. The active ingredient is trade named “Recaldent”. Recaldent is amorphous liquid calcium derived from milk. (I do not know if a person who is lactose intolerant would have any issues with this but I would guess that the amount is too small to cause a reaction.) The formulation buffers acids as well. This normalization of pH in addition to the liquid calcium penetrates into beginning decays in the teeth and actually helps to heal them! So, go ahead and enjoy a sweet treat that is good for your teeth!

Introducing “Logicon”

Our office has been using digital x-rays for the last 8 years. The advantages are undeniable. First, we get our images immediately. There is no waiting for an x-ray processor (7-8 minutes) to develop the images. If the x-ray is improperly aligned or otherwise unusable, you must wait again for another image to develop. Second, the digital x-rays require much less radiation to produce an image than do the conventional films. Third, the images can be enhanced and analyzed to improve interpretation and can be easily shared with other practitioners.

One difficulty is that the digital x-rays provide so much information that it is difficult to interpret. The human eye can distinguish only about 20 shades of gray in one x-ray image. The digital x-ray provides 100's of shades. Therefore, diagnosing problems can sometimes be more difficult than with a traditional film x-ray!

Logicon is a program that facilitates computer assisted analysis of the digital image created when we take a digital x-ray. The software employs an algorithm that uses data from the USC Dental School to compare and analyze your image to predict with a very high degree of probability whether a decay is present. The technology has its origin in software developed for the U.S. Department of Defense to analyze data from surveillance satellites. We are very excited to be able to bring this capability to the Deerfield Valley.

Dental Tourism

A few weeks ago, a patient of mine stopped me in a local store and asked me to take a look at his new dental work. Although it is very difficult to really see details trying to squint into a person's mouth, it was obvious that this person had obtained some truly extensive dental care. He proudly informed me that he had traveled to Central America to have it done. According to this patient, he had saved about $8-9,000 on his care! (He claimed that travel expenses, including airfare, hotel and other expenses were minimal...I have no way of verifying this.)

Google “Dental Tourism” and the vaunted search engine serves up nearly 9.4 million listings, most of them links to other Web sites that offer a dizzying array of options for dental patients willing to cross borders or even oceans in pursuit of cut-rate dental care. This is not as prevalent in northern states as it is in southern states that are closer geographically to Mexico and Central America. Review of the literature reveals some extreme horror stories of incompetence that could make your hair stand on end. My purpose here is not to repeat these stories...I simply want to urge caution.

Tales of poor results are not intended as an indictment of dental care in foreign countries. Capable dentists and quality care can be found all over the world. The question is what happens to patients who fall victim to incompetence. What do you do if things go badly? Who do you call if something breaks? Does the dental tourist head back to, say, Costa Rica, if something goes wrong? Even more importantly, has the patient been treated to a comparable standard of care to that practiced in the USA? What if the patient with the shiny new bridgework has a history of gum disease? Was that addressed in the two weeks in Central America? This can take a LOT of time to get under control. If it was not addressed, is the enormous restoration built upon a poor foundation? Let the buyer truly beware!